Public Health Draft

7/23/2019 Public Health Draft

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Physicians in Public Health: Their Roles, Knowledge Needed, and Numbers

This chapter examines the roles of physicians in public health, describes thenowledge that they need to practice public health, and estimates the number of

physicians needed to maintain an ade!uate public health physician worforce"

R#$%& 'N( $%)%$& #* %N+'+%%NT

&ince the inception of organi-ed public health programs, physicians ha.e been seen

as essential to the deli.ery of good public health ser.ices" /n any list of the multiple

professions needed for the high0!uality practice of public health, physicians are

included with nurses, dentists, .eterinarians, en.ironmental health specialists,

laboratorians, epidemiologists, health educators, and others" /n the early years of

the 21th century, statutes that established public health departments at the stateand local le.els re!uired that the public health ocial 3the public health ocer or

health commissioner4 be a duly licensed physician" The si-e and complexity of the

public health worforce ha.e grown o.er the inter.ening century, many statutes

ha.e been rewritten without specifying the professional discipline of the agency

leadership that is re!uired, and the uni!ue role of physicians in public health has

become more dicult to describe"

any more physicians than are currently recogni-ed engage in public health

acti.ities at some point in their careers" *irst, all physicians intersect with public

health in many acti.ities of their practice and can be .iewed as participating in

public health acti.ities" &econd, the practices of some physicians include some

public health elements" These physicians include infectious disease physicians

in.estigating health care0associated disease outbreas, pediatricians woring in

school health, and emergency medicine specialists ser.ing as the medical directors

of emergency medical ser.ices" 5eyond their day0to0day duties, the stories that

they can tell of pre.ention e6orts that ha.e not been practiced may be a critical

factor in public policy maing" /t was the .oice of a practicing pediatrician, for

example, that launched the national e6ort to place e.ery child in an appropriate

restraint when the child was tra.eling in a mo.ing .ehicle"

*inally, some physicians ha.e careers in public health7 that is, they can be identi8ed

as speciali-ing in public health, whether they practice this specialty for their entire

career or enter it as a change in specialty at some point in their career" These public

health physicians wor in a .ariety of settings, including nongo.ernmental

organi-ations, managed care organi-ations, occupational medicine, aerospace

medicine, academia, public hospitals, and go.ernmental agencies" *igure 2"9

illustrates these di6erent le.els of physician engagement with public health"


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o.ement upward in the 8gure, as indicated by the arrow, indicates the need for

higher le.els of public health nowledge and practice"

' public health physician policy maer in.ol.ed in the de.elopment of population

health policies might wor with legislators to ensure that they understand the

health implications of proposed legislation, present the health implications of publichealth programs to the public, or ensure that public health programs are structured

to use the best emerging public health science" ' public health physician leader or

manager may be found to be the head of a managed care organi-ation, a director of

a state health department, or the manager of epidemiological sur.eillance in a

hospital" 't each of these le.els the public health physician leader and manager is

responsible for de.eloping clear goals, using resources eciently and e6ecti.ely,

and ensuring that the worforce for which he or she is responsible is well trained

and well organi-ed to ful8ll its responsibilities"

Public health physicians also play a ey role in a number of practice areas that

re!uire both public health perspecti.es and extensi.e clinical expertise" entalhealth, occupational health, and corrections health are a few of these" 't least at

the le.el of leadership, these re!uire the participation of well0trained public health

physicians"

's described abo.e, all physicians are a part of the public health system7 for a

smaller number of physicians, a portion of their practice in.ol.es public health,

while career public health physicians practice in a wide range of settings, including

go.ernmental public health agencies"

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The report states that ?an ecological model assumes that health and well being are

a6ected by interaction among multiple determinants including biology, beha.ior,

and the en.ironment" /nteraction unfolds o.er the life course of indi.iduals, families,

and communities, and e.idence is emerging that societal le.el factors are critical to

understanding and impro.ing the health of the public@ 3/#, 211>b4"

Table 2"9 lists the content areas recommended for public health professionals 3/#,

211>b4" These content areas ha.e been expanded by this committee to identify how

each area applies to physicians" These essential areas are epidemiology,

biostatistics, en.ironmental health, health ser.ices administration, social and

beha.ioral sciences, informatics, genomics, communication, cultural competence,

community0based participatory research, global health, policy and law, and ethics"

'gain, endorsing the recommendations of the 211> report 3/#, 211>b4, the

introduction of this content to all physicians should occur in medical school" The

mechanisms for preparation beyond that basic introduction are discussed in "

