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Public Health and Medicine

Where the Twain Shall Meet

      Introduction

      Public health and medicine approach the challenge of health and health care from distinct, complementary perspectives (Table 1). In medicine, the focus is on the individual patient, within the context of family and community. In public health, the focus is on the health of populations, with the expression of illness found in the lives of individuals. Medicine draws mainly on the biological sciences, with secondary emphasis on quantitative sciences, physics, chemistry, and parts of engineering. Public health depends on a spectrum of disciplines centered in the quantitative and social–behavioral sciences, and has its origins as much in engineering and environmental sciences as in biological sciences. Public health stresses the prevention of disease, while medicine deals with the prevention, diagnosis, and treatment of individuals. Medication, surgery, and other forms of individual intervention are the principal tools of the medical clinician. Public health employs a wide array of social and community interventions ranging from immunization campaigns to urban design in order to preserve and protect health. In the U.S., medicine is grounded in private enterprise, while public health is associated with public sector and regulatory responsibility.
      Table 1Perspectives of medicine and public health
      MedicinePublic health
      Primary focus on individualPrimary focus on population
      Personal service ethic, conditioned by awareness of social responsibilitiesPublic service ethic, tempered by concerns for the individual
      Emphasis on diagnosis and treatment, care for the whole patientEmphasis on prevention, health promotion for the whole community
      Medical paradigm places predominant emphasis on medical carePublic health paradigm employs a spectrum of interventions aimed at the environment, human behavior and lifestyle, and medical care
      Well-established profession with sharp public imageMultiple professional identities with diffuse public image
      Uniform system for certifying specialists beyond professional medical degreeVariable certification of specialists beyond professional public health degree
      Lines of specialization organized, for example, by organ system (cardiology, neurology); patient group (obstetrics, pediatrics); etiology and pathophysiology (infectious diseases, oncology); technical skill (radiology, surgery)Lines of specialization organized, for example, by analytic method (epidemiology, toxicology); setting and population (occupational health, international health); substantive health problem (environmental health, nutrition)
      Biologic sciences central, stimulated by needs of patients; move between laboratory and bedsideBiologic sciences central, stimulated by major threats to health of populations; move between laboratory and field
      Numeric sciences increasing in prominence, although still a relatively minor part of trainingNumeric sciences an essential feature of analysis and training
      Social sciences tend to be an elective part of medical educationSocial sciences an integral part of public health education
      Engineering and physical sciences relevant, especially materials science, electronics, imaging, and information technologyEngineering relevant, especially systems analysis, operations management, sanitary engineering, and information technology
      Clinical sciences an essential part of professional trainingClinical sciences peripheral to professional training
      Rooted mainly in the private sectorRooted mainly in the public sector
      Despite these differences in perspective, a moment's reflection reinforces the continuity and overlap between the concern with populations of public health and the individual responsibility of medicine. For ample historical and practical reasons, education in public health and in medicine has proceeded much more in parallel than by intersection. Today, however, numerous initiatives are bringing the principles, values, experience, and analytic perspectives of public health into the daily practice of medical education. These range from clinical cases to field experiences and from brief learning modules to integrated degree programs, and they are exemplified by the array of papers gathered in this supplement to the American Journal of Preventive Medicine.
      • Maeshiro R.
      • Koo D.
      • Keck C.W.
      Integration of public health into medical education: an introduction to the supplement.
      • Novick L.F.
      • Lazorick S.
      • Clay M.C.
      • Merricks P.A.
      • Daugherty J.C.
      • Efird J.T.
      Using clinical skills exams to evaluate medical student skills in prevention.
      • Geppert C.M.A.
      • Arndell C.L.
      • Clithero A.
      • et al.
      Reuniting public health and medicine: the University of New Mexico School of Medicine Public Health Certificate.
      • Carney J.K.
      • Maltby H.J.
      • Mackin K.A.
      • Maksym M.E.
      Community–academic partnerships: how can communities benefit?.
      • Betz M.E.
      • Bernstein S.L.
      • Gutman D.C.
      • et al.
      Public health education for emergency medicine residents.
      • Johnson I.L.
      • Scott F.E.
      • Byrne N.P.
      • MacRury K.A.
      • Rosenfield J.
      Integration of community health teaching in the undergraduate medicine curriculum at the University of Toronto.
      • Fiebach N.H.
      • Rao D.
      • Hamm M.E.
      A curriculum in health systems and public health for internal medicine residents.
      • Saravanan Y.
      • Pels R.
      Community health training for internal medicine residents working with community partners.
      • Crandall M.L.
      Integrating population health into a general surgical residency curriculum.
      • Schapiro R.
      • Stickford-Becker A.E.
      • Foertsch J.A.
      • Remington P.L.
      • Seibert C.S.
      Integrative cases for preclinical medical students: connecting clinical, basic science, and public health approaches.
      • Carney J.K.
      • Schilling L.M.
      • Frank S.H.
      • et al.
      Planning and incorporating public health preparedness into the medical curriculum.
      • Taylor B.D.
      • Buckner A.V.
      • Walker C.D.
      • Blumenthal D.S.
      Faith-based partnerships in graduate medical education: the experience of the Morehouse School of Medicine public health/preventive medicine residency program.
      • Meurer L.N.
      • Young S.A.
      • Meurer J.R.
      • Johnson S.L.
      • Gilbert I.A.
      • Diehr S.
      The urban and community health pathway: preparing socially responsive physicians through community-engaged learning.
      • Gehle K.S.
      • Crawford J.L.
      • Hatcher M.T.
      Integrating environmental health into medical education.
      • Harvey B.J.
      • Moloughney B.W.
      • Iglar K.T.
      Identifying public health competencies relevant to family medicine.
      • Stebbins S.
      • Sanders J.L.
      • Vukotich Jr, C.J.
