PUBLIC HEALTH MEDICINE AS A CAREER

PUBLIC HEALTH MEDICINE AS A CAREER
An Introduction by the Public Health Physicians of Canada Residents Council Presented by: (Insert Name Here) (Month, DD, YYYY) (Insert Contact Info Here)

Placeholder Brief opening video showing public health physicians and residents discussing their careers and why it is exciting

Outline What are Health, Public Health, & Health Care? What do Physicians in Public Health do? What is Public Health & Preventive Medicine Residency? How Can You Explore a Career in Public Health? This presentation will cover four topics: What is health, public health, and health care. How are they related, and how are they different? What do physicians do in public health What is the Public Health & Preventive Medicine specialty And how can you explore a career in public health.

WHAT IS HEALTH? WHAT IS PUBLIC HEALTH? WHAT IS HEALTH CARE?

A Case You May be Familiar With . . . Middle-aged man presents to the emergency department with chest pain and shortness of breath Troponin and Creatine Kinase are elevated Knowing only the above, what are some things you can guess about the patient? This is a presentation everyone is likely familiar with. What are risk factors people can guess based on this?

Weight? Diet? Smoker? Race & gender? White collar or blue collar? University educated? High school educated? Poll the class to see what they think is most likely for this patient?

The patient receives a stent and medications What do you think the patient’s prognosis will be? How will quality of life change over time? What are the patient’s barriers to avoiding another heart attack? The prognosis is that the patient will likely have declining cardiac health, future heart attacks, and possibly surgery down the road. Quality of life will slowly decline. Barriers to good health that may be mentioned are adhering to medication, changing diet, getting more exercise. If students mention the above, probe further to get at what are underlying reasons for these barriers. Try and get to having a job that’s flexible enough to go to medical appointments, get more activity in at work, avoid stress, etc; having the income, education, and culinary skills to start preparing a healthier diet; have support (enough leisure time, social supports, income, family and friends who understand cardiac illness) to reinforce and support changing to a healthier lifestyle; enough sense of control over life (e.g. free time, absence of stressors, other means to find enjoyment in life) to stop smoking, change diet, and adhere to medications.

Another Case A 76 year old female has suffered a fall on a cold winter’s day and had a hip fracture. Why might she have suffered a fall and fracture? What will her prognosis and quality of life be, with the best orthopedic care? Looking for answers like Osteoporosis, or decreasing bone strength Unsteady on feet Need to move about to get errands done With the best orthopedic care, she will have a long recovery which may lead to other health problems (e.g. DVTs, MIs).

How much better would preventing this have been? (No disrespect to the great work of orthopedic surgeons!) What was needed to prevent all this? Preventing the illness would have been much better for the patient since what orthopedic surgeons can do is limited. What was needed to prevent the fall: Nutrition and exercise to maximize bone strength Avoiding going outside on a cold day A transportation system to avoid needing to travel on foot. Underlying causes to probe for Income and knowledge of bone health to have gotten better nutrition and physical activity Living arrangements (e.g. parks, safe streets, enough leisure time) to enable physical activity Income to afford transportation Social supports to help her avoid navigating outside Social groups that exercise and are active together A society that has invested in good public transportation Government policies on cleaning sidewalks of snow and ice, and even building safe sidewalks

How might these have helped? Education? Living arrangements? Income? Social supports? Public transportation? Street and sidewalk design? Government policies? Discuss briefly

One More Case A 36 year old female street worker was referred to your gynecologic practice after presenting to a walk-in with unusual bleeding. You diagnose her with cervical cancer and plan to operate. What has led to this illness? What may be some underlying causes? Depending on time, may want to do this case, or skip if you think it will be redundant. Should talk about Poor health care access (at a walk-in rather than family doctor) Probably didn’t get regularly screened Street work likely exposed to HPV virus May have been a smoker Underlying causes? No HPV vaccination Stigmatized and didn’t want to seek health care Was abused and didn’t have freedom to access health care Lacks income, education, social supports to transition to a safer line of work Perhaps had addictions forcing this line of work