/n reAecting more deeply on the demands facing the Bnited &tates today 3e"g",

public health preparedness in the face of natural and human0made disasters4, the

committee belie.es that certain responsibilities may fall more directly on physicians

and re!uire nowledge and sill in three additional areas not included in the prior

report that are crucial to preparing e6ecti.e public health physicians" These areas

are leadership, public health emergency preparedness, and clinical and community

pre.enti.e ser.ice pro.ision" %ach of these areas is described in detail in the

following sections"

$eadership

Physicians in.ol.ed in the health of the public re!uire leadership sills that allow

analysis and planning for complex threats to the health of small groups,

neighborhoods, and entire populations" edical schools, howe.er, generally prepare

their students only for clinical medicine and medical research, with the learning of

management sills and leadership taing place through on0the0Cob experience or

during the postgraduate period" Physicians pro.ide leadership, for example, in the

rapid responses to industrial explosions or spreading infections, as well as in

immuni-ation, health promotion, disease pre.ention, nutrition, tobacco control, and

.iolence pre.ention programs" /ndeed, policy maers, the public, and other health

care professionals loo to physicians to be well0informed resources, guides,

spoespeople, and leaders"

$eadership de.elopment has se.eral elements, including, as Dohn +ardner 39EE14

commented, ?%n.isioning goals, arming .alues, moti.ating others, managing,

achie.ing worable unity, explaining things in appropriate settings, ser.ing as a

symbol, representing the group, and in the important tas of self0renewal"@ /n the

complicated world of public health, these tass must be carried out by leaders who


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also demonstrate global awareness, cultural competence, respect for others, humor,

per0

T'5$% 2"9 Public Health


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Pro.iding assurance that health policy and management do not misuse medical

information or neglect important clinical insights7 de.eloping and managing

go.ernmental or community programs7 and woring with go.ernmental, hospital,

and other health care systems

'rea

(escription

'pplication for Public Health Physicians

&ocial and beha.ioral sciences


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(emonstration of the highest possible le.el of competence in dealing with the

multiple cultural groups in the community, e6ecti.ely identifying and responding to

the needs and concerns of di.erse populations, and woring to address health

disparities


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odeling the highest ethical standard of beha.ior for all colleagues in public health

and clinical medicine, contributing to the ethical interpretation of proposals or

e.ents, and balancing the needs and resources for indi.iduals and the community

and among di6erent populations

a(e8nition taen from ;asno6, " '", P" " #F


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medical and public health communities ha.e also identi8ed the need for them to

pay increased attention to these special areas of practice" 'lthough all physicians

ha.e some emergency0related responsibilities 3early detection and reporting of

potential problems, implementation of public health directi.es in patient care, and

the accurate communication of ris to patients4, public health physicians play a

particularly important role in population0based acti.ities in response to emergenciesand disasters"

The o.erall management of emergency preparedness and the response to an

emergency does not re!uire medical nowledge7 but almost any emergency has the

potential to threaten the publicFs health, such as the ris of foodborne disease when

power supplies are cut for extended periods, waterborne disease if water supplies

are contaminated by Aood waters, or hyper0 and hypothermia at temperature

extremes" edical expertise may be essential to interpreting the degree of ris and

ensuring that appropriate communications to the public and protecti.e actions are

taen" 5eyond these more common challenges, epidemic diseases, chemical

exposures, and other human0caused or naturally occurring threats to health re!uire

attenti.e physicians in the community and medical expertise on the public health

response team to ensure that threat detection is handled well and the best possible

inter.entions are put to use" *urthermore, in public communication during an

emergent e.ent with health implications, the .oice of a well0prepared public health

physician can be the ey to the community understanding of the riss and the steps

to be taen for harm reduction and a return to normal function"

Public health professionals are in.ol.ed in emergency responses in a number of

ways" *or example, the responsibility for the regulation of state and local

emergency medical ser.ices has been located in public health agencies and has

always included medical o.ersight" ost go.ernmental emergency preparedness

and disaster plans gi.e the responsibility for planning for and response to the health

component of the plan to state and local public health entities" /n addition, public

health ocials ha.e speci8c legal authorities and police powers that they can use

under emergency conditions, particularly conditions in which the potential for the

transmission of a disease from person to person is encountered" The use of disease0

speci8c information on which to base the use of such powers re!uires sound

medical interpretation"

#.er the past decade, agencies and associations in public health ha.e de.eloped

clear statements of the competencies in emergency preparedness and responsere!uired by any clinician in a position to identify a problem early 3which would

include all physicians42 and all public health worers 3including public health

physicians4"> These competencies go beyond the clinical information about the

treatment of indi.idual patients in cases of natural disasters7 disease epidemics7 or

biological, chemical, or radiological emergencies" The competencies applicable to a

physician practicing in public health include the management and operational sills


