Public Health—the Role of Family Physicians
Am Fam Physician. 2003 Nov 15;68(10):1926-1930.
In its recent report on educating health professionals to keep the public healthy, the Institute of Medicine (IOM) produced a thorough and scholarly assessment of public health problems and proposed educational solutions.1 The following are paraphrased examples of some of the IOM's recommendations:
Schools of public health and medicine should collaborate in community-based research on the prevention and care of chronic disease.
All medical students should receive basic training in a population-based approach geared toward health promotion and disease prevention.
A significant proportion of medical school graduates should receive advanced training at the Master of Public Health level to take an ecologic approach to population health.
Schools of nursing should provide community-based training in an ecologic approach to health, in close collaboration with schools of public health.
In 281 pages, the IOM lays out an educational framework for the experiences and training necessary for several types of health professionals to enhance the public health system and protect the health of the public. Unfortunately, this framework is laid on the foundation of a health care system that is shaky, at best. Irrespective of the education of health professionals, the system itself is not designed to improve the health of populations—rather just the opposite. It focuses on the numerator (patients seen by health care professionals) rather than the denominator (patients in need, but not seen) in most quality measures.
Managed care systems manage finances rather than care, and rarely on a true population basis. An increasing number of patients are uninsured and underinsured,2 with increasing exclusionary conditions; cost shifting to patients; restricted access; inadequate support for routine and preventive care; and poor care for patients with disabilities, chronic disease, terminal illness, and mental illness. Our political and social systems lack a commitment to the concept that basic health care is a right for all rather than a privilege dependent on employment status and income.
The health system is essentially unaddressed in the IOM report, and the system will need to change before these educational recommendations will find a fertile ground on which to grow and thrive. In addition, the medical care and public health systems have grown far apart in the United States during the past century.
Given all this, why would family physicians have any interest other than intellectual or theoretic in educating public health professionals to keep the public healthy?
The answer lies in the IOM report. Buried in the report are several critical concepts that family physicians intuitively understand and value: an ecologic approach to understanding health care, population-based medical informatics, a commitment to health promotion and disease prevention, cultural competence, community-based participatory research, and ethical dilemmas arising from the competing needs of individual patients and their communities.
The American Academy of Family Physicians, in its recent call for health care access and insurance for all Americans,3 bases its plan on several of these concepts. Despite the lack of a functional and effective health care system committed to public health, family physicians contribute to the health of our communities and practice populations by adapting their practices to these concepts in subtle, but effective, ways.
Family physicians might ask themselves specific questions about the health of the public as they work through their schedule of individual patients. For example:
How much do I know about the major health threats to the specific patient populations for which I care?
What kinds of medical care and educational programs could I design to respond to these threats?
How much effort and energy do I or my office staff put into health promotion, such as smoking cessation, exercise promotion, and seat-belt use?
How often do I ask my patients about interpersonal violence, hidden substance abuse, and the risk of sexually transmitted diseases?
How would my practice fare in an immunization audit (e.g., for influenza or hepatitis B) compared with national benchmarks?
What is the rate of postmyocardial infarction use of aspirin and beta blockers in my patients?
If I do not know the answers to these questions, how could I find out?
The willingness of family physicians to ask and answer these questions will contribute in a large and tangible way to our specialty making a legitimate claim as the foundation of a health care system truly committed to the health of the public.
1. Who will keep the public healthy? Institute of Medicine. Accessed October, 2003 at:http://www.iom.edu/project.asp?id=4307.
2. Committee on the Consequences of Uninsurance. Care without coverage. Institute of Medicine. Accessed October, 2003 at:http://www.iom.edu/project.asp?id=4660.
3. Assuring health care coverage for all: a plan by the American Academy of Family Physicians. Accessible online at:http://www.aafp.org/unicov.xml.
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