What might have been the role of these in preventing this? Access to health care? Stigma? Abuse? Addiction? Income? Education? Social Supports? Discuss

Health is determined by many factors Medical care Preventive care Good treatment Lifestyle Socioeconomics Social attitudes (e.g. stigma) Government policies Not Health Care Some of these aren’t health care

Health is determined by many factors Medical care Preventive care Good treatment Lifestyle Socioeconomics Social attitudes (e.g. stigma) Government policies } Not Health Care Some of these aren’t health care

Public health is the practice of improving the non-health care factors that affect health Public health physicians are the medical experts within the diverse group of professions that work in public health

Health Is a Partnership Good Health Lifestyle Socioeconomics Social attitudes (e.g. stigma) Government policies Access to medical care Preventive care Good treatment Good health is ultimately a partnership between public health and health care. Preventing illness is often the best way to give people healthier lives. But not everything is preventable; we need health care for when prevention doesn’t work. HEALTH CARE PUBLIC HEALTH

This video downplays the role of health care because it comes form a Public Health organization who is trying to sell themselves. But it explains why public health is important. Courtesy of the Sudbury & District Health Unit (in northern Ontario)

HISTORY OF PUBLIC HEALTH & HEALTH CARE
What is the history of public health and health care working together for health?

Average Expected Age at Death in Ontario for a 50 Year Old Here is how the average age at death has evolved in Ontario over the last 200 years. A 50 year old in 1800 had under 10 years to live. Ask: where was the biggest gain in life expectancy seen? Ask: why do you think there was that big improvement in ? LifeInsuranceCanada.com Inc.

Case Fatality Rate from TB Here is how mortality from TB has declined over time. What have been contributing factors to TB’s decline? CCDR: Volume 40-6, March 20, 2014

Infant Mortality Another example from neonatal care: most of the gains in infant mortality preceded neonatal care.

The Middle Ages (Europe) Life expectancy in early teens Perinatal mortality Unhealthy living conditions (e.g. no toilets, waste dumped to streets) Vector-borne diseases Stray animals roaming streets No insect control; breeding in waste on streets If we take the long view of health, in the middle ages people on average didn’t live into their teens because of many infant deaths and rampant infections

“ Refuse from the table was thrown on the floor to be eaten by the dog and cat or to rot among the rushes and draw swarms of flies from the stable. The smell of the open cesspool in the rear of the house would have spoiled your appetite, even if the sight of the dining room had not. Medical Historian Howard W. Haggard ”

Establishing Public Health in Canada Isolating the very ill 1800s: Quarantine laws in Lower Canada 1816 Physician health officer to increase quarantine capacity Gross Isle, Quebec — focus of newcomer quarantine Public Health first began to tackle infections in the 1800s. These made the initial gains in health. Sanitation in the late 1800s was promoted and developed by public health before being turned over to others while public health refocused on new challenges. Photo: D.A. McLaughlin / Bibliothèque et Archives Canada / C Reference: This is Public Health: A Canadian History by Christopher Rutty and Sue Sullivan – Canadian Public Health Association

Establishing Public Health in Canada Collecting data to understand population health 1879 Census and Statistics Act mandated collection of vital statistics Widespread Vaccination 1875 Smallpox vaccination program in Montreal Photo: D.A. McLaughlin / Bibliothèque et Archives Canada / C Reference: This is Public Health: A Canadian History by Christopher Rutty and Sue Sullivan – Canadian Public Health Association

Establishing Public Health in Canada Formal Public Health Structures 1874–1892 first public health journal published (Dr. Edward Playter, sanitation leader) 1882 Ontario establishes a full-time provincial Board of Health to manage public health 1890s: Sanitation Infrastructure Photo: D.A. McLaughlin / Bibliothèque et Archives Canada / C Reference: This is Public Health: A Canadian History by Christopher Rutty and Sue Sullivan – Canadian Public Health Association

