Will you blossom in public health medicine?BMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7097.2 (Published 21 June 1997) Cite this as: BMJ 1997;314:S2-7097
- David Pencheon, Consultant in public health medicine
Cambridge consultant and academic David Pencheon discusses the prospects for the budding public health physician.
Public health medicine is the medical specialty devoted to improving health in populations rather than treating illnesses in individuals. The specialty has always had a profound impact on the health of the population in the UK, particularly at the turn of the last century. It continues to have an important effect both within health care and on the other (often more important) determinants of health, such as housing, employment, and the environment.
What do we do?
In Britain most public health physicians work for health authorities, health boards or their equivalent, in the communicable diseases centres, or in the armed forces. An increasing number work, either part or full time, in trusts or in primary care, and some work outside the health service-where, after all, most health is won or lost-in local government, a relationship which dates back into the 19th century.
Public health physicians tend to be subdivided into those who are consultants in communicable disease control (CCDC) or their equivalents full time and the majority who are involved in wider health care strategy, and who only get involved in communicable disease control work when on call. Although it is easy to recognise, for example, surgeons, by looking at what they do in a day, the range of professional activities with which public health physicians are associated is much broader. Some provide the medical input into the strategic decision making of health authorities. Others spend much of their time identifying those areas of health care that can be improved, either in making the health service more effective, more efficient and more equitable, or more widely in the field of health promotion. Understandably the increasing agenda of evidence based health care and clinical epidemiology falls the way of many people in public health medicine.
Qualities sought in applicants
Public health medicine differs from many other disciplines in important ways
it is a discipline of methods as well as knowledge
practitioners need a very broad knowledge of the health service, without being diverted or distracted by details. In short they need the ability to be able to see the bigger and more strategic picture and ability to ask the most pertinent questions
there is often a more overt political dimension to the work within public health medicine, both tactically and strategically
like GPs many of the skills needed to do the job are generic, transferable and personality dependent: to be able to communicate well, to summarise well, to sort the wheat from the chaff, to identify and prioritise soluble problems.
Skills being sought are therefore the ability to
learn quickly, to see the essentials of a situation, to master a brief, and to identify the soluble elements of important problems, and to develop skills that one may want to specialise in and trade
think broadly, laterally, innovatively, quickly and sensibly
be a clear, sensitive, diplomatic, and courteous communicator and presenter
to manage and sort problems/opportunities and the related PROCESS (in terms of identifying, clarifying, refining, framing, and solving problems). In addition you will need:
the determination to be persistent, assertive, confident, competentÑthat is, a finisher
the motivation to be self starting, survive without a dependence on excessive guidance, a proactive desire to change things (a missionary/scientist blend) and a passion to change things thoughtfully.
Why choose it?
Don't necessarily. Like most specialties, only some people blossom. It is only when you know how you and the discipline will work together that you can determine whether it will allow you to contribute, develop, be fulfilled and be valued. If you give or need careers advice make contact with your local faculty adviser and be aware of the profound and unexpected pressures that come to play on those who enter the discipline.
There are about 800 practising public health doctors at consultant level in the UK today and about 350 in training as specialist registrars. Each year 40 or 50 trainees are recruited to the discipline. The application process is becoming more competitive, both in terms of quality and quantity of applicants. The interview procedures are becoming more sophisticated as interview panels seek to offer appointments to those who most clearly match the person specification.
People who have most of the above attributes-and the confidence to use and develop them-will thrive in the discipline. Those who look for quick fixes, get bogged down in the minutiae, have no particular passion to make things better, and who wish to please everyone, can become fed up in public health medicine very quickly. The most common reasons for people feeling they have made an inappropriate career move are easy to understand. The transition from the clinical world of a trust or GP surgery is not easy. In that setting you are a respected, understood, appreciated, highly trained and knowledgeable clinician; someone who always has the individual patient's best interest at heart. The positive fruits of your effort- in terms of clinical benefit, gratitude, or both-are reaped reasonably quickly. The non-clinical world of a health authority or academic unit offers a stark contrast to the raw recruit: you will be perceived by clinical colleagues as someone who may threaten their service, may never see the fruits of your efforts, and rarely receive gratitude from outside the immediate team. This is particularly common in the first couple of years. However, most people eventually develop a confidence and competence to tackle problems in a way that maintains self esteem and which is highly rewarding, both to the individual and others.
After you have been accepted on to a five year training scheme, you are likely to spend about a year in a part or full time academic course that will usually lead to a masters or diploma in public health and give the necessary training to take Part 1 of the membership examination of the Faculty of Public Health Medicine. Epidemiology is always cited as the key subject underpinning the discipline, although many other skills are necessary: demography, communicable diseases, health economics, health promotion, health information management, medical sociology, critical appraisal, and getting research into practice. The most important skill is the willingness to develop the skills, and to use a pre-existing passion to change things, in order to make things relating to health and health care better. One of the great advantages of training is the opportunity to tailor your own training to meet your chosen professional development. This involves identifying your interests and skills, even if embryonic, and identifying the best ways to develop them. This may be threatening and a disadvantage for those who like a routine non-personalised training laid out before them. It can involve working in another part of the country temporarily or with another organisation such as the Health Education Authority in the UK, the World Health Organisation, or a non-governmental organisation (NGO). The result is close relationships between many people working in public health medicine and those who work overseas and in politics.
How do I start?
You must have two years of post-registration general professional training, at least one of which is in a clinical job. A higher degree or diploma (MRCGP, MRCP, MBA, PhD) is not essential but desirable. Contact the public health faculty (see box) for full details of education and training in the specialty. Get the names and talk to your local faculty adviser or training location coordinator. Clearly the broader and longer your experience, the more you will be able to contribute. Jobs are listed in the public health section of the BMJ's classified supplement.
Public health physicians increasingly work with other non-medical public health professionals, such as medical geographers, information analysts, community health workers, and environmental health officers. Furthermore, public health physicians, like many other professionals, are unlikely to be working in an environment where they will be offered jobs for life. More likely, public health physicians will build up a set of explicit skills and a body of complementary knowledge which will allow them to serve the public health via a wide range of employers and organisations, underlining the importance of developing a career portfolio1 which explicitly identifies key skills maintained on a broad generic base.
Faculty of Public Health Medicine, 4 St andrew's Place, London NW1 4LBPhone 0171 935 0243 Fax 0171 224 6973
Look at the Faculty's Home page on the World Wide Web: http://fester.his.path.cam.ac.uk/phealth/fphm.htm