Residency Training in Preventive Medicine - American Journal of ...

Teaching Preventive Medicine

Residency Training in Preventive Medicine Challenges and Opportunities Alan M. Ducatman, MD, MSc, James M. Vanderploeg, MD, MPH, Mark Johnson, MD, MPH3,, Judith Rubin, MD, MPH, Philip Harber, MD, MPH, Rosemary Sokas, MD, MOH, Robert G. Harmon, MD, MPH, Peter Rumm, MD, MPH, Elizabeth Nilson, MD, Paul Batalden, MD, Glenn Merchant, MD, MPH, USN, Margot Krauss, MD, MPH, COL, MC, Robert L. Goldberg, MD, Michael Valdez, MD, MPH, S. Edwards Dismuke, MD, MPH, Gregory R. Wagner, MD, Karyn Leniek, BS, Jill Rosenthal, MD

Introduction

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ith the assistance of senior leadership of the Accreditation Council for Graduate Medical Education (ACGME), the Residency Review Committee (RRC) in preventive medicine and invited guests considered the status of residency training in preventive medicine. Data concerning the number of trainees in preventive medicine document disappointingly small growth rates and underutilization of residency positions, but no crisis. Challenges lie ahead in three domains: quality, clinical competence, and funding for training. Specialty training should focus on quality, particularly in the interface between clinical competence and population health competence. Funding for preventive medicine training is inadequate, particularly in light of federal and state initiatives focusing on an all-hazards approach to disaster pre-

From the Department of Community Medicine, School of Medicine, West Virginia University (Ducatman), Morgantown, West Virginia; American Board of Preventive Medicine (Vanderploeg, Merchant), Chicago, Illinois; Residency Review Committee in Preventive Medicine (Ruben, Harber, Nilson, Merchant, Krauss, Valdez); Jefferson County Department of Health and Environment (Johnson), Golden, Colorado; Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine (Rubin), Baltimore, Maryland; Division of Occupational and Environmental Medicine, Department of Family Medicine, University of California at Los Angeles School of Medicine (Harber), Los Angeles, California; Department of Environmental and Occupational Health Sciences, University of Illinois School of Public Health (Sokas, Rosenthal), Chicago, Illinois; Ingenix United Health Care Group (Harmon), Eden Prairie, Minnesota; Center for Public Health Readiness and Communication, Drexel University School of Public Health (Rumm), Philadelphia, Pennsylvania; Preventive Medicine Residency, New York Presbyterian Hospital, Weill Cornell Medical College (Nilson), New York, New York; Health Care Improvement Leadership Development, Dartmouth-Hitchcock Medical Center (Batalden), Hanover, New Hampshire; Department of Defense Center for Education and Research in Patient Safety (Merchant), Bethesda, Maryland; Walter Reed Army Institute of Research (Krauss), Silver Spring, Maryland; Division of Occupational and Environmental Medicine, University of California at San Francisco (Goldberg), San Francisco, California; University of Kansas School of Medicine (Dismuke), Wichita, Kansas; National Institute for Occupational Safety and Health (Wagner), Washington, DC; and University of Illinois College of Medicine (Leniek), Rockford, Illinois Address correspondence and reprint requests to: Alan M. Ducatman, MD, MSc, Professor and Chair, Department of Community Medicine, School of Medicine, West Virginia University, P.O. Box 9190, Morgantown WV 26506. E-mail: [email protected].

paredness, a strength of the specialty. To address the needs of the public and the future of the specialty, preventive medicine should clearly articulate its values and the value it adds. Two ideas emerged to address quality, clinical competence, and, perhaps, the ongoing problems of inadequate funding. Neither idea is unique to these deliberations. One idea is an increased emphasis on dual boards, so that numerous specialties have increased access to population medicine and prevention skills. This approach augments our current strengths, and relies on other disciplines to supply much of the clinical context, the area where preventive medicine is weakest. This approach links funding to a specific model of training. The other approach is an additional required year (PG-4) of training for residents to ensure clinical outpatient and systems skills. These considerations are not mutually exclusive, nor are they promulgated as policy; other considerations are welcome. They are intended to start a discussion, the goal of which is to “raise the bar” for training. They, and all future suggestions, should increase quality, public confidence, and job market desirability of certificate holders. Both proposed approaches challenge prospective residency candidates to consider careers in population medicine and prevention, and funding agencies to provide the needed support.