Eradication of Polio 1930s & Great Depression: Polio outbreaks
PUBLIC HEALTH MEDICINE AS A CAREER Eradication of Polio 1930s & Great Depression: Polio outbreaks Peaked in 1953: 9,000 cases in Canada. 1955 Polio vaccine 1994 Polio eradicated in Canada (WHO Certifies) Polio eradication is a great example of what public health accomplished Reference: This is Public Health: A Canadian History by Christopher Rutty and Sue Sullivan – Canadian Public Health Association

Impact of Vaccines Table 1 Incidence of selected vaccine-preventable disease in Canada, pre-vaccine era compared with 2007 to 2011 Vaccines have had a huge impact as we can see from this table. Canadian Immunization Guide (March 2015)

Leading Causes of Death in Canada 1910 Pneumonia & Influenza TB Diarrhea Heart Disease Stroke 2011 Cancer Heart Disease Stroke Chronic lower respiratory diseases Unintentional injuries These are the top 5 causes of death in Canada both 100 years ago and now. This table shows how infection which used to be the great killer has disappeared form the top-5 list. Chronic diseases (stroke, heart diseases) however have taken over. Diabetes is an interesting new addition. That’s the success of public health, but also what is left to be done. Statistics Canada, CANSIM table

Leading Causes of Death in US 1900 Pneumonia & Influenza TB Diarrhea Heart Disease Stroke Kidney Disease Unintentional Injury Cancer Senility (Alzheimer’s?) Diptheria 1998 Heart Disease Cancer Stroke Chronic lower respiratory diseases Unintentional injuries Influenza & Pneumonia Diabetes Suicide Kidney Disease Chronic Liver Disease These are leading causes of death in the US. This shows more illnesses than the previous table, but the same trend. CDC. Leading Causes of Death, 1900–

Shifting from Infection to Chronic Disease
PUBLIC HEALTH MEDICINE AS A CAREER Shifting from Infection to Chronic Disease 1971: mandatory seatbelt laws 6,000 per year to less than 2,500 per year Cost per life saved is $69 1970s-80s Smoking restrictions 1986 Ottawa Charter on Health Promotion Public Health is now trying to shift focus to preventing these chronic diseases. We’ve made some progress. Car collision injuries and smoking are two examples. Reference: This is Public Health: A Canadian History by Christopher Rutty and Sue Sullivan – Canadian Public Health Association

Cost-Benefit of Public Health Interventions Table 3: Cost per life year saved for selected immunization programs and other public health interventions (adapted from references) We can see how cost effective it is when public health is successful at preventing an illness. * Monetary resources required to save one year of “statistical” life Canadian Immunization Guide (March 2015)

Future Directions in Public Health Controlling health care costs Restructuring our society to be healthier What’s today’s game changer like sanitation was 100 years ago? Anti-vaccination advocates Climate change With chronic diseases still a challenge, there’s much more work left to be done.

Courtesy of the Canadian Public Health Association

A MEDICAL CAREER IN PUBLIC HEALTH
How to Get Involved in Public Health as a Physician

Specialties Working in Public Health Public Health & Preventive Medicine Family Physicians Emergency Medicine Infectious Disease Medical Microbiology Pediatrics Internal Medicine Many Others Many different specialists can work in public health

Clinician who includes prevention in work Public Health in Medicine Clinician who focuses on preventive health Public Health Physician There are three different ways for medical professionals to be involved in public health

Including Prevention in Practice Vaccination Preventive health counseling (e.g. smoking) Advocating supports for patients Actively ensure all school children are immunized Collaborating with Public Health Departments to support those with chronic infectious diseases to reduce spread (e.g. HIV, Hep C) Providing sexual health services to underserviced populations As a clinician, there are many aspects of public health already in most medical practices, and some you can also integrate if you want to be more involved.