      • Mahoney J.F.
      Public health area of concentration: a model for integration into medical school curricula.
      • Mahoney J.F.
      • Fox M.D.
      • Chheda S.G.
      Overcoming challenges to integrating public and population health into medical curricula.
      • Preston C.
      • Almashat S.
      • Peik S.
      • Desale M.
      • Alexander M.
      Role of preventive medicine residencies in medical education: a national survey.
      • Potts S.E.
      • Deligiannidis K.E.
      • Cashman S.B.
      • et al.
      Weaving public health education into the fabric of a family medicine residency.
      • Simoyan O.M.
      • Townsend J.M.
      • Tarafder M.R.
      • DeJoseph D.
      • Stark R.J.
      • White M.V.
      Public health and medical education: a natural alliance for a new regional medical school.
      • Dysinger W.S.
      • Pappas J.M.
      A fourth-year medical school rotation in quality, patient safety, and population medicine.
      • Varkey P.
      • Billings M.L.
      • Matthews G.A.
      • Voigt R.G.
      The power of collaboration: integrating a preventive medicine–public health curriculum into a pediatric residency.
      • Brill J.R.
      • Chheda S.G.
      • Rusch R.B.
      • Seibert C.S.
      A mapping process for identifying and enhancing public health education in required medical student clerkships.
      • Shore B.
      • McDowell I.
      • Johnson I.L.
      • Donovan D.
      A primer on population health: a new resource for students and clinicians.
      • Campos-Outcalt D.
      The integration of public health and prevention into all years of a medical school curriculum.
      • McNeal M.S.
      • Blumenthal D.S.
      Innovative ways of integrating public health into the medical school curriculum.
      • Bachofer S.
      • Velarde L.
      • Clithero A.
      Laying the foundation: a residency curriculum that supports informed advocacy by family physicians.
      • Monroe J.A.
      Exploring the context: contemporary public health.
      • Frank S.H.
      Principles for authentic population health.
      • Prescott J.E.
      Exploring the context: contemporary medical education.
      • Stange K.C.
      Refocusing knowledge generation, application, and education: raising our gaze to promote health across boundaries.
      Public health matters to medical care and therefore to medical education in at least six ways:
      • 1
        Epidemiology, the core discipline of public health, is essential to understanding the cause and distribution of disease. Without some grounding in the quantitative disciplines of biostatistics and epidemiology, no physician can hope to independently and sensibly interpret the medical literature, or to apply it rationally to an individual patient. Dealing with uncertainty and probabilistic reasoning is as essential to sound medical care as it is to health policy and public health practice.
      • 2
        Public health teaches the influence of environmental, nutritional, social, and behavioral factors on health, illness, recovery, and wellness. Understanding the etiology of disease and the optimal management of patients depends on a comprehensive appreciation of the multiple origins of illness, including those traditionally emphasized in public health. Integrative explanations of illness that embrace genetic, molecular, biochemical, and physiological factors with behavioral, social, nutritional, and environmental factors require the joint perspectives of medicine and public health.
      • 3
        The physician who appreciates the role and potential for public health interventions—public education, social campaigns, ordinances and laws, standards and regulations, surveillance and preparedness—has a deeper understanding of the conditions that preserve health, of the primacy of disease prevention, and of the interfaces between personal medical care and community health protection.
      • 4
        Public health emphasizes cultural sensitivity (similarities and differences in values, mores, and practices), community engagement, and health literacy, which have a direct bearing on the ability of patients to participate in their own health care and to protect their family's health.
      • 5
        Public health stresses systems thinking, an engineering concept that explains observed performance in terms of connected parts that interact in a variety of interdependent ways. The same way of thinking bears directly on patient safety and the quality of medical care, and it provides a way of describing and understanding the performance of everything from an individual medical encounter to the health system as a whole.
      • 6
        Public health exposes physicians to exciting and fulfilling career opportunities in such diverse areas as global health, disaster response, health policy, and environmental health. Apart from those who will choose to concentrate in a public health field, such as epidemiology, general preventive medicine, or occupational health, many practitioners in such fields as general and specialty medicine, emergency medicine, pediatrics, family medicine, obstetrics and gynecology, ophthalmology, and general surgery will find rewarding opportunities for part-time engagement in one or another aspect of population health. In analogy to Clausewitz's observation that “war is merely the continuation of policy by other means,”
        • von Clausewitz C.
        On war.
        many physicians will find that public health is the continuation of medicine by other means, potentially affecting millions of individuals at a time.
      The examples in the papers in this supplement are part of a recognized global need for greater interprofessional educational experience across medicine, nursing, and public health.
      • Frenk J.
      • Chen L.
      • Bhutta Z.A.
      • et al.
      Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.
      IOM
      The future of nursing: leading change, advancing health.
      To be successful, interprofessional education must be matched to interprofessional practice. An IOM study currently underway is examining ways to integrate public health and primary care (iom.edu/Activities/PublicHealth/PrimaryCarePublicHealth.aspx). At this stage, much remains to be learned about the optimal ways to organize and conduct interprofessional educational experiences, identify the most successful pedagogic methods, define and assess professional competencies, link to interprofessional practice, and measure ultimate effects on clinician and patient experience and health system performance. We can, however, take encouragement and learn from the many creative initiatives that incorporate public health into medical education, as described in this supplement to the American Journal of Preventive Medicine.
      Publication of this article was supported by the CDC-AAMC ( Association of American Medical Colleges ) Cooperative Agreement number 5U36CD319276 .
      No financial disclosures were reported by the author of this paper.

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