Purpose This article is targeted to those who are interested in preventive medicine training, and the relationship of training to the future of the specialty. In 1984, Douglas Scutchfield1 wrote: “It appears that the specialty of preventive medicine is declining as a viable specialty, with inadequate numbers of practitioners and with a declining number of physicians entering residency training.” Recent literature documents ongoing malaise,2– 4 and includes such topics as clinical credibility, market demand and compensation for preventive medicine services, career opportunities for preventive medicine clinicians, federal support for training, the small

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numbers of trained specialists, and public awareness of the contributions of preventive medicine physicians. Board certification is a widely regarded quality measure.5 The number of board-certified practitioners is a function of training, and formal training is essential infrastructure for a viable medical specialty. The requirements, structure, funding, and future paths of preventive medicine training will fundamentally influence the numbers, activities, social utility, and preparation of qualified practitioners. The goal of this paper is to stimulate a specialty-wide conversation to develop a consensus for an improved model for the future of specialty training in preventive medicine.

The Specialty of Preventive Medicine: What Do We Add? The American Board of Preventive Medicine was created in 1948 for the purpose of providing a home for teachers of clinical prevention.6 Today, preventive medicine includes this original goal and links individual care to population-based services and measures. Well-trained physicians bring unique and irreplaceable clinical competence to prevention science, and welltrained population scientists bring a needed perspective to clinical care. Their skills and service to patients and to the public’s health justify and illuminate the existence of our discipline. While other specialties are also heavily invested in evidence-based clinical prevention, preventive medicine is unique because its constant, central focus is on population health. The preventive medicine discipline pioneers and utilizes health services technology to improve the health of the patients and populations we serve. Preventive medicine is in a position to work closely with other specialties because of its strength in clinical health systems, population (health) outcomes, and public health. Disciplines can be distracted into beliefs that their chief purpose is to improve the lives of their specialists, or to increase the power of the discipline. A focus on protecting the specialty of preventive medicine, or a focus on increasing its numbers independent of a clear demonstration of its value, can lead only to a downward spiral in relevance and reputation. Viable growth and any increase in prestige will spring from clear public and professional recognition that the specialty of preventive medicine addresses core health needs of populations. A challenge for the discipline is a substantial discrepancy between goals and demonstrable accomplishments. Consider these twentieth-century triumphs of public health in the United States: immunization, control of infectious diseases, motor vehicle safety, safer workplaces, decreased coronary heart disease and stroke mortality, safer and healthier foods and water 404

(including fluoridation of drinking water and improved dentition), healthier mothers and babies, family planning, and recognition of tobacco as a health hazard with targeted individual and community intervention to decrease exposure.7 Preventive medicine has contributed across the spectrum of these public health triumphs, yet it is not necessarily the driving force for most. Medical colleagues and the American public are likely to attribute the clinical aspects of workplace safety, and perhaps the recent successes in influencing environmental tobacco smoke policy in public places and workplaces, to preventive medicine, with other positive outcomes largely attributed to other disciplines. Health care and population health are increasingly interdisciplinary activities. Preventive medicine is intentionally adept in interdisciplinary environments, and need not seek sole credit for progress. An absence of public recognition is, however, an accurate reflection of the need to carefully articulate the role of preventive medicine, to temper language about professional expectations and achievements of practitioners, and to project clearly and without exaggeration the nature of its value to society. Preventive medicine can also take substantial credit for a cultural shift in American medical thought about the value of evidence, and the need for understanding the quality of evidence. Clinician teachers for this topic have come largely from preventive medicine for more than 50 years. The creation of practice guidelines requires clear-eyed evaluation concerning the availability, quality, and appropriate use of evidence. This ascendance of the prevention perspective harkens back to the rationale for the formation of the specialty.6 In turn, an implication of this success is that many others now share a prevention niche. No other medical specialty features a central focus on population medicine, and all medical disciplines must be involved to make needed progress. Preventive medicine training must prepare residents to perform within a specialty-dominated and evidencebased healthcare structure. Preventive medicine certificate holders must also be competent clinicians, that is, experts in implementing preventive services and analyzing the impact of clinical systems on individual health care and population health outcomes.

