How public health and MPHs are influencing medicine

Way back in the mid 20th century when I graduated from George Washington University with an MD degree I imagined that I had arrived.

I remember my classmates selecting different specialties and eventually going off to clinical training. I could not imagine doing anything other than clinical work, and perhaps dabbling in some clinical research.  Some of my friends were studying ‘epidemiology’ and a new field ‘public health’.  At that time, it mostly  was dedicated to ‘epidemics’, vaccinations, preventive medicine, and things that to me did not really involved patient care.

Turn the page, 50 or 60 years. This specialty has morphed into having an MPH (Masters in Public Health), and perhaps an MBA in health administration.  Previously these professionals had little to do with your clinical practice on a daily basis.  Now these people are the groundbreakers, movers and shakers throughout the medical world in which we all practice.

My school is now known as “George Washington University School of Medicine and Health Sciences.” The previous formal division of Medical Clinical pursuits from allied health and health business has become blurred at the educational level.  This blurring of distinction has also occurred in the clinical world with PAs. NPs, Advanced Degree nursing specialties and the like.

As a delayed and recent student of this field , and as a result of my blogging research I see that the topography has changed drastically.  Previously treated with disdain, MPHs, and MBAs, and MHAs increasingly have invaded our insular clinical world.  Many health reformers and policy makers delved deep into the social psychology of medical practice, medical group organization, quality measures, and even reimbursements.

All of this has evolved into an environment of MPHs having a huge influence on governmental policy makers.   Many MPHs have evolved into a new specialty of Political Influence.  Many practice medicine, not by treating patients or treating diseases, but by spreadsheets, algorithms, and formulating treating diseases from 40,000 feet … far removed from the implications of their edicts.

 

The flack is coming from we clinicians on the ground.

Gee, I wish I had gotten that MPH.

Gary Levin is a physician who blogs at Health Train Express.

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  • http://www.therextras.com Barbara Boucher, PT,PhD,OT

    No, no! Dr. Kevin! That would have been like drinking the koolaid!

    “Many practice medicine, not by treating patients or treating diseases, but by spreadsheets, algorithms, and formulating treating diseases from 40,000 feet … far removed from the implications of their edicts.”

    Are you hopeless that this trend can be reversed?

  • http://healthtrain.blogspot.com Gary Levin MD

    Barbara, That is a great question. I awaken each morning place my feet on the floor, flip a coin….heads it is hopeless, tails I am hopeful….but then again I tend to be ambivalent about most things. I leave that up to my readers. I merely comment…the analysis takes too much effort.

  • http://amjmed.blogspot.com Pamela Powers

    I went back to school in the 1990s and earned an MPH from The University of Arizona College of Public Health. This was one of the best decisions I have ever made. The MPH degree enhanced my work in cancer prevention and smoking cessation in the 1990s and has added a public health sensibility to my current work with The American Journal of Medicine.

  • http://wellescent.com/health_blog/5_ways_to_limit_rheumatoid_arthritis_pain_without_pain_medication Wellescent Wellness Blog

    There is always a danger from decisions being made by those not in the trenches, but given that there is always a chain of command, there will always be those trusting their data and formulas to make decisions. If the data can be made accurate, there is a chance it can be used for public benefit. The more dangerous problems result when those making the decisions choose to ignore some data or to put their own political spin on the data to make policy that promotes a particular political agenda.

  • http://www.healthmatters4.blogspot.com Citizen K.

    The national commitment to public health is so small that it typically doesn’t show up in macro analyses of the federal budget. Nations that have a strong commitment paired with a robust primary care are generally good at preventive health and at reducing costs. Certainly, the United States cannot hope to contain the ravages — personal and financial — of asthma, cancer, depression, diabetes, and heart disease without effective public health programs at the national, state, and community levels.

