Careers in . . . public healthBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4653 (Published 18 November 2009) Cite this as: BMJ 2009;339:b4653
Kate Mandeville outlines the training and work you should expect during a career in public health
Ever since I wrote an article for BMJ Careers “coming out” with my desire to be a public health specialist,1 I have been receiving furtive emails from similar minded individuals. “Please help me,” they usually start, “I want to go into public health, but I don’t know how to find out more.” I write back reassuringly, wanting to reach out to these underground enthusiasts, “It’s all right—you’re perfectly normal. Lots of people want to go into public health.”
Public health has never had the highest profile among medical careers. There are few role models at medical school, and any teaching is usually focused around statistics. Practically the only time public health is mentioned once students qualify is in hospital when there is a notifiable disease case to sort out.
Yet public health is one of the most exciting specialties around (box 1). Where else would you have the opportunity to organise an immunisation campaign that will affect millions of people? Or devise policy that will shape the health system for decades to come? That’s without mentioning the international opportunities and balanced lifestyle. It’s little wonder that the competition for specialist trainee (ST) year one entry in 2008 was one of the highest for all specialties, with 18 applications for each post.
Box 1: Reasons to go into public health
To improve the health of the population, not just individual patients
To prevent people becoming ill in the first place
To handle outbreaks and epidemics
To obtain high profile policy positions
To work in international health
To enjoy an excellent work-life balance
What is public health?
One question that all trainees in public health quickly grow to anticipate is, “But what exactly is public health?”
Public health is “the science and art of prolonging life, preventing disease, and promoting health, through the organised efforts of society.”2 Just as clinical doctors look after the health of individual patients, public health doctors look after the population’s health. Hospital doctors may weigh up the value of a new treatment in one specific patient, whereas public health doctors would evaluate the benefit of that new treatment across the whole population.
Many different skills other than those gained in medical school are therefore needed in order to specialise in public health. It really is time to look at the bigger picture, and that includes economics, sociology, management, and, yes, even statistics.
Entry to public health training
Entry to public health is now at ST1 level. This is a major change because public health used to be a late entry specialty, usually done after gaining membership of another specialty. Shortlisted candidates will go on to an assessment day. These vary according to region, but are usually a combination of aptitude tests and objective structured clinical exam type stations. There are also ST1 academic clinical fellow posts available.
Another major change in recent years is the acceptance of non-medics on the training scheme. This recognises the potential contribution to public health that individuals from many different backgrounds can bring. Non-medics train alongside medics, but are entered on a different specialist register at the end of training.
Training is five years, divided into three phases. The first two years usually consist of work in a primary care trust, and a masters degree in public health, paid for by your deanery. Three to four months in a local health protection unit is also required in phase 1. There are no on calls during this phase, and pay is unbanded.
Completion of part A of the membership examinations for the Faculty of Public Health and the health protection placement allows passage into phase 2. On calls begin at this stage of training, usually banded at 1C.
Passing part B of the membership examinations marks transition into the final phase of training. Here, diverse placements can be chosen for individual training, including stints at the Department of Health, the National Institute for Health and Clinical Excellence, the King’s Fund, the World Health Organization (WHO), and academic placements.
Sudeep Chand is an ST5 working in the Global Health Team at the Department of Health, and was recently seconded to WHO. “I had been doing some work on the international response to swine flu,” he says. “We had worked closely with WHO and they suggested they could do with an extra pair of hands,” A typical day was spent “running around the corridors of WHO and watching Margaret Chan in action.”
Dual accreditation with another specialty is not yet possible, but it is under discussion. If you would like to maintain patient contact throughout your career, it is probably best to specialise first, then enter public health training.
Part A of the membership examinations for the Faculty of Public Health is usually taken after about 18 months of training. It has an extensive syllabus, including epidemiology, statistics, management, and critical appraisal.
Part B is usually taken about six to nine months after part A. It is an objective structured clinical exam-type examination, with stations covering a range of common public health scenarios.
After passing both, you are officially a member of the Faculty of Public Health.