Preventive Medicine Specialty Roles Specialties may be characterized by an organ system, a disease process, a technically assisted evaluative process (e.g., pathology), or patients sharing demographic characteristics.2 The preventive medicine specialties are characterized by process (clinical prevention) and patient demographics (workers, other populations). Three nominal specialty areas address four generic roles in preventive medicine. The American Board of Preventive Medicine Web site (www.abprevmed.org/)

American Journal of Preventive Medicine, Volume 28, Number 4

lists core competencies that are common across the disciplines, and competencies that are unique to each. In 1983, the fields of general preventive medicine and public health were combined (GPM/PH) because of the substantial similarity in Part II of their board examinations, although practice distinctions persist.6 Some GPM/PH specialists choose public health careers, that is, formal activities of local, state, or federal government. Public health clinical practitioners may deal with health needs of indigent populations, surveillance, immunization and infection control, disaster planning, and environmental concerns in “routine” times. These essential planning and maintenance roles may swing toward coordinating population health response in times of disease outbreaks or disasters. The other general preventive medicine/public health practitioner, the general preventive medicine specialist who does not work in a governmental public health agency, has a less-defined role. Substantial overlap with the work of competent generalists in other specialty disciplines is noted. Some serve insured population groups or provide health services analyses. Some preventive medicine specialists teach public health and epidemiology at schools of medicine or public health, the original rationale for founding the specialty. Less clear is whether the distinctive roles of general preventive medicine and public health have been well served by combining them into a now 20-year-old “marriage of convenience.” A possibility is that they have distinct training needs. Occupational medicine practitioners have a defined role in the health care and prevention of disease in workplaces and other potentially unhealthy environments. They also bring expertise in benefits, etiologic causation, and disability determination to insurance. Aerospace medicine serves similar functions for a specific work population, and is tied closely to federal military and space activities. Both occupational medicine and aerospace medicine have diverse, yet clear roles in the care of working or recreational populations. Clinical practice in occupational and aerospace medicine is supported by federal or state requirements for population care, such as Occupational Safety and Health Administration and Federal Aviation Administration regulations. Aerospace medicine and occupational medicine designate unique competencies in early hazard recognition, early diagnosis of environmental disease, and effective hazard mitigation or specific treatment of outcomes of exposure. Both have firm identities. The current structure of preventive medicine reflects history, but perhaps not actual function within the spectrum of specialty care, and on behalf of society. One view of the three (or four) disciplines is that they came together out of necessity to achieve board status, and share common principles and some common goals, but they do not yet plan together consistently, or

well. Training requirements should be more coherent and better defined. There is a substantial opportunity for planning based on societal value and specialty goals in population health. A recent ACGME emphasis on competencies has altered residency training paperwork in all specialties; it has not yet aligned the training with values, goals, essential skills, or future practice patterns of preventive medicine trainees. The absence of a conjoined professional meeting that is equally attractive to all preventive medicine disciplines is both a reflection on the status of the disciplines, and a significant barrier to planning for evolution in training, a necessary characteristic of any medical specialty.

Specialty Size and Market Demand The present size of the training pool and the present/ future market demand for new board certificate holders vary for the preventive medicine specialties. The job market for aerospace medicine physicians is small, stable, and easily filled by candidates whose training has been funded and controlled by federal military and space needs. For practical and operational reasons, many aerospace trainees also receive training and/or certification in occupational medicine. This dual certification route has addressed the possible aerospace specialty oversupply in the civilian market. It has also improved the quality of training and broadened the expertise provided at federal aerospace facilities, which are substantial, highly technical industrial operations. A diverse job market attracts residency-trained occupational physicians, dual- or single-certified aerospace physicians who enter occupational medicine after their federal careers, and general preventionists who find opportunities in managing workplace health. It also attracts a variety of generalists and specialists from other disciplines within organized medicine, who practice some aspects of occupational medicine part-time or full-time. Some of these doctors, aware that their practice features specialty care for which they are neither trained nor certified, desire the opportunity to obtain board certification. This goal is sometimes articulated in the context that it be achieved during full-time employment. Accommodation of this request by untrained physicians who provide occupational medicine services, and who desire to become board certified “in place,” is a question that has occupied those planning for preventive medicine training for the past decade, usually framed in the context of meeting or creating “pipeline needs” for more specialists. The question should be addressed in the larger context of how to identify the value of preventive medicine, and how to upgrade training in general. The number of full-time, trained occupational medicine specialists required to meet national needs is Am J Prev Med 2005;28(4)