    • http://Www.twitter.com/alicearobertson Alice

      Could I ask what nations you refer to above? Maybe expound a bit on what type of public health programs work. Incentives? Fines? Mandates? Just curious…I have a daughter with cancer and I can’t figure out how this happened…yet…three moms and a father in our small group have the same type of cancer. Another….just curious….from me! Isn’t our health a good enough incentive? Knowledge is powerful….surely Dr. Oz deserves credit for helping a lot of people help themselves without government involvement.

      • http://www.healthmatters4.blogspot.com Citizen K.

        Please accept my sincere regrets over your daughter’s illness. I have two sons and don’t even want to imagine what you must be going through.

        Beveridge Model systems (government owned and operated health systems) tend to invest heavily in public health because the tax basis of the system rewards preventive care. The United States isn’t going to adopt the Beveridge Model, but that doesn’t mean we can’t learn from its successes. Finland, for example, has managed to (so far) reverse an obesity trend, something that has eluded almost every western nation. Here’s a story about it:

        http://www.guardian.co.uk/befit/story/0,15652,1385645,00.html

        The Finns have also managed to blend some public health practices with primary care. Mostly, though, it’s about commitment, as the public health responsibilities there (education, alcohol and tobacco control, environmental regulation, etc) aren’t much different than anywhere else.

        The American Lung Association recommends a comprehensive public health policy at the federal, state, and community levels to combat asthma:

        http://www.lungusa.org/lung-disease/asthma/advocacy/reports/National-Asthma-Public-Policy-Agenda-January-2009.pdf

        This will give you an idea of what coordinated public health policy looks like. Now, if we would only do it…

        • http://www.twitter.com/alicearobertson Alice

          Beveridge Model systems (government owned and operated health systems) tend to invest heavily in public health because the tax basis of the system rewards preventive care. The United States isn’t going to adopt the Beveridge Model, but that doesn’t mean we can’t learn from its successes. Finland, for example, has managed to (so far) reverse an obesity trend, something that has eluded almost every western nation. Here’s a story about it:

          http://www.guardian.co.uk/befit/story/0,15652,1385645,00.html
          [end quote]

          Alice: This is interesting. I have shared before I lived in Britain and my husband immigrated here from Scotland. Having firsthand experience with the consequences of socialism means I am not objective. I am no fan of the NHS because I feel the system killed several of my relatives. To my limited knowledge the Beveridge model is a bit like our VA system? As long as it is incentives and not mandates it would seem to be fine..um…thinking……. Sometimes we view a government mandate by the outcomes….and we rationalize that it must be good if it is productive….but the peripheral issues are clouded. I am a civil libertarian and worry. Particularly, after the shooting this weekend and the calls to mandate everything from free speech to a national writer in The New Republic calling for a way to turn in people who “may” have some problems. Sounds good, huh? Until it’s the right wingers getting hauled into the psych ward and being treated by liberals!:) Now that may sound phantasmagoric to some readers….and if it does……well…..let’s imagine a reversal. Not so good, huh?

          [quote] When officials said the population must start eating fruit, protests poured in that fruit would have to be imported. To placate the farmers, the scheme was revised to encourage the growing of berries that thrive in a Baltic climate. Now Finland has a healthy industry producing all manner of berries, from redcurrants to blackberries. [end quote]

          Alice: What does the writer mean by “must start eating fruit”?

          [quote] The early push in North Karelia was largely successful in weaning the population away from its staple diet of fat and fags, but there remained the problem of inactivity. [end quote]

          Alice: I hope anyone who followed your link knows “fags” are cigarettes in the UK. Out-of-context that sentence would cause a double take. ha!

          [quote] Dubbed “Fat men in pubs ” by Len Almond, the founding director of the National Centre for Physical Activity and Health at Loughborough University, the scheme was less ambitious than its Finnish counterpart [end quote]

          Alice: Can you imagine a program with this name succeeding in the states? Long ago there was a movie where Gwyneth Paltrow put on a fat suit and the movie premiers were protested by people who thought it was poking fun at those who are overweight. But, upon, viewing the movie it was about overcoming our own mental limitations that are so focused on looks. Anyhoo…….thanks for the link and the giggle! I like to follow links posters post……usually, not agreeing, but it helps in understanding.