Focusing on Public Health Prevention-focused practice Offering mix of clinical and support services for chronic diseases Addictions medicine If you are more passionate about Public Health, there are ways for any physician to become more involved and even work full time in public health.

Focusing on Public Health Working within Public Health Departments Travel Clinics Sexual Health Clinics Medical Director for Sexual Health Clinics Public Health Laboratories Emergency Preparedness Occupational Health Academics

Public Health Physician Medical consultant to a Public Health Department Infectious disease (e.g. prophylaxis of contacts) Environmental hazards (e.g. what is the risk to health?) Chronic disease (e.g. program planning) Advocacy (e.g. media, to government) Emergency management (e.g. ensuring health and safety) Research & teaching Leading health organizations Occupational Health And of course, you can become a public health specialist Occupational health is a fellowship that can be entered from family medicine, internal medicine, or public health and preventive medicine

Public Health & Preventive Medicine Specialist Public Sector Public Health Private Sector Academia Non-Governmental Organization Preventive Medicine Clinician Local Public Health Provincial/ Federal/ International Public Health Organization Pharmaceutical Companies Teaching Public Health to Medical Students Research Occupational Health Consulting PHPM Program Director Administration/ Leadership Sexual Health Medical Officer of Health (or Associate) Administrator/ Manager/ Leader Full-time Research Leadership of Community Health Centres Travel Medicine Clinic Medical Director The array of what you can do as a public health physician is huge Content Expert Community-focused clinical practice CAREERS IN PUBLIC HEALTH Many people work a combination of these too! Other Possibilities

Lifestyle Issues Work intensity Part time, flexible Multiple careers combined (e.g. clinical practice & local public health) Most specialists have a 40–50 hour work week Call Home call 1 in 2 to 1 in 5 depending on number of colleagues Call is very light—rare for urgent issues needing after hours response Public health is a flexible career option, with relatively light call.

Lifestyle Issues Income Public sector: $200–300,000 (no overhead) Researcher: $150–225,000 (no overhead) Clinician: $250–$350,000 (overhead) Public sector and academic jobs come with benefits packages

PUBLIC HEALTH & PREVENTIVE MEDICINE TRAINING
Introduction to the Residency Program

Training Components Basic Clinical Training 5 Years These are the three major components to PH&PM training in Canada. Different schools will organize/sequence them in different ways. Five years. 2014 RCPSC training requirements are: 1 year of basic clinical training 4 years of additional training, divided as per below: Minimum 2 semesters of relevant academic work Minimum 18 months of PH&PM field placements Up to 12 months of “other” field placements (e.g. clinical pharmacology) Up to 18 months of relevant research Up to 12 months of CFPC/RCPSC clinical training, relevant to PH&PM Source: w/~edisp/tztest3rcpsced pdf Academic Work in PH&PM PH&PM Field Placements

Clinical Training 1 year required Similar to first year in most programs Major disciplines (e.g. Internal Medicine, Pediatrics, OB/GYN) Mostly inpatient work; reinforces medical knowledge and skills

Clinical Training Up to 1 additional year of clinical training “Related to disease prevention or health promotion” Can be used to complete requirements for CFPC certification Can be used to gain competence in area of preventive medicine (e.g. sexual health, travel medicine, occupational health)

Academic Work 1 year required Generally graduate school E.g. Master’s degree or 1 year of courses Competencies needed for public health practice Epidemiology, statistics, surveillance methods Qualitative/quantitative research methods Policy and program evaluation Management and leadership Varying flexibility by program for how and where academic training is completed

Public Health Field Placements 1 year required Typically 1.5 to 2 years required to meet readiness for exams Rotations Local, provincial, and national public health agencies Public Health expert bodies NGOs offering public health services (e.g. addictions prevention)

Public Health Field Placements Exposure to different domains of Public Health Communicable disease control Health promotion Environmental health Etc.

