American Board of
Preventive Medicine
Careers in Preventive Medicine
in the 21st Century
Cheryl S. Barbanel, MD, MBA, MPH, FACOEM
Boston University School of Medicine
Public Health Achievements
and
Current Public Health Issues
Ten Great Public Health Achievements United States 1900 - 1999
MMWR 4/2/99/48(12);241-243.





Vaccination
Motor-vehicle safety
Safer workplaces
Control of infectious
diseases
Decline in deaths from
coronary heart disease
and stroke





Safer and healthier food
Healthier mothers and
babies
Family planning
Fluoridation of
drinking water
Recognition of tobacco
use as a health hazard
Leading
Causes of
Death
Death Rate
for Infectious
Diseases
Emerging Disease Issues







Antibiotic resistance
Foodborne and Waterborne Diseases
Vectorborne and Zoonotic Diseases
Disease transmission by blood
Chronic diseases caused by infectious agents
Vaccine development and use
Travelers, immigrants, and refugees and disease
transmission
Environmental Conditions Favoring
the Spread of Infectious Disease




Globalization of the food supply
Development projects that alter the habitat
of disease carrying insects and animals
Increased human contact with the wilderness
habitat that may harbor unknown infectious
agents
Increased use of antimicrobial agents and
pesticides hastening resistance
Demographic Conditions
Favoring the Spread of
Infectious Disease

Population growth and movement due to man
made and natural disasters

Global travel

Human behaviors such as intravenous drug use
and risky sexual behaviors
The Role of Physicians in
Public Health in Biological and
Chemical Terrorism

CDC calls for integrated training designed to
ensure core competency in public health
preparedness and the highest level of scientific
expertise on local, state and federal levels

The proportion of students of public health who
were physicians declined from 35% in 1944 to 11%
in 1978
What is Preventive Medicine?
Preventive medicine physicians work
with large population groups as well as
with individual patients to promote
health and understand the risks of
disease, injury, disability and death.
Prevention

Primary Prevention - preventing the occurrence of
disease and injury, for example by immunizations.

Secondary Prevention - early detection and
intervention, by reversing, halting or retarding the
progression of a condition.

Tertiary Prevention - minimizing the the effects of
disease and disability by surveillance and
maintenance to prevent complications.
Preventive Medicine
Competencies






Biostatistics
Epidemiology
Environmental and occupational medicine
Planning, administration, evaluation of health
services
Social and behavioral aspects of health and
disease
Practice of prevention in clinical medicine
Careers in Preventive Medicine
Preventive Medicine
Physicians Have Key Roles In:

Global environmental risk assessment

Health care systems

Prevention and control of infectious diseases
Careers in Preventive Medicine
Preventive Medicine Physicians May
Specialize In One of Three Areas:

Aerospace Medicine

Occupational Medicine

Public Health/General Preventive Medicine
Where Do Preventive Medicine
Physicians Work?






Public health agencies
Community agencies
Outpatient and primary care settings
Industry
Managed care organizations
Academia
What Do Preventive Medicine
Physicians Do?





Initiate programs in the infectious disease prevention
and control
Manage programs in public and community health
and research
Provide patient care (nearly 70%)
Identify health and safety hazards in the workplace
to prevent illness and injury
Work to improve preventive health services in the
underserved and high risk populations
The Public Health Physicians




Direct multidisciplinary teams to provide health
services on the city county or state level
Plan community intervention programs (e.g.
vaccination programs)
Serves on task forces that solves community
problems
Provides clinical services in traditional public
health areas - tuberculosis, sexually transmitted
diseases, or primary care settings
International Health Preventive
Medicine Physician
Assess Disease Risks for the Global
Environment



Diseases that have no respect for national
boundaries: AIDS/HIV and tuberculosis
Diseases more common in developing countries:
malaria, cholera
Diseases associated with under-nutrition
Preventive Medicine Physicians
in Medical Administration


Serve as director of health departments and
corporate medical departments
Work as managers of HMO’s or group
practices, community-based clinics or
university-based health centers
The Preventive Medicine
Physician in Academic
Medicine



Research and teach in medical schools, public
health schools, and other institutions
Teach clinical prevention, epidemiology, and
health services administration
Research prevention of HIV and TB
transmission, cancer, and the role of life style
modification in prevention of disease
Preventive Medicine Physician
in Clinical Practice

Identifying risk factors and methods of
intervention for chronic, occupational, infectious
disease and/or sexually transmitted diseases

Develop practice guidelines, quality assurance
and utilization review programs

Practice medicine in primary care, sports
medicine, exercise physiology, behavioral
epidemiology, addiction medicine, geriatrics or
maternal and child health
American College of Preventive
Medicine (ACPM)

National medical specialty society for physicians
committed to disease prevention and health promotion

Represent more than 2,000 physicians boarded in
preventive medicine and other specialties (e.g., family
practice, internal medicine, pediatrics, emergency
medicine, psychiatry, etc.)

