key: cord-1021717-10vhnirm authors: Jung, Paul; Warne, Donald K. title: Integrating the preventive medicine specialty in the rural and public health workforce date: 2020-06-26 journal: Prev Med DOI: 10.1016/j.ypmed.2020.106187 sha: 1acd4dc065702871c3fa45917308c72b3e165700 doc_id: 1021717 cord_uid: 10vhnirm Abstract The majority of the U.S. American Indian and Alaska Native (AI/AN) population live in rural areas, and are thus disproportionately affected by rural health issues. In addition, the AI/AN population has unique health characteristics resulting from a distinct cultural and sociopolitical history. A public health approach to both rural and Tribal health should include the medical specialty of preventive medicine, a unique physician specialty that combines both direct patient care and public health skills. To best prepare preventive medicine physicians for rural and Tribal practice, medical schools could recruit students from rural and Tribal areas and encourage them to pursue the specialty of preventive medicine. Additionally, preventive medicine residency training programs could establish clinical and public health practicum rotations in rural and Tribal areas, and develop curricula that address rural and Tribal health issues. Currently very few preventive medicine residency programs expressly state a mission to train physicians in rural or Tribal settings. J o u r n a l P r e -p r o o f Efforts to improve public health in both Tribal lands and in rural areas are welldocumented. 16, 17 However, one aspect of public health investment that has not received significant attention is the medical specialty of preventive medicine and its potential role in rural and Tribal public health, specifically in their utilization within rural and Tribal public health systems. Preventive medicine is one of the 24 recognized physician specialties of the American Board of Medical Specialties; preventive medicine specialists are licensed and boardcertified physicians trained in both direct patient care and in population health, and they obtain a Master of Public Health (or equivalent) degree as part of their residency. No other medical specialty provides such training. As of January 2020, there are 73 accredited preventive medicine residency programs in the U.S. and approximately 6,431 board-certified preventive medicine physicians currently in the U.S. 18 It is important to draw a distinction between the medical specialty of preventive medicine and preventive medicine services such as immunizations, breast cancer screening, and blood pressure testing. While the two overlap in that preventive medicine physicians can provide preventive medical services, they are not the same. While any clinician may provide or recommend preventive medical services, the specialty of preventive medicine is unique in combining both direct patient care clinical skills and public health expertise. Preventive medical services are not provided exclusively by preventive medicine physicians, and preventive medicine physicians are not limited to the provision of J o u r n a l P r e -p r o o f preventive medical services. In this paper, the authors specifically want to promote the specialty of preventive medicine in rural and Tribal areas. Although preventive medicine is the medical specialty of public health and preventive medicine specialists naturally fit within health departments, 19 that is not by any means the only type of practice where preventive medicine physicians practice the specialty of public health. Any system that is truly interested in improving population health would benefit from the expertise of a preventive medicine physician. Tribal health delivery is a multifaceted, complex undertaking, of which rurality is merely one aspect. In Alaska, population density is as low as 1.1 people per square mile, with some villages only accessible by boat or airplane. 20 There are 573 federally recognized Tribes in 37 states, served by 116 federal IHS facilities and 498 Tribal facilities, 41 Urban Indian Organizations, 21 and 11 Indian Health Boards. 22 Given this wide array of health systems, there should be ample opportunity for preventive medicine physicians to engage in rural and Tribal health activities. As physicians trained in public health, preventive medicine specialists can participate and lead all the standard functions of a public health program, such as leading epidemiologic investigations, collecting data and performing statistical analyses, making judgements on how best to apply the results of those analyses, identifying hazards and implementing harm reduction and risk mitigation strategies. In addition, as licensed physicians, preventive medicine specialists can also provide direct patient care and be involved in clinical activities such as quality improvement, ongoing and focused professional practice evaluation, etc. This can occur at public health clinics like a tuberculosis control clinic or a maternal-child health clinic, or it can occur within clinical health systems, presumably those interested in maintaining or improving public health. The COVID-19 pandemic has revealed the fragility of rural and Tribal health. 23, 24 It is precisely for situations such as this that the preventive medicine specialty should be integrated within health systems, linking patient care and population health in the context of public health to prevent disease and promote health. In short, preventive medicine physicians can ensure both that clinical activities are meeting standards of care, that public health activities are informed by clinical information, and vice-versa. It is exactly this ability to straddle both worlds that makes the Preventive Medicine physician unique. However, merely parachuting a brigade of preventive medicine physicians into a rural or Tribal area alone cannot does not guarantee that they will immediately integrate well into those communities. Journal Pre-proof J o u r n a l P r e -p r o o f Just as standard clinicians may not be well-prepared for rural or Tribal practice, a parallel question could be asked of the preventive medicine specialty: Are preventive medicine physicians prepared for rural or Tribal practice? Simple measures can be taken to assess the state of preventive medicine in rural and Tribal public health. Although voluminous references direct attention to rural health and AI/AN health, the authors could find no publications related to the search terms -preventive medicine physician‖ along with either -American Indian‖ or -Rural‖ in PubMed. This evident lack of publications describing the rural or Tribal practice patterns of preventive medicine physicians precludes the opportunity to identify the number of preventive medicine physicians who practice with rural or Tribal populations. Unfortunately, there is no reason to believe that preventive medicine physicians currently practice with rural or Tribal populations at higher rates than other clinicians. As an aside, one difficulty in assessing the effect of preventive medicine physicians may be that, unlike direct-patient care providers, a preventive medicine physician's practice location may not necessarily rule out rural or Tribal practice (e.g., a health department located within a city, but focused on large rural geographic areas surrounding the metropolitan area), so a descriptive measure of the population being addressed is likely a better gauge of rural or Tribal practice than the physical location of the preventive medicine physician's activity. Rural and Tribal health issues are unique and require direct attention. A public health approach to these health issues is likely to result in the most sustained improvements to health. The paths of public health and preventive medicine are inextricably linked. The pursuit of improved health status through public health programming would benefit from specific and active recruitment and inclusion of preventive medicine specialists. If public health and population health are the mechanism by which rural and Tribal health are to be addressed, as the authors believe it should be, preventive medicine physicians should have a role in these efforts. Training programs for preventive medicine physicians specially tailored to addresses the public health needs of rural and Tribal populations may be the best way to prepare and develop preventive medicine specialists for this critically important work. Twice Invisible: Understanding Rural Native America. 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