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unclear. More than a decade ago, a widely cited Institute of Medicine8 report projected a markedly increased need for occupational physicians. This job marketplace did not come to pass. Care for injured workers is frequently provided as the sum of part-time efforts by many physicians in local niches,9 and therefore may not be pertinent to residency training. The training needs of physicians who provide some intermittent occupational medicine services may reasonably center on better exposure to workplace issues during medical school, or during residencies in other specialties. An aggressive continuing medical education (CME) stance by appropriate professional organizations seems well suited to this need. The creation of a more formal, intermediate certificate of added competence may be an important nonspecialty credential for practitioners who want training without career disruption. The employment base for occupational medicine specialists has evolved from an industrial base to a primarily clinical base, often in a multispecialty freestanding clinic or hospital-affiliated setting.10 This ongoing migration of planning and care to the outpatient clinic suggests a strong need for both clinical and population competence in order to inform patient care, health services, and policy roles in a clinical setting. Yet, it is unclear that residency training requirements adequately emphasize clinical competence, including mastery of patient care and of the systems that support patient care. Further, the classic public health paradox may constrain the clinical job marketplace— successful policies drive substantial decreases in “classic” occupational injuries and illnesses, and may lead to declining interest in specialization by physicians.2 The paradox pertains to all of preventive medicine: public health successes may result in decreased interest in the field. Occupational medicine residency graduates enter a robust and diverse employment market, requiring clinical and organizational skills for many entry-level jobs. Nevertheless, the Institute of Medicine11 has recommended re-examination of the structure and needs of existing training programs in occupational medicine, an activity consistent with the goals of this paper. The job market for specialists in the public health part of public health and general preventive medicine is problematic. Physician leadership of public health agencies at the local, state, and federal levels is regarded as essential by preventive medicine specialists. A combination of clinical and population health training should be ideal for public health enterprises. The job market reality, however, features resistance to providing salary support for clinician leadership in public health positions that often do not involve direct patient care. In addition, a reluctance of elected leadership to hear professional messages in political environments may constrain employment of physicians, who predict406

ably owe primary allegiance to patient needs. While it is essential to train doctors for this role, it will remain a discrete and limited market so long as the underfunding and politicization of public health agencies persist. Strengthened training for leadership and management may improve the palatability of important public health principles in a political environment, and mass disasters will prompt re-evaluations when they occur. The historic role of general preventive medicine in academic medicine, including training medical students in epidemiology and interpretation of medical evidence, remains clear. A potentially bright future exists for those whose general preventive medicine training prepares them to augment health services and population health expertise across clinical disciplines. This market is expected to grow as medical specialties increasingly base decision making on the best available evidence, and compete based on publicly available data concerning outcomes and quality measures. However, health services research to date has not necessarily been led by general preventionists; leadership includes specialists from many disciplines working in concert with epidemiologists, economists, or health policy experts. The future job market for general preventive medicine as a “stand-alone” discipline is not well characterized. Perhaps as a consequence, the general preventive medicine/public health programs also struggle to fund and fill residency slots. Preventive medicine residencies are accredited by the ACGME RRC for more slots than they are presently able to fund, or fill. (See Table 1, which includes both core and subspecialty programs.) Among core programs, preventive medicine had 2.1% of all residency programs in 2003–2004, and 0.4% of all residents. It is in the interest of the specialty and its funding agencies to attract new residents and to reward programs that fill their positions with highly qualified candidates.

Specialty Size: Is There a Crisis? Excess training capacity and diminishing “market share” do not imply a diminishing specialty size. Boardcertification data document that the preventive medicine disciplines have increased slightly over the past 20 years (Figure 1). Another small increase in successful certificate applications was recorded by the American Board of Preventive Medicine in 2004.12 An increase in the decade from the mid-1980s to the mid-1990s represented a cohort effect for those entitled to use an “alternative” (nonresidency) pathway to board certification (pre–January 1, 1984, medical school graduates). Annual numbers of new certificate holders have increased about 74% since 1984, and about five percent since 1995, lower than the increase for other medical specialties. Preventive medicine trainees now comprise 0.8% of all U.S. trainees in allopathic medicine.13


Table 1. Resident physician data as reflected on the Accreditation Council for Graduate Medical Education public health website, July 2004

Specialty/subspecialty Preventive medicine Selected other specialties Family practice Internal medicine Medical genetics Pediatrics Transitional year All specialties including subspecialties

Total programs

Total approved positions

Count of residents on duty

Percentage of positions filled

82

653

348a

53

477 388 47 202 131 7,968

10,505 23,949 193 8,596 1,419 111,046

9,785 21,685 82 7,742 1,274 100,176b

93 91 42 90 90 90

Source: Accreditation Council for Graduate Medical Education, available at: www.acgme.org. File under Resident Physician Population. Data provided to Center for Medicare and Medicaid Studies (CMS). Accessed November 24, 2004. a Does not count 27 preventive medicine residents in combined training. b Does not count 1991 residents in combined training.