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essential for the indi.idual to mae a successful contribution within the context of

the National /ncident anagement &ystem"


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tuberculosis and sexually transmitted diseases, as well as emerging infectious

diseases at the time of 8rst recognition 3e"g", se.ere acute respiratory syndrome

and $egionnairesF disease4" /n epidemic settings, for example, a cluster of cases of

meningococcal meningitis or an outbrea of %scherichia coli #9I:H infection,

public health physicians will be called on to establish appropriate diagnostic and

treatment guidelines" 'n additional area of public health physician expertise relatesto the diagnosis and treatment of conditions not commonly seen by practicing

clinicians, for example, suspect botulism, lead poisoning, malaria, or rabies"


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5ecause there are indications that the current public health worforce is

inade!uately trained in many respects 3see


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some local health departments and was supplemented by information from the

federal #ce of Personnel anagement and the B"&" (epartment of (efense" 't the

state le.el, only one state was able to report on worers throughout the state

go.ernment"


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/t does not include those physicians woring in other go.ernmental agencies with

public health responsibilities, a problem common to se.eral of these reports"

/t does not include physicians with board certi8cation in other specialties woring in

public health agencies, a group that includes many with specialty certi8cation in

pediatrics, infectious diseases, emergency medicine, and more"

The tremendous di6erences in the data sources, time frames, and de8nitions used

in these .arious reports prohibit any meaningful integration or interpretation of the

numbers of public health physicians7 challenges to any one of the methods used

can easily be de.eloped and thus prohibit the arbitrary use of any one of them" /n

determining the si-e of the current public health physician worforce, the

committee relied most hea.ily on %numeration 2111 and 5$& data since they are

most complete" These two most useful resources pro.ide widely di.ergent numbers:

%numeration 2111, approximately G,1117 5$&, 22,111" 5ecause the 5$& data include

physicians in other than public health positions and physicians with other than

public health speciali-ation, the committee determined this was an o.erestimate"Howe.er, the %numeration most liely undercounted because categori-ation was by

Cob title, and physicians are employed under titles such as commissioner, director,

super.isor, epidemiologist, and sur.eyor as well as physician and public health

physician" Taing into account the number and si-e of agencies at all le.els of

go.ernment, stang patterns both reported and nown to members of the

committee, and indications from agencies about le.els of .acancies, the

committeeFs considered opinion is that an estimate of 91,111 is reasonable, and

could be used until such time as an impro.ed data system is in place"

H# 'N; PB5$/< H%'$TH PH;&/


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physicians" *urthermore, according to +lass 321114, the numbers of physicians in

public health and pre.enti.e medicine is decreasing"

Table 2"2 presents the committeeFs estimates of both the current number of public

health physicians and the number needed to achie.e an

T'5$%" 2"2 %stimated Present and *uture Numbers of Physicians in +o.ernmental

Public Health 'gencies

'gency

Present

*uture

*ederal 3public health and other4

,111

,I11OI111

&tate 3public health and other4

2,111

2,I11O>,I11

$ocal

91,111O9I,111

Nonspeci8ed

,111

Total

91,111

9,111O2>,I11

ade!uate supply" The committee bases its estimates on the assumption that public

health would be ser.ed best by physician participation in the public health

leadership team, both at the agency le.el and in maCor programmatic areas" The

committee belie.es that these 8gures present conser.ati.e estimates, gi.en the

continuing increase in public health0related nowledge and the demands for a high


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le.el of public health practice that cannot be accomplished without an ade!uate

public health physician presence throughout the go.ernmental public health

system" The estimates tae no account of the potential need for increases in the

numbers of public health physicians in other areas of medical practice"

The committeeFs best estimate of the current number of physicians in state andlocal public health agencies is in excess of 2,111, or approximately 1 per state"

&eparation of the numbers of public health physicians at the state and the local

le.els is not possible at present" *urthermore, the current number of public health

physicians woring in state and local go.ernmental positions is liely greater than

2,111 because of the large number 3,1114 of public health physicians reported to

wor in positions not speci8ed by le.el of go.ernment" &ome of these physicians

liely wor in ocial public health agencies"

/t is liely, howe.er, based on the minimal data a.ailable regarding understang

presented earlier in this report and on the committeeFs expert opinion, that state

public health agencies, except for those ser.ing .ery small populations, need morephysician participation, perhaps as many as 91 more in ey leadership positions in

the state agency 3>J states 91 physicians Q >J14" 'n additional 91 physicians

might be needed in speciali-ed programs in health departments 3for example, in

clinical ser.ices programs4 in these same states 3>J states 91 physicians Q >J14"

