American Board ofPreventive Medicine

Careers in Preventive Medicine

in the 21st Century

Cheryl S. Barbanel, MD, MBA, MPH, FACOEM

Boston University School of Medicine

Public Health Achievements and

Current Public Health Issues

Ten Great Public Health Achievements -United States 1900 - 1999

MMWR 4/2/99/48(12);241-243.

Vaccination Motor-vehicle safety Safer workplaces Control of infectious

diseases Decline in deaths from

coronary heart disease and stroke

Safer and healthier food Healthier mothers and

babies Family planning Fluoridation of

drinking water Recognition of tobacco

use as a health hazard

Leading Causes of

Death

Death Rate for Infectious

Diseases

Emerging Disease Issues

Antibiotic resistance Foodborne and Waterborne Diseases Vectorborne and Zoonotic Diseases Disease transmission by blood Chronic diseases caused by infectious agents Vaccine development and use Travelers, immigrants, and refugees and disease

transmission

Environmental Conditions Favoring the Spread of Infectious Disease

Globalization of the food supply Development projects that alter the habitat

of disease carrying insects and animals Increased human contact with the wilderness

habitat that may harbor unknown infectious agents

Increased use of antimicrobial agents and pesticides hastening resistance

Demographic Conditions Favoring the Spread of

Infectious Disease

Population growth and movement due to man made and natural disasters

Global travel

Human behaviors such as intravenous drug use and risky sexual behaviors

The Role of Physicians in Public Health in Biological and

Chemical Terrorism CDC calls for integrated training designed to

ensure core competency in public health preparedness and the highest level of scientific expertise on local, state and federal levels

The proportion of students of public health who were physicians declined from 35% in 1944 to 11% in 1978

What is Preventive Medicine?

Preventive medicine physicians work with large population groups as well as with individual patients to promote health and understand the risks of disease, injury, disability and death.

Prevention

Primary Prevention - preventing the occurrence of disease and injury, for example by immunizations.

Secondary Prevention - early detection and intervention, by reversing, halting or retarding the progression of a condition.

Tertiary Prevention - minimizing the the effects of disease and disability by surveillance and maintenance to prevent complications.

Preventive Medicine Competencies

Biostatistics Epidemiology Environmental and occupational medicine Planning, administration, evaluation of health

services Social and behavioral aspects of health and

disease Practice of prevention in clinical medicine

Careers in Preventive Medicine

Global environmental risk assessment

Health care systems

Prevention and control of infectious diseases

Preventive Medicine Physicians Have Key Roles In:

Careers in Preventive Medicine

Aerospace Medicine

Occupational Medicine

Public Health/General Preventive Medicine

Preventive Medicine Physicians May Specialize In One of Three Areas:

Where Do Preventive Medicine Physicians Work?

Public health agencies Community agencies Outpatient and primary care settings Industry Managed care organizations Academia

What Do Preventive Medicine Physicians Do?

Initiate programs in the infectious disease prevention and control

Manage programs in public and community health and research

Provide patient care (nearly 70%) Identify health and safety hazards in the workplace

to prevent illness and injury Work to improve preventive health services in the

underserved and high risk populations

The Public Health Physicians

Direct multidisciplinary teams to provide health services on the city county or state level

Plan community intervention programs (e.g. vaccination programs)

Serves on task forces that solves community problems

Provides clinical services in traditional public health areas - tuberculosis, sexually transmitted diseases, or primary care settings

International Health Preventive Medicine Physician

Assess Disease Risks for the Global Environment

Diseases that have no respect for national boundaries: AIDS/HIV and tuberculosis

Diseases more common in developing countries: malaria, cholera

Diseases associated with under-nutrition

Preventive Medicine Physicians in Medical Administration

Serve as director of health departments and corporate medical departments

Work as managers of HMO’s or group practices, community-based clinics or university-based health centers

The Preventive Medicine Physician in Academic

Medicine Research and teach in medical schools, public

health schools, and other institutions Teach clinical prevention, epidemiology, and

health services administration Research prevention of HIV and TB

transmission, cancer, and the role of life style modification in prevention of disease

Preventive Medicine Physician in Clinical Practice

Identifying risk factors and methods of intervention for chronic, occupational, infectious disease and/or sexually transmitted diseases

Develop practice guidelines, quality assurance and utilization review programs

Practice medicine in primary care, sports medicine, exercise physiology, behavioral epidemiology, addiction medicine, geriatrics or maternal and child health

American College of Preventive Medicine (ACPM)

National medical specialty society for physicians committed to disease prevention and health promotion

Represent more than 2,000 physicians boarded in preventive medicine and other specialties (e.g., family practice, internal medicine, pediatrics, emergency medicine, psychiatry, etc.)

