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The value of preventive medicine training and certification
Editorials and Commentary
The Value of Preventive Medicine Training and Certification What Do We—and Others—Know? F. Douglas Scutchfield, MD, Kevin Patrick, MD, MS
T
his issue of the journal presents an article by Nitzken et al.1 on the issue of preventive medicine physician supply and demand. The article is provocative, just as its authors intended it to be. In our view, however, the article has several problems, both methodologic and with respect to some of its conclusions. They use two surveys to examine the hypothesis that general preventive medicine/public health (GPM) education and board certification are of little value and that employers will either use nonphysicians or they will not recognize the added value of preventive medicine education or certification over that provided by other medical specialties. They have not examined two preventive medicine disciplines, aerospace or occupational medicine, but have focused their efforts on GPM. The two survey methods they used included a review of ads in four national journals and a survey completed at a national preventive medicine meeting (Prevention 99). One could certainly call into question the validity of the Prevention 99 meeting survey. First, one wonders about the validity of the finding that over 40% of the respondents to this survey were considering or seeking new employment. Moreover, the meeting is intended to draw broadly from physicians interested in preventive medicine, and the meeting is broadly advertised in a number of primarily clinical-focused journals, as well as in prevention and public health journals. Thus, attendance at one preventive medicine meeting is likely to be of limited generalizability. The authors’ advertising survey focused on two general interest journals: one public health journal and an academic journal. However, they point out that less than 20% of respondents in the preventive medicine meeting survey found their job through an ad. Moreover, one could question the appropriateness of the journals they selected. Recent evidence suggests, for example, that population skills taught in GPM programs are in demand by managed care organizations for their medical directors.2 Examination of ads in
From the American Journal of Preventive Medicine, San Diego, California. Address correspondence and reprint requests to: Kevin Patrick, MD, MS, San Diego State University, 5500 Campanile Drive, San Diego CA 92182-4710. E-mail: [email protected].
journals intended for managed care organizations and their medical directors might have created a very different pool of ads. Similarly, their definition of GPM seems to be tightly focused. In other words, the American Association of Public Health Physicians is focused primarily on individuals who are state or local health directors. As the authors point out, not only is the physician public health director becoming extinct, but so too is a public health director with any public health training.3 While we agree that this is a sorry state of affairs, a broader definition might have included other categories of GPM-trained physicians such as physician epidemiologists. Thus, ads in epidemiology journals might have created different results. When one of us (DS) receives the EIS Bulletin as an alumnus, it is always impressive to note the volume of ads from folks obviously seeking candidates for positions with skills that the Epidemic Intelligence Service (EIS) is famous for producing. One also wonders at some of the statements made in interpreting the data. For example, to suggest that preventive medicine certification or education was not seen as useful seems to fly in the face of the fact that over 55% of the Prevention 99 meeting respondents considered their training and certification of major importance in securing their most recent job. Again, the meeting is intended to draw not only those in public health and preventive medicine, but also clinicians in other specialties with an interest in clinical preventive medicine, such as family physicians or general internists, two specialties that are very committed to research and practice focused on clinical preventive services and community-oriented primary care. This, combined with the finding that nearly 35% consider clinical skills important in their job might suggest that—among Prevention 99 meeting attendees anyway—preventive medicine training is a valuable adjunct to clinical practice. The issue of the validity of the paper aside, it still raises several provocative questions. Is the specialty of preventive medicine valued by employers? Is the field oversubscribed? Are nonphysicians usurping the place of the preventive medicine physician? All of these represent important questions to which the discipline needs to respond. They are not new questions. In a recent editorial in the American Journal of Preventive
Am J Prev Med 2001;20(1) 0749-3797/01/$–see front matter © 2001 American Journal of Preventive Medicine • Published by Elsevier Science Inc. PII S0749-3797(00)00256-7
75