Leadership in the science, policy, and practice of
preventive medicine
Preventive Medicine Trends
and
The Public Health Workforce
Public Health Workforce
Physician Trends



Small number of certified specialists in Public
Health / Preventive Medicine
Decline in proportion of self-designated
preventive medicine specialists among U.S.
physicians
Decline in total number of preventive medicine
residents with greatest decline in number of
public health residents
American Board of Preventive Medicine
Living Diplomats by Certifications
2000
Aerospace Medicine
Occupational Medicine
Public Health and / or General Preventive Medicine
TOTAL
Unduplicated* living diplomats
*Counts those with multiple PM certifications only once
922
2563
2839
6324
5966
Preventive Medicine Residency
Training
1993 - 1999*
Year
Programs
1993
1994
1995
1996
1997
1998
1999
82
85
89
89
89
90
88
Residents
441
448
434
381
438
420
426
* Source: AMA GME Database, copyright 1993-1998, Chicago IL
Distribution of Residents in
Preventive Medicine Programs
General
Preventive
35%
Public
Health
16%
Aerospace
15%
Occupational
34%
Needed Incentives to Address Public
Health Workforce Trends


Include preventive medicine explicitly in specialty
mix to meet national workforce needs
Support for infrastructure departments of
preventive medicine in medical schools
–
–

Health departments
Schools of public health / graduate MPH programs
Preserve loan forgiveness for preventive medicine
trainees
–
Add tuition reduction for academic year
Funding Sources for Preventive
Medicine Training Programs
Federal
• HRSA
• VA
• NIOSH
• CDC
• HCFA
• NASA
• NIH
• DoD
• NASA
State/Other
• Health agencies
• Public health schools
• University medical
centers
• Foundations
• National health
organizations
• Private industry
COGME Resource Paper
Preventive Medicine Workforce
Recommendations:

Increase the number of physicians with public
health competencies

Increase funding of preventive medicine residents,
programs, faculty and faculty development

Increase funding through Title VII, Medicare
GME, and National Health Services Corps
scholarships
http://www.cogme.gov/resourcemain.htm
Occupational and Environmental Medicine
A Medical Career for the 21st Century
Occupational
Medicine
The specialty devoted
to the prevention and
management of
occupational injury,
illness, disability, and
the promotion of
health and
productivity.
Environmental Medicine
The branch of medical
science devoted to the
prevention and management
of adverse health outcomes
from exposure to chemical
or physical agents in the
home and community or
their effect on the
environment.
The U.S. Workforce
• U.S. Population, 270.4 million
• U.S. Workforce, 137.2 million
• Persons employed, 131.1 million
• Employee to population ratio, 48.5%
• Male workforce, 55%
• Female workforce, 45%
Source: US Bureau of Labor Statistics 1999
Non-Fatal Occupational Injuries
8,000,000 per year
Overexertion 27.7%
Contact with objects 27%
Falls 16.2%
Exposure to toxics 4.6%
Repetitive motion 4.1%
Transportation accidents 4%
Slips/trips 3.1%
Assault 0.9%
Fires/explosions 0.2%
Source: Bureau of Labor Statistics 1999
All other 11.9%
Occupational Illness
429,800 Per Year
Disorders associated with
repeated trauma 64.3%
Skin diseases, disorders, 13.4%
Respiratory conditions due to
toxic agents, 4.7%
Disorders due to physical
agents, 3.8%
Poisoning, 1.1%
Dust diseases of the lungs,
0.6%
All other occupational
diseases, 11.7%
Source: Bureau of Labor Statistics 1999
The OEM Physician Workforce






