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President's Column 6/4/09
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Adapt and Thrive:
Preventive Medicine's Bankruptcy Protection
By Mark B. Johnson, MD, MPH, FACPM - ACPM President

The year I graduated from high school, 1970, the coolest car on the road was the Chevrolet Corvette Stingray. With its relatively new "shark" design, and the choice between its small block 350 cu. in. engine with 370 horse power or the large block 454 cu. in. engine with 425 horse power there was no other American car that could come close to matching or catching it. General Motors, the parent company of Chevrolet was riding high and the only guy I knew who had one could always seem to get dates with the most popular girls in school even though he was a real jerk!1

Today General Motors (GM) filed for Chapter 11 bankruptcy protection, citing a debt of $172.81 billion and assets of $82.29 billion. GM's bankruptcy filing is the fourth-largest in U.S. history and the largest ever for an American industrial company. The company plans to cut 21,000 employees, about 34 percent of its work force, and reduce its 6,100 dealers by 2,600.

The guy with the Corvette is on his third marriage.

Both of these tragedies stemmed from the same basic human flaw: the inability to make changes when changes were needed. Even though there have been at least two major gasoline shortages since 1970 and the price of gas has skyrocketed, GM continued to make gas-guzzling vehicles. They even added the Hummer line as the flagship of its gas-guzzling fleet. Foreign automakers, on the other hand, have been building cars that get better and better gas mileage, and led the wave of building cars that don't even need gasoline.

Preventive medicine is also facing a time of change. Due to my position on various committees I have been engaged for the past few years in gathering ideas, concentrating information and drafting potential new program requirements for our specialty's training programs. At least three viable options for framing the future of this field have now been considered and rejected. My personal fear, based on my activities along these lines, is that our medical specialty is closer to a day of reckoning than many understand or are willing to believe.

Preventive medicine training cannot remain as it is!

To paraphrase Dr. Laurence J. Peter, "Preventive medicine is defending the status quo long past the time when the quo has lost its status." The Accreditation Council for Graduate Medical Education (ACGME) Monitoring Committee, the Federation of State Medical Boards, and key House and Senate staffers in Congress, all powerful forces in the funding, accrediting and licensing of physicians, are converging on the point of recognition that there is a fatal flaw in our residency training requirements, i.e., a Masters of Public Health (MPH) degree is not graduate medical education. In spite of William H. Welch's belief that all physicians should obtain this degree, one does not need a Doctorate of Medicine before matriculating for an MPH. This irrefutable and unequivocal fact disturbingly exposes our diplomates as potentially being inadequately trained in today's medical environment where three years of graduate medical education are accepted as the minimum standard.

This is not a new discovery. In the fall of 2004, the Preventive Medicine Residency Review Committee (RRC), with the assistance of sympathetic senior leadership at the ACGME, convened a group of experts in preventive medicine and graduate medical education and concluded that "the discipline of preventive medicine must raise the bar for training, and ensure competence of program graduates." 2 This recognition came on the heels of years of chipping away at the rigor of our training, all changes directly attributable to difficulties in funding our residency programs. Whereas in the past residents had been required to complete a clinical year, an academic year, two practicum years and a year of practice before they were deemed "eligible" to sit for the board examination, by 2004 the mandatory practice year and one of the two practicum years had been eliminated.

The panel of experts concluded that two approaches might adequately address the preventive medicine training needs: 1) an increased emphasis on dual medical boards, and; 2) an additional year of training to ensure clinical outpatient and systems skills. Some of our residency programs have already anticipated the need to change and have adopted one of these two strategies on their own. These options were acknowledged as not being mutually exclusive, nor were they considered to be exhaustive. Since that time, one other approach has been identified and proposed - the removal of the MPH (academic year) requirement, with an increased emphasis on clinical training combined with rigorous didactic instruction for the final two years of the residency.