Medicine (AJPM),4 we point out that although questions about education in preventive medicine have been debated for many years, we just seem to rediscover the problems every so often. In a recent article in AJPM, Lane5 decries the declining numbers of preventive medicine physicians, particularly in GPM. She points, as have others, to the lack of resident support and small numbers of preventive medicine departments and faculty in medical schools. It would not seem to be a good idea to be urging the creation of more residents in preventive medicine if, as Nitzken et al.1 suggest, there are no openings for them. In point of fact, the American College of Preventive Medicine (ACPM) and the Association of Teachers of Preventive Medicine (ATPM) have consistently insisted that there continues to be a profound shortage of preventive medicine physicians that needs to be addressed, primarily through reform of reimbursement for residency training in preventive medicine, particularly GPM. Much of this is predicated on the observation that many, if not all, of the competencies developed through training in preventive medicine—population health, evidencebased practice, cost-effective decision making, and clinical epidemiology—are precisely those that are needed and valued in managed care, an observation validated in a recent Journal of the American Medical Association paper by Yedidia et al.6 Surveys of residency programs, the results of which have been published in this journal, are also telling in regard to the issues of preventive medicine training and certification. Liang et al.7 studied graduates of preventive medicine residency programs in the 1980s. They found that graduates of these programs were employed in settings very different from nonpreventive medicine physicians and that the nature of their work was very different in that it provided an opportunity for them to use their clinical skills as well as epidemiologic and administrative skills. They conclude that this unique blend of skills provides a superior product for the market. A second, more disconcerting, paper by Dannenberg et al.8 focused on board certification of residency graduates. They found that only 45% of graduates of preventive medicine residency programs were certified by the American Board of Preventive Medicine. Reasons for not taking the board examination included the perception of limited benefit of board certification in current employment or professional endeavors, previous board certification in a clinical specialty, lack of a master of public health (MPH) degree, high cost of the board exam, the amount of time commitment for the examination, and uncertainty about examination admission requirements. Interestingly, those who were least likely to become certified were those who had come through the Centers for Disease Control and Prevention (CDC) program, one of the largest training programs. Dannenberg et al.,8 76
like Nitzken et al.,1 also advocated for an increased visibility of preventive medicine training and certification. One could argue that these studies, conducted on the cohort completing residency in the 1980s, are out of date and they may well be. This observation leads us to our concluding comments. First, we have been working with very little data. The paper by Nitzken et al.1 refers to studies by Miller et al.9 regarding the experience of individuals completing residency training in fields other than preventive medicine. Nitzken et al.1 correctly refuse to make the direct comparison with the data in Miller et al.9 However, it would be instructive to examine, using the methodology in Miller et al.,9 the experience of those finishing preventive medicine residencies. We have very little data that enable an examination of either the need or demand for preventive medicine physicians. Our specialty has been arguing for increasing the size of training programs based on conventional wisdom. Perhaps it is time to try to put some science into our discussions. We suspect that the issues raised by this paper potentially pertain to aerospace and occupational medicine as well as GPM. We also suspect that these fields have similar data problems. The last reported assessments of the experience of preventive medicine residents are obsolete.7,8 Perhaps it is time to gather and examine data. As we indicated, this is not the first call to see if the specialty can be rejuvenated. During Suzanne Dandoy’s tenure as president of the ACPM, this issue was her top priority. In fact, she was responsible for the creation of the Forum for Leadership in the Specialty of Preventive Medicine, a group that included all major organizations involved in the specialty of preventive medicine. The forum issued a report in 1996 with a series of 34 recommendations intended to revitalize preventive medicine as a medical specialty.10 Nitzken et al.1 reference this report, but only to make a point about one of the recommendations. Unfortunately, the forum recommendations are not widely quoted and most have still not been implemented. Among other things, politics within the specialty—much of which continues to the present— has diverted attention that could have been focused on the forum report. Perhaps it is time to put politics aside, dust the recommendations off, and get about the process of their implementation. We owe this to those who long ago created the specialty of preventive medicine and to those who have entered the field more recently. We also owe this to the populations and individuals who will benefit from our profession as it matures and moves into the new century.