AMA estimates 10,000 physicians who do some
occupational medicine
2,400 Board-certified occupational medicine physicians
since 1955
1,500 - 1,800 are actually in practice
National need - 5,000
Bureau of Health Professions needs estimate - 4,830
Institute of Medicine needs estimate - 3,100 - 5,50
Institute of Medicine’s Report
Safe Work in the 21st Century
Recommended an increase in the supply
of physicians and other practitioners
who have the skills to evaluate, treat and
prevent ill health in the workplace
OEM Sites of Practice







Physician’s office
OEM clinic
Multi-specialty clinic
Industrial site
Corporation headquarters
Academic institution
Governmental agencies
–
Public health service
–
Veteran’s Administration
–
Military
–
Department of Labor
–
Centers for Disease Control
and Prevention
The Occupational Medicine
Residency Program



Year 1: The clinical year (internship)
Year 2: The academic year (M.P.H., M.S. or equivalent)

Biostatistics and epidemiology

Health services organization and administration

Environmental and occupational health

Social and behavioral influences on health

Industrial hygiene

Ergonomics

Industrial toxicology

Occupational diseases
Year 3: The practicum year (study with industry)
The Practicum Year





Didactic education and topics
of occupational medicine
importance
Participate in data gathering
and analysis
Four months or more engaged
in supervised practice within
the world of work
Clinical care of workers
Management responsibilities
in planning, administration
and supervision of
occupational medicine
programs
Characteristics of the Occupational
and Environmental Medical Specialty
• Broad scope of practice
• Variety of practice settings
• Treatment of individual workers
• Population-based preventive medicine
• Resource for regulations and policies
Challenges Facing Occupational
and Environmental Medicine
• Effective use of health care resources
• Compliance with government rules and regulations
• Technological advancement and shifting work
force demographics
• Social, ethical
and moral attitudes
• Global industrial
development and its
impact on the work force
An exciting,
challenging
career awaits the
occupational and
environmental
medicine
physician in the 21st
century
Aerospace Medicine
Aerospace Medicine Definition
The specialty area of Preventive
Medicine that deals with the
clinical and preventive medical
requirements of man in
atmospheric flight and space
The Flight Surgeon

Initially this was driven by a need for qualified
military pilots to fly planes in war
The Flight Surgeon’s Role


Main function was to
first develop and
then apply physical
qualifications for
flight duty
Driven by high
losses of life due to
physically
unqualified pilots
History
After World War II the technological
advances were applied to the airline
industry. Increases in aircrew led to
increases in civilian aviation medicine.
History

In the 1960’s advances
were made to meet the
challenge of manned
flight beyond the earth’s
atmosphere. . .Aviation
Medicine evolved to
Aerospace Medicine
Aerospace Medical Issues
Related to the Requirements of
Flight and Space





Trapped air
Sinus block
Ear block
Decompression
sickness
Effects of acceleration
forces







Spatial Disorientation
Zero Gravity
Motion Sickness
Cardiovascular
Neurovestibular
Musculoskeletal
Psychiatric
How to Become a Flight Surgeon

Initially one must first be a physician
–
–

Medical School
Internship
Then must decide if you want to…
–
Do a residency in Aerospace Medicine
»
»
–
–
Civilian
Military
Or attend a short course that will permit you to do
flight medicine in the military
Or be an Aviation Medical Examiner as a civilian
Short Courses

Military
–
–
–
Air Force, Navy, and Army offer courses that range
from 6 weeks to 6 months that prepare you to be a field
flight surgeon. (Most of the actual learning in this
occurs on-the-job)
Emphasis is on being a member of the aircrew so that
you can interact with aircrew in their environment
Requires that the physician meet same physical
standards that the aircrew must meet and participate in
regular flying duties
Civilian
FAA offers training programs
for the position of Aviation
Medical Examiner (AME)
through seminars throughout the
US and through formal on-site
training at the Civil Aviation
Medicine Institute (CAMI) in
Oklahoma City.
Qualifies the physician to
perform Class 2 examinations.
Residency in Aerospace
Medicine

Offered both by the military (Navy and Air Force) and by
two civilian universities:
»
»


University of Texas Medical Branch (UTMB) at Galveston
Wright State University in Dayton, Ohio
A year of ACGME-accredited clinical training is required
for admission to the residency.
Each residency program includes an initial year of
training to obtain a masters degree in public health and a
practicum year covering the physiologic, environmental
and clinical aspects of Aerospace Medicine.
Board Certification in
Aerospace Medicine