The committee chose to designate states with populations of less than 9"I million as

states that ser.e ?.ery small populations"@ #f the I1 states in the Bnited &tates, 92

ha.e populations of less than 9"I million 3/nfoplease" 211" Population by state"

http:www"infoplease"comipa'###EJG"html Laccessed arch 9, 211M4"

*inally, a further 91 or more would be needed in other agencies in these states that

perform public health functions, such as mental health and en.ironmental health

agencies 3>J states 91 physicians Q >J14" This would bring the estimated total

number of physicians needed for state public health agencies to >,91 32,111

current physicians S 9,91 additional physicians4" +i.en that these 8gures are not

exact, the committee has chosen to adopt a range for estimated need of 2,I11 to

>,I11"

*or local health agencies, it may be that .ery small health agencies might

successfully be ser.ed by fewer physicians" *or example, the 9,J11 local healthdepartments 3$H(s4 ser.ing less than 911,111 people might ha.e only one to two

physicians 39,J11 $H(s two physicians Q >,G114" Howe.er, the I11 local health

departments ser.ing larger populations might well ha.e a need for the same I to 91

physicians in leadership positions needed by states 3I11 $H(s 91 physicians Q

I,1114, as well as an additional 91 in programmatic areas 3I11 $H(s 91

physicians Q I,1114" The estimated total number of physicians needed for local

public health agencies, then, would be 9>,G11" 'gain, because of the lac of speci8c


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data, the committee has chosen to express the estimated number of physicians

needed in $H(s as a range from 91,111 to 9I,111"

&uch numbers would bring the estimated potential total number of public health

physicians need for state and local public health agencies to between 92,I11 and

9J,I11"

5y using the same leadership and programmatic criteria outlined abo.e, the federal

public health agencies 3primarily the B"&" (epartment of Health and Human

&er.ices and the B"&" (epartment of (efense, with smaller numbers in the

%n.ironmental Protection 'gency and the B"&" (epartments of 'griculture, $abor,

and )eterans '6airs4 could need ,I11 public health physicians 3an increase of I11

o.er the current estimate4" $ooing at all of these estimates, the estimated number

of physicians needed in go.ernmental public health agencies ranges from 9,111 to

2>,I11" +i.en the diculties in accurately estimating the number of public health

physicians in practice today, as well as the diculty of extrapolating that number to

the number re!uired to meet future needs, the committee has chosen to use expertopinion, as described abo.e, to arri.e at the conclusion that the country needs

21,111 physicians in public health careers, an increase of 91,111 o.er the current

number engaged in public health careers" The number 21,111 pro.ides a more

comfortable margin that allows the inclusion of the public health physicians needed

by community partner agencies, such as .oluntary health associations, infection

control physicians employed by hospitals or health care systems, and physicians

employed by academic institutions, such as schools of medicine or public health"

The committee is !uite aware that greater accuracy in estimating these numbers

could be achie.ed if regular, comprehensi.e enumeration e6orts were undertaen"

/t is also essential to plan for the replacement of physicians lea.ing the publichealth worforce because of retirement or for other reasons" /f it is assumed that an

a.erage career path in public health is 9I years 3which is based on the assumption

that some physicians enter the 8eld late in their careers4,I the country needs

approximately 9,>I1 properly prepared public health physicians e.ery year to

replace those lea.ing the existing worforce" This 8gure is arri.ed at by di.iding the

estimated number of physicians needed 321,1114 by the estimated a.erage length

of a career in public health 39I years4" The resulting number of 9,>>> has been

rounded to 9,>I1" Therefore, once the desired number of 21,111 public health

physicians in go.ernmental agencies is reached, the system must ha.e the capacity

to train at least 9, >I1 new physicians each year to replace those lea.ing publichealth careers"


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identi8ed three broad groups of physicians who are considered to practice public

health: all physicians, those who practice public health for a limited amount of time

or in a limited role, and physicians who choose a career in public health" 's can be

seen from the preceding discussion in this chapter, estimating the number of

physicians currently in public health careers, as well as the number needed for an

ade!uate worforce, is hampered by a lac of data"

'lthough .arious attempts ha.e been made to collect data on the number of public

health physicians practicing in the Bnited &tates, each is Aawed in di6erent ways,

which maes it extremely dicult to estimate accurately both the current pool of

public health physicians and the desired number" This, in turn, impedes e6orts

aimed at planning for the numbers and inds of training programs needed to

prepare physicians for e6ecti.e public health practice" Therefore, the committee

recommends that the B"&"


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the well0being of the B"&" population are too important to allow the current

uncertainty about the public health worforce to continue"

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