I have been working, individually and with many others, on the preventive medicine program requirements since that time, and I have not identified any other significant categories of change that I feel would adequately address the problem. I firmly believe that we must adopt at least one of these options if training in preventive medicine is to survive. Each option has benefits and each has drawbacks. Up until now, however, I believe those in our specialty have over-emphasized the drawbacks of each option to such a degree that very little has been accomplished.

I see at least four polarizing forces exerting a powerful influence on our training programs that have resulted in a downward spiral of resident recruitment and have produced a predicament for which we seem to have no acceptable solution. As with all polar forces, some of these are positive and some negative. On the positive side, the Institute of Medicine report, based on a thorough review of the current health care climate, called for a doubling of physicians trained in preventive medicine, and we appear to be closer than ever to convincing Congress and the governing Administration that additional funds need to be provided for such training. At the same time, however, organized medicine is questioning the rigor of our training requirements and our residency programs are withering away for a lack of funding and qualified residents. Unfortunately, the negative forces appear to be the stronger, and I believe they will have a destructive impact on our specialty field if we do not address them immediately.

Let me summarize the situation as I see it:

1)The ACGME has called for the revision and strengthening of our program requirements, and has patiently waited for almost five years now for us to respond. I believe their patience is understandably wearing thin, and we appear to be no closer to an acceptable solution than we were five years ago.

2)The world of organized medicine, including the ACGME, the American Board of Medical Specialties (ABMS), and the Federation of State Medical Boards, has determined that three years of postgraduate clinical training is the minimum standard for the licensure and accreditation of competent physicians, and preventive medicine is seen as having two years, at best - only one of which is directly provided by the preventive medicine residency program.

3)One of the requirements for improving preventive medicine training programs is federal funding, and key Congressional staffers are aware of the training issues delineated above. Unless we can show that we are embarking on a new and improved path to certification in preventive medicine, we will lose their support.

4)The only viable paths to acceptable improvement in preventive medicine residency training appear to be one of the following options, or a combination of them that may yet be formulated:

a.An additional clinical year of training;

b.The elimination of the MPH requirement ("academic year") and the clinical strengthening of the two resulting practicum years, or;

c.The requirement of ACGME-approved clinical board certification prior to preventive medicine training.

Admittedly, each option has serious, problematic consequences. Additional training will require additional resources that are not currently available. The elimination of the MPH requirement will take away a feature that has great appeal with prospective residents. Requiring prior board certification begs the question of whether preventive medicine is a medical specialty or a medical fellowship. Although each of these problems has been addressed at length, apparently we still do not have consensus in the field. I feel it is incumbent upon the leaders in our field to force the issue and move forward.

I strongly believe that preventive medicine training provides a vitally important component of a comprehensive health care system, which will become even more essential as we move forward with health reform in this country. I also firmly believe that this training needs to remain as graduate medical training. But it cannot remain an acceptable pathway of graduate medical training the way it is currently formulated. We as leaders in preventive medicine must show our colleagues in the house of medicine that we are seriously undertaking the necessary steps to strengthen and improve our training programs or we will be further marginalized and perhaps even de-accredited or decertified as a medical specialty.

We have met, dialogued, discussed and debated for at least five years. The time for action is now. The ACPM Graduate Education Committee has reviewed the options and has made recommendations that have been shared with those on the committees and boards with the responsibility and authority to make such changes. Whatever the course may be, the status quo is not acceptable, nor is it sustainable. If we do not take action soon, I fear that the ability to decide may be reluctantly, but forcibly taken from us.

Footnotes:

1.I really don't know anything about car specifications, so if these are wrong, please don't hold it against me. I also know that the term "girls" is politically incorrect in 2009, but since this paragraph is a historical retrospective, it's really the only word that comes close to being politically correct enough to use here.

2.Ducatman A, Vanderploeg JM, Johnson M, et al. Residency Training in Preventive Medicine: Challenges and Opportunities. Am J Prev Med 2005;28:403-412.


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