Life as a trainee
Life as a public health trainee is very different to being on the wards. Firstly, there is little or no patient contact. Moreover, you are often the only medic on the public health team. Although you will be using your medical knowledge and clinical experience every day, you will also be rapidly developing your skills of communication, negotiation, and strategic thinking.
Jennifer Hall is an ST3 in London and entered public health after her foundation programme. “Although I did enjoy my clinical years I felt like most of the time I was ‘fire fighting’ and that I would be able to make a much bigger difference working upstream in public health.”
She enjoys the opportunities open to public health trainees, “Being given responsibility for project areas and the chance to lead groups is an opportunity seldom afforded to junior doctors of my level in hospitals. Also it’s great to be involved with topical issues such as swine flu.”
There are downsides to the training, however. “The lack of clinical contact is an obvious disadvantage,” says Dr Hall. “Job satisfaction can be a long time coming rather than the immediate satisfaction of curing someone. There is also a considerable pay cut owing to being unbanded, although for many people this is offset by the reduction in working hours. Having to explain to everyone exactly what you do is also a little frustrating” (box 2).
Box 2: Likely responses from your colleagues to your career plans
“What a waste”
“Can’t handle patients, eh?”
“You’re going to spend your life on statistics?”
Possible responses to your colleagues
“And do you know where the Tamiflu stockpile is?”
“When’s your next week of nights?”
“That’s true—the World Health Organization’s special representative to the Pacific Islands doesn’t really compare to Colchester General”
Life as a consultant
When training is completed, a vast range of job options is available. For example, you could be a consultant in communicable diseases, an associate director of public health in a primary care trust, or a consultant at the Department of Health. The choice really depends on your interests and skills.
There are currently plans to expand the public health workforce, so there should be more consultant posts available in the future. Public health is more vulnerable to cuts and reorganisations than other consultant posts, however, and most consultants expect to change jobs several times during their career.
Ike Anya is a newly qualified consultant and works in a large primary care trust. “I enjoy the variety of my job—no two days are ever the same,” he says. “One day I might be dealing with a local outbreak, and another I might be presenting to school heads on increasing physical activity in schools.” He feels the main challenges of public health are “the long time scales for completing projects and observing outcomes, which requires continued motivation. You may sometimes be pushing a minority view and that requires commitment.”
Professor Martin McKee works at the London School of Hygiene and Tropical Medicine and was a medical registrar before making the decision to train in public health. “I was seeing patients in my outpatient clinic in Belfast with scurvy and beri-beri,” he says. “Although I knew almost nothing about public health, the importance of tackling the social determinants of disease was all too apparent. I was also increasingly dissatisfied with how we organised our work in hospitals, and I recognised that I needed new skills I was unlikely to acquire where I was.”
He is pleased with his career choice. “Firstly, it embraces so many different issues. Secondly, I have the satisfaction of knowing that we do make a difference, with our work cited in recent European Union legislation on public health. And finally, although I admit that the novelty has long worn off, my job has allowed me to visit about 80 countries.”
How do I get into public health?
If you recognise yourself anywhere in this article, there are a few ways to explore public health as a career choice. Look at the websites in box 3. Read the Oxford Handbook of Public Health Practice—this is concise and a handy introduction to many topics. If you have the opportunity, arrange a placement at a local public health organisation.
Jennifer Hall agrees. “Public health has been a very competitive specialty over the past few years,” she says. “My main piece of advice would be to organise some sort of taster at your local primary care trust, as this will not only show your interest but also help you to see what it is really like to work in public health. Even if you are working in a hospital, there are things you can do that are related to public health; for example, I did an audit on meticillin resistant Staphylococcus aureus (MRSA).
I think that demonstrating an interest and being proactive are things that the assessors really look for—I applied straight from foundation year two with no formal public health experience and they accepted me.”
Most importantly, be persistent. Public health is not pushed as a possible career choice for junior doctors, but it is definitely one of the most rewarding and fascinating specialties. Be prepared to look at the bigger picture—it will be worth it.
Competing interests: None declared.