Preventive medicine residency programs have been closing, especially programs facing funding difficulties due, in part, to reductions of federal funding and decisions to favor larger programs in the federal funding formula. Program closures have potential geographic, urban–rural, and resident recruitment consequences. The recent loss of programs reverses a previous increase of eight programs from 1993 to 1998, an increase that was not accompanied by increases in trainees (see American Medical Association Graduate Medical Education database, 1993–1998, Chicago IL). A concern exists regarding insufficient numbers of qualified applicants to support the complex logistics of an excellent certification process. The problems of slow growth are neither new nor immediately threatening, except perhaps to unfounded expectations. To address concerns, initial planning should focus on training needs and conditions rather than specialty size.

vide mentored clinical experience concurrently with the academic experience.) The final (PG-3) year of residency is the “practicum year,” designed to foster a broad range of clinical and administrative training, including external rotations away from the hospitalbased clinical enterprise. These “away” rotations are not unique in organized medicine, but their extent and emphasis on nonhospital systems represent a third vivid distinction of the field. These rotation requirements can be excellent for training and enhance the relevance of the specialty, yet they may put financial pressure on the institution because there is no returned service, and they require considerable administrative effort.

Structure and Funding of Programs The structure and funding of preventive medicine training are remarkably different from other specialties. Most residencies do not offer the PG-1 year. Thus, recruitment campaigns such as the American College of Preventive Medicine’s mentoring initiative may be limited by PG-1 placement needs of medical students. Many trainees come to preventive medicine training after a full residency in another specialty, and/or as a second career. Second, the PG-2 year, or “academic year,” consists mainly of master of public health (MPH) or MPH-equivalent coursework. This unique academic requirement provides skills in epidemiology, statistics, policy, and administration. The academic year tuition also increases the cost of training. Some state licensure boards have questioned the clinical relevance of the academic year, and even refused to count it toward licensure, limiting the options of physicians who might enter directly from internship and seek to practice in affected states. (Programs can be constructed to pro-

Figure 1. American Board of Preventive Medicine applications and exam data. *The number of examinees can exceed applications because of repeat test takers. Source: American Board of Preventive Medicine.

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The fourth unique structural element is the inadequacy of funding for residency programs, except for programs housed in the federal sector,4 such as aerospace medicine. The major source of nonmilitary federal funding of general preventive medicine/public health is U.S. Health Resources and Services Administration (HRSA) Title VII funds. However, these funds have decreased over time and currently fund only seven programs. Even while federal language praises their purpose, they are also routinely under threat for nonrenewal by the Office of Management and Budget. The Department of Veterans Affairs and the American Cancer Society have also funded some positions. Host institutions sometimes pay for resident services during off-site rotations, especially federal sites hosting resident rotations. Where funding arrangements do exist, they generally provide less than the federal payments to most other residency programs for equivalent time. Inadequate funding of general preventive medicine training is both evident and perplexing at a time when political leaders at all levels are strongly in favor of providing skill-based training pertinent to clinical prevention and disaster response. One option that has been used to a limited extent has been to partner widely with other clinical departments in multiple combined residencies in order to receive the more substantial Medicare graduate medical education funding. It is unclear whether all programs can use this promising approach. Occupational medicine residencies are funded primarily by the National Institute for Occupational Safety and Health (NIOSH), in a competitive model that can be described as a compromise between the usual HRSA funding stream in other medical specialties, and the more stringent National Institutes of Health (NIH) research fellowship model, which assumes a substantial training and research capability before applications will be considered. For successful programs, NIOSH funding has been more stable than other civilian funding in preventive medicine. NIOSH has experienced relative funding losses in the decades since its founding. Training has lost support, along with other initiatives related to worker health. The current funding formula reflects a conscious decision to favor large programs in an effort to achieve cost-effective use of scarce training dollars. A resultant recent decrease in training programs has not demonstrably decreased the total number of trainees. An essential discussion now is whether the “pruning” has achieved the desired target and whether it is time to nourish what is in place. The funding designed to support residents goes to competing programs with structures and geography that may or may not meet the individual applicant’s needs. This constraint, at least, could be addressed by transitioning resident funding to accepted applicants, rather than to programs. Program infrastructure is already inadequately funded, and should not be diminished. NIOSH 408

Table 2. Residency director turnover rates for Accreditation Council for Graduate Medical Education specialties Turnover rate (%)