Public Health Field Placements Roles Follow-up of reportable infectious disease cases (e.g. identifying contacts, prescribing prophylaxis) Contribute to or lead organizational projects Management of units within organization Apprentice the role of a public health physician

Multiple Training Pathways Family Medicine option Order of training components Sequential Pathway Clinical -> Academic -> Public Health Academic -> Clinical -> Public Health Integrated Pathway Clinical, academic, and public health all interspersed Multiple Different ways in which the three components come together to comprise the five years. First distinction is PHPM only training vs PHPM+FM PHPM only: 1 year of basic clinical training, but no clinical work required beyond that. Generally more of a focus on academic work and public health practice. Not sure if this is the place to mention it, but clinical opportunities are much more limited. Ends in FRCPC. PHPM + FM: Additional time is found within the five years to complete the requirements of a family medicine residency. Allows residents to complete a CFPC + FRCPC. Necessarily means less time for academic/PH placements, or perhaps just less time for electives. Can still meet minimum time requirements for all components as mandated by RCPSC. Additionally, there can be a further distinction made between programs in terms of how the clinical, academic, and field work are integrated together. This is the issue of sequential vs integrated, which we’ll get to in a minute.

Multiple Training Pathways These are some of the sequential pathways First is what University of Calgary does. Segmented clinical, academic, and field rotation components Longitudinal PH exposure would be limited to academic half-days Second is University of Toronto. Another approach is to devote the first two years to Family Medicine, including the half-days. Indistinguishable from being in a regular FM residency for those two years. Not much exposure to PHPM until at least year 3 (and no field rotations until even later, likely). Note that some programs vary this up by having the Academic in PGY-1, then clinical across years 2-3. Additionally, most programs now offer some sort of Intro rotation in first year (e.g. in place of an elective block). Third is UBC There are just examples. There are many options possible!

Multiple Training Pathways This is what an integrated pathway looks like e.g. McMaster Integrated pathway Early exposure to PHPM half-days in PGY-1 clinical time Additional FM requirements completed across PGY-2/3 Academic time begins in PGY-2, extends to 3/4. During this time, mix of half-days. Earlier exposure to PH field rotations, prior to the completion of clinical or academic portions.

Key Points about Training Three major training requirements Clinical Training Academic Work PH&PM Field Placements Mix of requirements can be tailored to career interest Different routes to completion With/without Family Medicine Sequential vs. Integrated pathways Some programs may suit you better than others!

Placeholder Residency Programs can add information about their program if they wish

Video Placeholder Video of Public Health residents discussing their residency and their career (a Canadian version of this)

PUBLIC HEALTH & PREVENTIVE MEDICINE PROGRAMS

Web Pages for Programs University of British Columbia University of Calgary University of Alberta Saskatchewan University of Manitoba Northern Ontario School of Medicine McMaster University University of Toronto Queen’s University University of Ottawa McGill University Université de Montréal Université Laval Université de Sherbrooke If you want more information on any of the residency programs, these links should get you there. The CaRMS web page is also a good source of information about the the various programs. The Royal College keeps a listing of program directors as well.

Pursuing Public Health without the Residency Training Many options Residency which interacts with Public Health Infectious disease, medical microbiology work with communicable disease public health Pediatrics works with vaccination and early childhood programs Emergency medicine works with emergency planning As discussed earlier, there are many options to get involved in public health even if you don’t do the specialty training.

Pursuing Public Health without the Residency Training Many options Another residency + special training E.g. tropical medicine certification, travel medicine, occupational health fellowships, sexual health Academic training (e.g. MPH, PhD) Research Focusing on public health issues in any discipline Serving your patients by treating the medical aspects, but also addressing social and other factors however possible

Benefits of the Specialty Training Scope of practice is wider Public sector public health positions strongly prefer PHPM specialists Broader training allows more flexibility More training in leadership & management More training in epidemiology and research skills 5 years of experience and connections in public health However, all that being said, there are advantages to the specialty training. If you are very passionate about public health, we encourage you to consider this option.