Leadership in the science, policy, and practice of preventive medicine

Preventive Medicine Trends and

The Public Health Workforce

Public Health Workforce Physician Trends

Small number of certified specialists in Public Health / Preventive Medicine

Decline in proportion of self-designated preventive medicine specialists among U.S. physicians

Decline in total number of preventive medicine residents with greatest decline in number of public health residents

Aerospace Medicine 922Occupational Medicine 2563Public Health and / or General Preventive Medicine 2839 TOTAL 6324Unduplicated* living diplomats 5966

*Counts those with multiple PM certifications only once

American Board of Preventive Medicine Living Diplomats by Certifications

2000

Year Programs Residents 1993 82

4411994 85

4481995 89

434 1996 89

381 1997 89 438 1998 90 4201999 88 426 *

Source: AMA GME Database, copyright 1993-1998, Chicago IL

Preventive Medicine Residency Training

1993 - 1999*

Distribution of Residents in Preventive Medicine Programs

Occupational 34%

Public Health16%

General Preventive

35%

Aerospace15%

Needed Incentives to Address Public Health Workforce Trends

Include preventive medicine explicitly in specialty mix to meet national workforce needs

Support for infrastructure departments of preventive medicine in medical schools

– Health departments– Schools of public health / graduate MPH programs

Preserve loan forgiveness for preventive medicine trainees

– Add tuition reduction for academic year

Funding Sources for Preventive Medicine Training Programs

Federal• HRSA • VA• NIOSH• CDC• HCFA• NASA• NIH• DoD• NASA

State/Other• Health agencies• Public health schools• University medical

centers• Foundations• National health

organizations• Private industry

COGME Resource PaperPreventive Medicine Workforce

Recommendations: Increase the number of physicians with public

health competencies

Increase funding of preventive medicine residents, programs, faculty and faculty development

Increase funding through Title VII, Medicare GME, and National Health Services Corps scholarships

http://www.cogme.gov/resourcemain.htm

Occupational and Environmental MedicineA Medical Career for the 21st Century

The specialty devoted to the prevention and management of occupational injury, illness, disability, and the promotion of health and productivity.

Occupational Medicine

The branch of medical science devoted to the prevention and management of adverse health outcomes from exposure to chemical or physical agents in the home and community or their effect on the environment.

Environmental Medicine

The U.S. Workforce

• U.S. Population, 270.4 million

• U.S. Workforce, 137.2 million

• Persons employed, 131.1 million

• Employee to population ratio, 48.5%

• Male workforce, 55%

• Female workforce, 45%

Source: US Bureau of Labor Statistics 1999

Non-Fatal Occupational Injuries

Overexertion 27.7%

Contact with objects 27%

Falls 16.2%

Exposure to toxics 4.6%

Repetitive motion 4.1%

Transportation accidents 4%

Slips/trips 3.1%

Assault 0.9%

Fires/explosions 0.2%

All other 11.9%Source: Bureau of Labor Statistics 1999

8,000,000 per year

Occupational IllnessDisorders associated withrepeated trauma 64.3%

Skin diseases, disorders, 13.4%

Respiratory conditions due totoxic agents, 4.7%

Disorders due to physicalagents, 3.8%

Poisoning, 1.1%

Dust diseases of the lungs,0.6%

All other occupationaldiseases, 11.7%

Source: Bureau of Labor Statistics 1999

429,800 Per Year

The OEM Physician Workforce

AMA estimates 10,000 physicians who do some occupational medicine

2,400 Board-certified occupational medicine physicians since 1955

1,500 - 1,800 are actually in practice National need - 5,000 Bureau of Health Professions needs estimate - 4,830 Institute of Medicine needs estimate - 3,100 - 5,50

Institute of Medicine’s Report Safe Work in the 21st Century

Recommended an increase in the supply of physicians and other practitioners who have the skills to evaluate, treat and prevent ill health in the workplace