2001–2002 2002–2003

2003–2004

Preventive medicine 12.94 21.18 8.54 Mean, all specialties 14.57 14.34 13.35 Range, all specialties 0–35.71 0–37.50 0–28.57 11.35 14.35 14.06 Mean, primary care specialties (pediatrics, internal medicine, family practice) Range, primary care 9.57–14.12 11.00–17.46 12.38–15.98 specialties

is currently evaluating its intramural and extramural programs, including training programs, and is considering options that include restructuring towards the NIH-research training model. Program directors in preventive medicine/public health and in occupational medicine must compete at intervals to acquire and maintain residency program funding, a time-consuming activity. It is unclear that competition for funding adds to the training experience of residents. Most other specialties attract much more than a resident salary to their institution for each resident trained, and without the labor or worry of competitive grant renewals. Preventive medicine residency directors are likely at a promotion and career disadvantage compared to colleagues in other fields who do not face this time-consuming need. Nonetheless, from July 2001 through June 2004, the average annual turnover rate of preventive medicine program directors (14.29%) was similar to the 14.09% for all ACGME residencies (Table 2). All residencies have a high turnover of directors, and preventive medicine’s turnover rate fluctuates around a problematic norm despite the handicap.

Does Our Training Match the Need? The specialty and each specialty area feature core competencies.14 Yet programs vary considerably with respect to structures, emphases, and resources. A conclusion is that training in the preventive medicine disciplines is heavily influenced by institutional factors, and a broad range of activities are acceptable to the RRC and the American Board of Preventive Medicine. By creating combined training for occupational medicine certification, aerospace medicine has upgraded its training experience and addressed job market needs of trainees. It recognized the flight environment as industrial, and created a competencies approach to include industrial operations beyond the needs of pilots, flight crews, and air carriers. It has also recognized that the post-federal careers of trainees are likely to be engaged in clinical and systems aspects of occupational health.


Occupational medicine residencies emphasize varying skill sets. Some residencies provide university-based mentorship for worker population research, reflecting the capabilities and interests of faculty. Clinical training in some programs may be provided by adjunct faculty at industrial locations or at affiliated private or hospital clinics where adjunct faculty serve a broad range of workforces. As little as 4 months of a 2-year residency may feature clinical experience, and this may include administration. The public expectation of clinical supervision15 must be addressed by occupational medicine to maintain its place as a clinical discipline, while maintaining the value of the nonclinical aspects of training. A suggestion to future physicians that other specialty training will equally serve doctors who care for workers16 illustrates the problem, and echoes sentiments of “headhunters” concerning open positions. A decision for the specialty is whether clinical care for illness and injury, and the resulting familiarity with the patient care environment, are a fundamental part of the occupational medicine repertoire, and, if not, what is the occupational medicine identity? Some general preventive medicine/public health programs have historically defined their training niche as “we are the physicians who do not see patients.” Even among our leaders and most ardent supporters, there is acknowledgment that the general preventive medicine training format leaves us vulnerable to the perception that we are not “real doctors.” Skepticism concerning this perspective may be reflected at licensure boards, by leadership decisions for medical enterprises, and in the job market. Retreat participants were not in full agreement concerning whether the job market for the GPM specialty areas qualifies as a “crisis.” It is a problem if the specialty is to grow into new medical leadership roles. The extent to which skill in individual patient care adds value to the work of addressing clinical systems and populations needs to be clarified. A concern with clinical competence also applies to the substantial skill sets of nonphysician specialists who provide some preventive services. Although preventive medicine’s commitment to clinical competence has been articulated before,17 an expanded stakeholder discussion concerning clinical competence and its place in the job market is essential.

Proposed Changes to Program Structure and Funding Health care is a dynamic enterprise. Changes to the structure and funding of preventive medicine training are inevitable. The decision as to which of a broad range of possible changes should be implemented requires input from residency directors and other opinion leaders, and endorsement of reasonable changes among federal and funding stakeholders. One

possibility is to discontinue RRC accreditation of the academic (PG-2) year. A proposal to drop the MPH or equivalent degree as a component of preventive medicine residency training might address a funding problem, but it might also further decrease the interest in public health training, public health competence, and the flow of specialists who can serve the public. A related consideration in a constrained economy is to decrease the funding for resident trainees below the equity level compared to other specialties. However, it is uncertain how transferring costs to trainees will serve the public’s need to train physicians who understand population health and clinical systems. An experimental cost-saving measure is already in place. Physicians, previously non–preventive medicine residency-trained but already practicing in an occupational medicine environment, have paid tuition for distance programs that include the practicum year. Often the simultaneous full-time employers (including national multispecialty group chains) have invested in the tuition. Potential concerns with this approach relate to the equivalency of training, equivalency of resident effort, the breadth of experiences available for training, the requirements of the simultaneous fulltime employer contract, and the quality and consistency of clinical supervision. These challenges are best addressed in an atmosphere that includes across-theboard specialty commitment to quality.