  • Janelle, MPH, CHES

    Well, I guess speaking as the “them” in the field of Health Services Research, I feel I need to provide an alternative viewpoint. Although I understand your frustration with the cost cutting measures that currently occur in the field of medicine, let me assure you that not all support the cost cutting. Much of the research that my department does is to document the issues associated with this, such as lack of providers for the area, various public health needs, and the crumbling infrastructure and develop policy briefs to share this information with policy makers. And yes, I will admit that there are a number of “MPHs” that will go out of their way to save a buck or two and will sacrifice patient care. Saying that we are all out to cut corners is frankly absurd and insulting.

  • Dr. Kene Mezue

    Improvements in sanitation, water supply, housing and nutrition have obviously had the greatest impact on humans…even before antibiotics and safe surgery were invented…and yes wait for it…before Public Health as a specialty was established…Public Health students are told that Public Health improvements have improved life span, yada yada yada…but the issue is that this wasn’t done by MPH holders…it was done by SENSIBLE POLITICIANS…the key to the health of communities and nations doesn’t lie with MPH holders…It lies with sensible economics and politics…fairness, equity and justice in the allocation of resources…and of course the environment…

    …In spite of this, I really enjoy Epidemiology…it gives great insights to the Big Picture in many ways…but it is of no use if we don’t follow the dictates of common sense.

  • http://healthtrain.blogspot.com Gary Levin MD

    I have been edified by the responses and comments. All good arguments, so I still cannot make up my mind. Someone is paying for all of this in funding the studies, fellowships, and degree programs. As private practitioners we read, study and hopefully find this information useful in the trenches. It does provide some framework for hope and progress amidst the chaos of life. No sense doing this and not evaluating it on it’s own merits for each practitioner. Perhaps this will also become a meaningful use requirement for CMS incentives, or perhaps the data will be quietly mined for future generations. We may find out that all patients exposed to computers or cell phones eventually died…Garbage in….garbage out. As Forest Gump would say “That’s all I have to say about that”

  • http://www.twitter.com/alicearobertson Alice

    We may find out that all patients exposed to computers or cell phones eventually died [end quote]

    Indeed, we can all agree on that! Everyone reading this has been exposed and will jolly well die…..the open discussion is certainly leading to eliminating expensive deaths though….isn’t it? Of course….if these activities are proven to be unhealthy we may need a Czar to make sure we protect ourselves….from who else……ourselves?

  • karl Hafner

    As one who has obtained both degrees MD and MPH I believe everyone in primary care should get both. It changes how you see people, their medical problems and solutions and our place in the community. It was the best decision that I made.

  • Lisa

    One of the most important roles of MPHs should still be listening to those who practice in the field. Just recently I attended a Public Health Conference in my state(Maine) and realized there were mainly MPHs attending and thought that I had also chosen the wrong path (Masters in Social Work), but I realized that I can have an impact and have had a profound impact on public health through the patients I see everyday. Coaching them, listening to their stories, their pain, and the stressors of their environments. One of the main issues in Public Health Policy is that we don’t listen and consult each other enough as professionals.

  • ESLMD

    The Return On Investment is not being considered – how much more uncompensated time should a person sacrifice to becoming a physician?

    The top down management approach that these academic disciplines promote can not effectively manage the actions of the workers at the bottom, when the workers are the ones with the actual responsibility: The Art Carney school of working in the sewer, for those who remember. But seriously, in medicine, just as pre-flight check lists outline where to look to avoid omissions, the lists are of little use when something goes wrong in the air. Then the responsible pilot has to make the appropriate decisions, training, not management, makes the difference.

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