OEM Sites of Practice Physician’s office OEM clinic Multi-specialty clinic Industrial site Corporation headquarters Academic institution Governmental agencies

– Public health service– Veteran’s Administration– Military– Department of Labor– Centers for Disease Control

and Prevention

The Occupational Medicine Residency Program

Year 1: The clinical year (internship) Year 2: The academic year (M.P.H., M.S. or equivalent)

Biostatistics and epidemiology Health services organization and administration Environmental and occupational health Social and behavioral influences on health Industrial hygiene Ergonomics Industrial toxicology Occupational diseases

Year 3: The practicum year (study with industry)

The Practicum Year Didactic education and topics

of occupational medicine importance

Participate in data gathering and analysis

Four months or more engaged in supervised practice within the world of work

Clinical care of workers Management responsibilities

in planning, administration and supervision of occupational medicine programs

• Broad scope of practice

• Variety of practice settings

• Treatment of individual workers

• Population-based preventive medicine

• Resource for regulations and policies

Characteristics of the Occupational and Environmental Medical Specialty

• Effective use of health care resources

• Compliance with government rules and regulations

• Technological advancement and shifting work force demographics

• Social, ethical and moral attitudes

• Global industrial development and its impact on the work force

Challenges Facing Occupational and Environmental Medicine

An exciting, challengingcareer awaits the occupational andenvironmental medicine physician in the 21st century

Aerospace Medicine

The specialty area of Preventive Medicine that deals with the clinical and preventive medical requirements of man in atmospheric flight and space

Aerospace Medicine Definition

Initially this was driven by a need for qualified military pilots to fly planes in war

The Flight Surgeon

Main function was to first develop and then apply physical qualifications for flight duty

Driven by high losses of life due to physically unqualified pilots

The Flight Surgeon’s Role

After World War II the technological advances were applied to the airline industry. Increases in aircrew led to increases in civilian aviation medicine.

History

In the 1960’s advances were made to meet the challenge of manned flight beyond the earth’s atmosphere. . .Aviation Medicine evolved to Aerospace Medicine

History

Aerospace Medical IssuesRelated to the Requirements of

Flight and Space Trapped air Sinus block Ear block Decompression

sickness Effects of acceleration

forces

Spatial Disorientation Zero Gravity Motion Sickness Cardiovascular Neurovestibular Musculoskeletal Psychiatric

Initially one must first be a physician– Medical School– Internship

Then must decide if you want to…– Do a residency in Aerospace Medicine

» Civilian» Military

– Or attend a short course that will permit you to do flight medicine in the military

– Or be an Aviation Medical Examiner as a civilian

How to Become a Flight Surgeon

Military– Air Force, Navy, and Army offer courses that range

from 6 weeks to 6 months that prepare you to be a field flight surgeon. (Most of the actual learning in this occurs on-the-job)

– Emphasis is on being a member of the aircrew so that you can interact with aircrew in their environment

– Requires that the physician meet same physical standards that the aircrew must meet and participate in regular flying duties

Short Courses

FAA offers training programs for the position of Aviation Medical Examiner (AME) through seminars throughout the US and through formal on-site training at the Civil Aviation Medicine Institute (CAMI) in Oklahoma City.

Qualifies the physician to perform Class 2 examinations.

Civilian

Offered both by the military (Navy and Air Force) and by two civilian universities:

» University of Texas Medical Branch (UTMB) at Galveston» Wright State University in Dayton, Ohio

A year of ACGME-accredited clinical training is required for admission to the residency.

Each residency program includes an initial year of training to obtain a masters degree in public health and a practicum year covering the physiologic, environmental and clinical aspects of Aerospace Medicine.

Residency in Aerospace Medicine

After completing a residency in aerospace medicine and

Qualifying for and passing the American Board of Preventive Medicine Examination,

Board certification can be achieved in the specialty of Aerospace Medicine.

Board Certification in Aerospace Medicine

There are many problems with the abnormal environment encountered in aviation and space. The flight surgeon is just one of many highly trained individuals working to minimize the effects of these adverse effects so that man can continue to have mastery over the air and space.