References 1. Nitzkin, JL, Falcoa P, Janusz N and Arriano J. Report of two preventive medicine job market surveys. Am J Prev Med 2001;20:56 – 60. 2. Halbert RJ, Bokor A, Castrence-Nazareno R, Parkinson MD, Lewis CE. Competencies for population-based clinical managers: a survey of managed care medical directors. Am J Prev Med 1998;15:65–70.
American Journal of Preventive Medicine, Volume 20, Number 1
3. Gerzoff R, Brown C, Baker E. Full-time employees of U.S. local health departments, 1992–1993. J Public Health Manag Pract 1999;5:1–9. 4. Parkinson MD, Scutchfield FD. From public health and medicine to population health improvement: the 50-year search for training in preventive medicine. Am J Prev Med 2000;18:99 –101. 5. Lane DS. A threat to the public health workforce: evidence from trends in preventive medicine certification and training. Am J Prev Med 2000;18:87–96. 6. Yedidia MJ, Gillespie CC, Moore GT. Specific clinical competencies for managing care: views of residency directors and managed care medical directors. JAMA 2000 284;1093– 8. 7. Liang AP, Dysinger WS, Ring AR, Hersey JC, Parkinson M, Cates W. Practicing preventive medicine: a national survey of general preventive
medicine residency graduates—United States, 1991. Am J Prev Med 1995;11:139 – 44. 8. Dannenberg AL, Salive ME, Forston SR Jr, Ring AR, Hersey JC, Parkinson MD. Board certification among preventive medicine residency graduates: characteristics, advantage and barriers. Am J Prev Med 1994;10:251– 8. 9. Miller R, Dunn M, Richter T, Whitcomb, M. Employment-seeking experiences of resident physicians completing training during 1996. JAMA 1998;280:777– 83. 10. Forum for Leadership in the Specialty of Preventive Medicine. The specialty of preventive medicine. Washington, DC: American College of Preventive Medicine, 1996.
Am J Prev Med 2001;20(1)
77
The Value of Preventive Medicine Training and Certification What Do We—and Others—Know? F. Douglas Scutchfield, MD, Kevin Patrick, MD, MS
T
his issue of the journal presents an article by Nitzken et al.1 on the issue of preventive medicine physician supply and demand. The article is provocative, just as its authors intended it to be. In our view, however, the article has several problems, both methodologic and with respect to some of its conclusions. They use two surveys to examine the hypothesis that general preventive medicine/public health (GPM) education and board certification are of little value and that employers will either use nonphysicians or they will not recognize the added value of preventive medicine education or certification over that provided by other medical specialties. They have not examined two preventive medicine disciplines, aerospace or occupational medicine, but have focused their efforts on GPM. The two survey methods they used included a review of ads in four national journals and a survey completed at a national preventive medicine meeting (Prevention 99). One could certainly call into question the validity of the Prevention 99 meeting survey. First, one wonders about the validity of the finding that over 40% of the respondents to this survey were considering or seeking new employment. Moreover, the meeting is intended to draw broadly from physicians interested in preventive medicine, and the meeting is broadly advertised in a number of primarily clinical-focused journals, as well as in prevention and public health journals. Thus, attendance at one preventive medicine meeting is likely to be of limited generalizability. The authors’ advertising survey focused on two general interest journals: one public health journal and an academic journal. However, they point out that less than 20% of respondents in the preventive medicine meeting survey found their job through an ad. Moreover, one could question the appropriateness of the journals they selected. Recent evidence suggests, for example, that population skills taught in GPM programs are in demand by managed care organizations for their medical directors.2 Examination of ads in
From the American Journal of Preventive Medicine, San Diego, California. Address correspondence and reprint requests to: Kevin Patrick, MD, MS, San Diego State University, 5500 Campanile Drive, San Diego CA 92182-4710. E-mail: [email protected].