Framework and Landscape for Desired Changes in Planning The three or four preventive medicine specialty areas are together, yet separate. Shared values may not translate to shared experiences. Attempts to assert leadership or to create a unifying focus above the level of the professional societies, such as the Preventive Medicine Leadership Forum, a coalition of 11 preventive medicine organizations, have been only partly successful. An optimistic, long-term vision is that our common, overriding interest in prevention and ability to form preventive alliances with other specialty areas put preventive medicine in a uniquely advantageous place as a specialty and career choice. Nevertheless, both training and the national understanding of the field would be strengthened if the three (or four) groups coordinated their major/annual meetings in time and space, and articulated a consensus vision and goals for residency training that is more coherent among the specialty areas. Identity issues faced by preventive medicine may be unique, yet colleagues in other fields face identity considerations for training and for their specialty.18 –20 The current specialty composition of organized medicine is heavily influenced by external forces such as funding for training, reimbursement patterns, market Am J Prev Med 2005;28(4)

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pressures from competing, nonphysician professionals, and the public image of specialists as portrayed in popular media. The preventive medicine disciplines, with the possible exception of aerospace medicine and its unique federal niche, are vulnerable to these pressures. The overarching importance of prevention argues forcefully for concerted effort to enhance excellence in training and in practice. The following guiding principles are proposed to inform the future discussion about training in preventive medicine.

Conclusions 1. Problems and challenges reflect the structure and funding of training. However, the data do not support the concept of “crisis” in resident numbers or job opportunities for certificate holders. Planning should preserve and enhance what is excellent rather than react to perceptions of crisis. 2. The value added by preventive medicine training should be clarified. It is inadequate to propose changes that will “grow the pipeline” or address fiscal problems without addressing added value and place in the rapidly changing world of medicine, or the relationship of training to values, goals, and unique areas of competence. Population strengths of training programs should be integrated with clinical experience that meets or exceeds public needs. Clinical competence and population health accomplishment are essential. The leadership of preventive medicine can support this goal by proposing and using measurements that rigorously document the supervised accomplishments of trainees. Preventive medicine will not be well served by any move toward being the “last resort” for those who choose not to meet more rigorous training criteria. Market niche, prestige, and leadership follow from demonstrating added value to society. 3. Innovative proposals must address the same expectations of quality, supervision, and clinical competence of all training programs. 4. Preventive medicine as a discipline can form collaborative partnerships to improve its product and that of other disciplines, across a broad spectrum of training. 5. While nominally “preventive medicine” by history and tradition, the specialty’s value and activity are equally in population medicine, a broader and proactive approach to human health.21 6. Preventive medicine, defined by healthcare needs of populations and characterized by population-based intellectual processes, is poorly understood by the public and even by medical colleagues. Changes in training should be accompanied by clear-headed efforts to communicate our goals, values, and the value added of our practitioners. Funding for train410

ing should increase when the public and the federal government see the added value.

A Proposal for Change These preliminary proposals from the ACGME RRC in preventive medicine, and its invited guests, follow from a strong consensus that the discipline of preventive medicine must raise the bar for training, and ensure competence of program graduates. There are several approaches to this goal; they need not be mutually exclusive to the needed outcome—a specialty certificate holder who is skilled at providing clinical services to individuals, recognizing population needs, and initiating and measuring the outcome of population interventions in several domains. These include evaluation of evidence, health services, clinical systems and measurements of quality, and healthcare organization decision making. Independent of these general recommendations, retreat participants recommend a serious discussion in general preventive medicine and public health concerning whether there is one training need or two distinct training needs, an ongoing discussion of the “academic year,” and further discussion concerning how best to target training to specific competence. More general recommendations follow. One approach is increased emphasis on training the double-boarded preventive medicine physician. Many, but not all, of these dual-certificate holders will come from primary care disciplines, and there is no reason to exclude any clinical specialty. Double-boarding allows preventive medicine residencies to concentrate on their strength—population health. Partial models exist for this dual boarding, such as in allergy/immunology, in concert with other programs. However, allergy/ immunology is a conjoint board with internal medicine and pediatrics as partners. Preventive medicine must partner more widely. By creating concurrent or successive dual training programs with other specialties, preventive medicine can participate in the creation of a recognized pathway for clinical population experts, researchers, and health systems leaders, across the broad range of medical specialization. The proposal is consistent with the incessant pace of expansion of medical knowledge, which in turn creates inexorable pressure for specialization.22 Preventive medicine is in a unique position to bridge the gaps created by the fragmenting forces of specialization, by unifying health systems and outcomes research needs of populations. A strong dual certification approach may also address the “all payer” funding support needed by the specialty, as previously articulated by the American College of Preventive Medicine Task Force on Preventive Medicine Funding. This concept faces limitations. Experience suggests that it abrogates the responsibility for clinical training to partner residencies. The primary allegiance of dual