Aerospace Medicine

Incorporated in 1948 Authorized by American Board of Medical

Specialties 1949 First Certificate Awarded in 1949

American Board of Preventive Medicine

General Certificates• Aerospace (1953-2001) 1266• Occupational (1955-2001) 3026• Public Health/General Preventive (1983-2001) 1623• Public Health (1949-1982) 1866• General Preventive (1960-1982) 547

Subspecialty Certificates• Undersea Medicine (1993) 10• Medical Toxicology(1995-2000) 23• Undersea and Hyperbaric Medicine (2001) 78

TOTAL (1949-2001) 8439

Certificates Issued 1949 - 2001

Provide assurance to the public Physician specialist certified by a Member Board of

ABMS has successfully completed– An approved educational program and evaluation

process– An examination designed to assess

Knowledge, skills and experience required to provide quality patient care

Why Board Certification

Medical School Graduate

Current Unrestricted License(s)

Clinical Year of Training (PGY-1)

Academic Year (MPH or equivalent)

Practicum Year Currency of Practice Practice (Alternative

and Special Pathways)

WHAT ARE THE REQUIREMENTS

Available only for medical school graduates prior to January 1, 1984

Must document training and experience Academic:

– Four Core Courses» Biostat., Epi., Admin./Mgmt., Env. Health

Practice Experience

Alternative Pathway to Certification

Guidelines approved by both boards in January 1993 Update to Guidelines in preparation

At least four years formal training Three programs approved by both boards Must be accredited by both residency review

committees Requirements for practicum experience Continuity of care requirements Potential for similar combined training with other

specialties

Combined IM/PM Training Programs

Joint effort with Emergency Medicine & Pediatrics

Approved by ABMS in 1992 Subboard established in 1992 Actions approved by Parent Boards

Medical Toxicology

Undersea Medicine– Approved by ABMS in 1989– First examination given in 1992– Name change to Undersea & Hyperbaric

Medicine approved March 18, 1999– Exam open to other ABMS diplomates– Exam given annually starting in November 1999

Undersea and Hyperbaric Medicine

GENERAL– Certificates Issued in and after 1998

are Time-Limited to 10 years– Valid ABPM Specialty Certificate – Unrestricted License in U.S. or Canada– Application: Requirements of ABPM

consistent with ABMS

Re-certification Requirements

Re-certification Requirements

SPECIFIC- Maintenance of Certification (ABMS)

- Professional Standing- Lifelong Learning & Self-Assessment- Cognitive Expertise (Examination)- Practice Performance Assessment

What is Available?– Application Forms– Information Book– Frequently Asked Questions & Answers– Study Guide & Exam Content Outlines

http://www.abprevmed.org

ABPM WWW Home Page

American Board ofPreventive Medicine

330 South Wells Street

Chicago, IL 60606

Tel: 303-939-ABPM [2276]

Fax: 312-939-2218

Residency Program

History

ACGME Status

Format

Linkages

Academic Year

Practicum Year

Resources American Board of Preventive Medicine

www.abprevmed.org American College of Occupational and

Environmental Medicine www.acoem.org Aerospace Medical Association www.asma.org American College of Preventive Medicine

www.acpm.org American Public Health Association www.apha.org Association of Teachers of Preventive Medicine

www.atpm.org

Resources (con’t) HRSA/Bureau of Health Professionals

www.bhpr.hrsa.gov Association of Schools of Public Health

www.asph.org Association of Preventive Medicine Residents

www.acpm.org/apmr/htm Accreditation Council for Graduate Medical

Education www.acgme.org American Medical Association Fellowship and

Residency Interactive Electronic Database www.ama-assn.org/cgi-bin/freida/freida.cgi

Sources of Information American College of Preventive Medicine American College of Occupational and Environmental

Medicine Aerospace Medical Association “Preventive Medicine and Public Health Workforce

Trends: Threats and Solutions”, a presented at Prevention 2000 by Dorothy S. Lane, M.D., M.P.H.

CDC’s Ten Great Public Health Achievements – United States 1900-1999

www.cdc.gov/epo/mmwr/preview/mmwrhtml/00056796.htm

Acknowledgements

Thanks to the members of the ABPM Client Services and External Relations Committee for their support and assistance with this presentation.

Thanks to Ms. Yolanda Rodriguez and Mr. Michael Moskowitz, staff of the Boston University Occupational Health Center for their administrative assistance.