journals intended for managed care organizations and their medical directors might have created a very different pool of ads. Similarly, their definition of GPM seems to be tightly focused. In other words, the American Association of Public Health Physicians is focused primarily on individuals who are state or local health directors. As the authors point out, not only is the physician public health director becoming extinct, but so too is a public health director with any public health training.3 While we agree that this is a sorry state of affairs, a broader definition might have included other categories of GPM-trained physicians such as physician epidemiologists. Thus, ads in epidemiology journals might have created different results. When one of us (DS) receives the EIS Bulletin as an alumnus, it is always impressive to note the volume of ads from folks obviously seeking candidates for positions with skills that the Epidemic Intelligence Service (EIS) is famous for producing. One also wonders at some of the statements made in interpreting the data. For example, to suggest that preventive medicine certification or education was not seen as useful seems to fly in the face of the fact that over 55% of the Prevention 99 meeting respondents considered their training and certification of major importance in securing their most recent job. Again, the meeting is intended to draw not only those in public health and preventive medicine, but also clinicians in other specialties with an interest in clinical preventive medicine, such as family physicians or general internists, two specialties that are very committed to research and practice focused on clinical preventive services and community-oriented primary care. This, combined with the finding that nearly 35% consider clinical skills important in their job might suggest that—among Prevention 99 meeting attendees anyway—preventive medicine training is a valuable adjunct to clinical practice. The issue of the validity of the paper aside, it still raises several provocative questions. Is the specialty of preventive medicine valued by employers? Is the field oversubscribed? Are nonphysicians usurping the place of the preventive medicine physician? All of these represent important questions to which the discipline needs to respond. They are not new questions. In a recent editorial in the American Journal of Preventive
Am J Prev Med 2001;20(1) 0749-3797/01/$–see front matter © 2001 American Journal of Preventive Medicine • Published by Elsevier Science Inc. PII S0749-3797(00)00256-7
75
Medicine (AJPM),4 we point out that although questions about education in preventive medicine have been debated for many years, we just seem to rediscover the problems every so often. In a recent article in AJPM, Lane5 decries the declining numbers of preventive medicine physicians, particularly in GPM. She points, as have others, to the lack of resident support and small numbers of preventive medicine departments and faculty in medical schools. It would not seem to be a good idea to be urging the creation of more residents in preventive medicine if, as Nitzken et al.1 suggest, there are no openings for them. In point of fact, the American College of Preventive Medicine (ACPM) and the Association of Teachers of Preventive Medicine (ATPM) have consistently insisted that there continues to be a profound shortage of preventive medicine physicians that needs to be addressed, primarily through reform of reimbursement for residency training in preventive medicine, particularly GPM. Much of this is predicated on the observation that many, if not all, of the competencies developed through training in preventive medicine—population health, evidencebased practice, cost-effective decision making, and clinical epidemiology—are precisely those that are needed and valued in managed care, an observation validated in a recent Journal of the American Medical Association paper by Yedidia et al.6 Surveys of residency programs, the results of which have been published in this journal, are also telling in regard to the issues of preventive medicine training and certification. Liang et al.7 studied graduates of preventive medicine residency programs in the 1980s. They found that graduates of these programs were employed in settings very different from nonpreventive medicine physicians and that the nature of their work was very different in that it provided an opportunity for them to use their clinical skills as well as epidemiologic and administrative skills. They conclude that this unique blend of skills provides a superior product for the market. A second, more disconcerting, paper by Dannenberg et al.8 focused on board certification of residency graduates. They found that only 45% of graduates of preventive medicine residency programs were certified by the American Board of Preventive Medicine. Reasons for not taking the board examination included the perception of limited benefit of board certification in current employment or professional endeavors, previous board certification in a clinical specialty, lack of a master of public health (MPH) degree, high cost of the board exam, the amount of time commitment for the examination, and uncertainty about examination admission requirements. Interestingly, those who were least likely to become certified were those who had come through the Centers for Disease Control and Prevention (CDC) program, one of the largest training programs. Dannenberg et al.,8 76