Video Placeholder Video of specialist discussing their work life

EXPLORING A CAREER IN PUBLIC HEALTH

Shadowing a Resident or Practitioner What to expect Every day is very different: Unpredictable Anything can happen! You will likely work with a multidisciplinary team This really enriches the experience Be prepared to move around May go to many sites Be prepared to have no idea what is going on What is neat about PH is that it is diverse Has its own language almost Many of the topics covered may not be familiar – but it is a great time to learn Shadowing can be a great way to get your first glimpse of public health

Shadowing a Resident or Practitioner Making it great Pick a time that works for you both Both total length and length per shadow session Have some areas of interest Do some pre-shadow research Dress to impress No white coats, but professional attire (office environment) Be excited Be honest Shadow a few times and different people So much diversity; one experience won’t give you a true sense

Setting Up An Elective in Public Health Local Public Health Agency (w/ MOH/AMOH) Provincial Public Health Expert Think Tank (e.g. BC Centre for Disease Control, Public Health Ontario) Provincial Ministry Federal Public Health Public Health Agency of Canada Federal Ministry (Health Canada) First Nations & Inuit Health Branch An elective is obviously a good way to get a deeper experience of the field.

Setting Up An Elective in Public Health Occupational health clinics Preventive medicine (e.g. smoking cessation, sexual health, addictions prevention) Not for profit groups (e.g. Canadian Cancer Society) Research elective

Finding an Elective AFMC Electives Portal: Ask what’s at your school Public health residency program at or near your school Contact the program director or residents — web sites often list their contact information Public health department at your university The local public health agency where you live These are some ways to find out what would be interesting electives for you.

Finding an Elective School websites Note that some schools require you contact a supervisor first, while others require you not to contact first Personal contacts Residents, mentors, organizational websites

What to Look for in an Elective? Research vs. public health practice vs. clinical? Is there a project that you can get involved in? Local vs. provincial vs. federal vs. international? Does your medical school have a memorandum of understanding (MOU) with the host agency of your elective? Look for an enthusiastic and engaging supervisor Think about what you want in an elective before you set one up. Unlike in other specialties, what you choose to do will make a huge difference.

What to Look for in an Elective? Do you want a reference letter? If so try to make your interest clear early on, and be keen! Duration 2 weeks can give you a taste of public health, but 4 weeks is better to allow you to possibly get involved with a project and a better feel for what doing the job would be like

Additional Resources about Public Health & Preventive Medicine Public Health Physicians of Canada Includes student forum, comparison of residency programs, and more Association of Faculties of Medicine of Canada Public Health Page Includes information for Public Health Interest Groups and learning resources If you want to find more information, these are some good links.

Placeholder Residency programs can add additional sources about their program here

Join the Public Health Physicians of Canada (PHPC) Represents the interests of public health and preventive medicine specialists and public health physicians in Canada. More than 200 members. PHPC is the unique and vibrant voice for public health and preventive medicine specialists/public health physicians and continues to grow each year in membership.

Join the Public Health Physicians of Canada (PHPC) Established as the National Specialty Society for Community Medicine (NSSCM) in 1998 and promotes the inclusion of a population and public health perspective in the development and implementation of health policy. Join Today: There is no cost to join PHPC for medical students and residents. Website:

Public Health & Preventive Medicine Video Series

QUESTIONS? Let us know your questions! Speaker is encouraged to put their address into this slide. To reach Public Health Physicians of Canada Residents Council:

Contributors Jasmine Hasselback PGY-3 University of Saskatchewan M. Mustafa Hirji (Editor) PGY-5 McMaster University Thomas Piggott PGY-1 McMaster University Matthew Tennenbaum PGY-2 McMaster University Rim Zayed PGY-4 University of Ottawa We acknowledge generous funding support provided by the Public Health Agency of Canada, and project management provided by the Association of Faculties of Medicine of Canada. Thanks to all those who made this possible! This work is licensed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License

PUBLIC HEALTH MEDICINE AS A CAREER

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