trainees may be to the partnership specialty. Participants decided that these are concerns, but not a barrier so long as the goals of clinical competence and population context were met. Combined training increases program administrative structure. Two boards increase the time commitment to residency candidacy, a potential barrier to applicants. Retreat participants believe that raising the bar for carefully planned dual training will attract more candidates, and more of the right candidates, than it will deflect. Dual-residency programs often focus their preventive medicine analytic skills to support research and leadership careers in specialties. So long as training is comprehensive, it is appropriate that certificate holders follow diverse career paths. Since “hot button” topics may come and go as the healthcare system changes, strong foundations in general preventive medicine are essential. A concern of participants was that the need and market for dual boarding may not apply to all trainees, particularly in occupational medicine, which can be practiced as an outpatient clinical specialty. Preventive medicine is currently structured so that residency graduates have 3 years of postgraduate training, in common with most other generalist fields. Yet a substantial part of the training is allocated to “academic” needs invested in the MPH or equivalent training. Retreat participants consider the core competencies in this training to be appropriate, although there are concerns about the Council on Education for Public Health (the accrediting agency for public health training programs) directives that appear to increase the already appreciable logistical difficulty of obtaining the MPH in the context of a residency. In addition, other academic models may be considered in future discussions, so long as core prevention and population skills are addressed. A consensus emerged that considering an additional year of strongly clinical outpatient care and health systems training was desirable for programs that are not limited to dual certifications. A resident participant pointed out that a fourth preventive medicine postgraduate year would provide much greater opportunity to participate in the activities of programs. Regardless of the ultimate program length, standardized approaches to competence should include supervised measures of clinical competence in specified domains. Defined clinical skills, which are accompanied by supervised means for acquiring them, are essential for preventive medicine’s future. Potential problems with a recommendation for longer and better supervised clinical training include possible negative incentives for prospective applicants who seek a short path to board certification. Retreat participants recognize this tension between length of training, intensity of training, and attractiveness to some applicants, and believe the tradeoff is in the proper direction. Another problem is that some programs do not currently emphasize extensive supervised

clinical experience. Participants respect the additional effort that will be required, and consider it fundamental to the goals and values of a viable medical specialty. Absence of funding for an additional training year is a major barrier in light of the performance of federal funders to current, weaker requirements. A recent report to Congress23 concerning alternative payment methodologies for the costs of training in nonhospital settings holds forth some hope that current, antiquated methods of payment may soon better account for preventive medicine needs, yet we should be appropriately skeptical based on federal performance to date. Current open training positions do create a funding target of opportunity. In addition, funding will be an easier “sell” in a constrained environment if preventive medicine is clearly striving to address clinical and population needs for excellent care. To achieve consistently excellent training, preventive medicine, and each specialty area, must be clear about the difference between skills needed by the public, and certificates needed by trainees and desired by others. The triple challenge is to (1) meet legitimate population health needs by enhancing clinical training, (2) coordinating population training with specialties that can augment preventive medicine’s clinical product, and (3) attracting both sufficient numbers of trainees and sufficient federal funding so that programs can train, supervise, and measure the competence of supervised trainees who will meet public needs. Attracting trainees who are interested in clinical care, clinical prevention, and population skills represents the most significant challenge to this vision of improved training. It is also essential to accomplishing the specialty’s mission. We are grateful to the Accreditation Council conveners, David Leach, MD, and Larry Sulton, PhD, and attendees Jeanne Heard, MD, PhD, Charles Rice, MD, and Susan Mansker. In addition, Linda A. Lilly, MA, provided technical support through multiple committee efforts and inputs.

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