like Nitzken et al.,1 also advocated for an increased visibility of preventive medicine training and certification. One could argue that these studies, conducted on the cohort completing residency in the 1980s, are out of date and they may well be. This observation leads us to our concluding comments. First, we have been working with very little data. The paper by Nitzken et al.1 refers to studies by Miller et al.9 regarding the experience of individuals completing residency training in fields other than preventive medicine. Nitzken et al.1 correctly refuse to make the direct comparison with the data in Miller et al.9 However, it would be instructive to examine, using the methodology in Miller et al.,9 the experience of those finishing preventive medicine residencies. We have very little data that enable an examination of either the need or demand for preventive medicine physicians. Our specialty has been arguing for increasing the size of training programs based on conventional wisdom. Perhaps it is time to try to put some science into our discussions. We suspect that the issues raised by this paper potentially pertain to aerospace and occupational medicine as well as GPM. We also suspect that these fields have similar data problems. The last reported assessments of the experience of preventive medicine residents are obsolete.7,8 Perhaps it is time to gather and examine data. As we indicated, this is not the first call to see if the specialty can be rejuvenated. During Suzanne Dandoy’s tenure as president of the ACPM, this issue was her top priority. In fact, she was responsible for the creation of the Forum for Leadership in the Specialty of Preventive Medicine, a group that included all major organizations involved in the specialty of preventive medicine. The forum issued a report in 1996 with a series of 34 recommendations intended to revitalize preventive medicine as a medical specialty.10 Nitzken et al.1 reference this report, but only to make a point about one of the recommendations. Unfortunately, the forum recommendations are not widely quoted and most have still not been implemented. Among other things, politics within the specialty—much of which continues to the present— has diverted attention that could have been focused on the forum report. Perhaps it is time to put politics aside, dust the recommendations off, and get about the process of their implementation. We owe this to those who long ago created the specialty of preventive medicine and to those who have entered the field more recently. We also owe this to the populations and individuals who will benefit from our profession as it matures and moves into the new century.
References 1. Nitzkin, JL, Falcoa P, Janusz N and Arriano J. Report of two preventive medicine job market surveys. Am J Prev Med 2001;20:56 – 60. 2. Halbert RJ, Bokor A, Castrence-Nazareno R, Parkinson MD, Lewis CE. Competencies for population-based clinical managers: a survey of managed care medical directors. Am J Prev Med 1998;15:65–70.
American Journal of Preventive Medicine, Volume 20, Number 1
3. Gerzoff R, Brown C, Baker E. Full-time employees of U.S. local health departments, 1992–1993. J Public Health Manag Pract 1999;5:1–9. 4. Parkinson MD, Scutchfield FD. From public health and medicine to population health improvement: the 50-year search for training in preventive medicine. Am J Prev Med 2000;18:99 –101. 5. Lane DS. A threat to the public health workforce: evidence from trends in preventive medicine certification and training. Am J Prev Med 2000;18:87–96. 6. Yedidia MJ, Gillespie CC, Moore GT. Specific clinical competencies for managing care: views of residency directors and managed care medical directors. JAMA 2000 284;1093– 8. 7. Liang AP, Dysinger WS, Ring AR, Hersey JC, Parkinson M, Cates W. Practicing preventive medicine: a national survey of general preventive
medicine residency graduates—United States, 1991. Am J Prev Med 1995;11:139 – 44. 8. Dannenberg AL, Salive ME, Forston SR Jr, Ring AR, Hersey JC, Parkinson MD. Board certification among preventive medicine residency graduates: characteristics, advantage and barriers. Am J Prev Med 1994;10:251– 8. 9. Miller R, Dunn M, Richter T, Whitcomb, M. Employment-seeking experiences of resident physicians completing training during 1996. JAMA 1998;280:777– 83. 10. Forum for Leadership in the Specialty of Preventive Medicine. The specialty of preventive medicine. Washington, DC: American College of Preventive Medicine, 1996.
Am J Prev Med 2001;20(1)
77