After completing a residency in aerospace medicine
and
Qualifying for and passing the American Board of
Preventive Medicine Examination,
Board certification can be achieved in the specialty
of Aerospace Medicine.
Aerospace Medicine

There are many problems with the
abnormal environment encountered in
aviation and space. The flight surgeon
is just one of many highly trained
individuals working to minimize the
effects of these adverse effects so that
man can continue to have mastery
over the air and space.
American Board of
Preventive Medicine



Incorporated in 1948
Authorized by American Board of Medical
Specialties 1949
First Certificate Awarded in 1949
Certificates Issued 1949 - 2001
General Certificates
•
•
•
•
•
Aerospace (1953-2001)
Occupational (1955-2001)
Public Health/General Preventive (1983-2001)
Public Health (1949-1982)
General Preventive (1960-1982)
1266
3026
1623
1866
547
Subspecialty Certificates
•
•
•
Undersea Medicine (1993)
Medical Toxicology(1995-2000)
Undersea and Hyperbaric Medicine (2001)
TOTAL (1949-2001)
10
23
78
8439
Why Board Certification


Provide assurance to the public
Physician specialist certified by a Member Board of
ABMS has successfully completed
–
–

An approved educational program and evaluation
process
An examination designed to assess
Knowledge, skills and experience required to provide
quality patient care
WHAT ARE THE
REQUIREMENTS



Medical School
Graduate
Current Unrestricted
License(s)
Clinical Year of
Training (PGY-1)




Academic Year (MPH
or equivalent)
Practicum Year
Currency of Practice
Practice (Alternative
and Special Pathways)
Alternative Pathway
to Certification



Available only for medical school graduates
prior to January 1, 1984
Must document training and experience
Academic:
–
Four Core Courses
»

Biostat., Epi., Admin./Mgmt., Env. Health
Practice Experience
Combined IM/PM Training
Programs







Guidelines approved by both boards in January 1993
Update to Guidelines in preparation
At least four years formal training
Three programs approved by both boards
Must be accredited by both residency review
committees
Requirements for practicum experience
Continuity of care requirements
Potential for similar combined training with other
specialties
Medical Toxicology




Joint effort with Emergency Medicine &
Pediatrics
Approved by ABMS in 1992
Subboard established in 1992
Actions approved by Parent Boards
Undersea and Hyperbaric
Medicine

Undersea Medicine
– Approved by ABMS in 1989
– First examination given in 1992
– Name change to Undersea & Hyperbaric
Medicine approved March 18, 1999
– Exam open to other ABMS diplomates
– Exam given annually starting in November 1999
Re-certification Requirements

GENERAL
– Certificates Issued in and after 1998
are Time-Limited to 10 years
– Valid ABPM Specialty Certificate
– Unrestricted License in U.S. or Canada
– Application: Requirements of ABPM
consistent with ABMS
Re-certification Requirements

SPECIFIC
-
Maintenance of Certification (ABMS)
- Professional Standing
- Lifelong Learning & Self-Assessment
- Cognitive Expertise (Examination)
- Practice Performance Assessment
ABPM WWW Home Page

What is Available?
–
–
–
–
Application Forms
Information Book
Frequently Asked Questions & Answers
Study Guide & Exam Content Outlines
http://www.abprevmed.org
American Board of
Preventive Medicine
330 South Wells Street
Chicago, IL 60606
Tel: 303-939-ABPM [2276]
Fax: 312-939-2218
Residency Program

History

Linkages

ACGME Status

Academic Year

Format

Practicum Year
Resources






American Board of Preventive Medicine
www.abprevmed.org
American College of Occupational and
Environmental Medicine www.acoem.org
Aerospace Medical Association www.asma.org
American College of Preventive Medicine
www.acpm.org
American Public Health Association www.apha.org
Association of Teachers of Preventive Medicine
www.atpm.org
Resources (con’t)





HRSA/Bureau of Health Professionals
www.bhpr.hrsa.gov
Association of Schools of Public Health
www.asph.org
Association of Preventive Medicine Residents
www.acpm.org/apmr/htm
Accreditation Council for Graduate Medical
Education www.acgme.org
American Medical Association Fellowship and
Residency Interactive Electronic Database
www.ama-assn.org/cgi-bin/freida/freida.cgi
Sources of Information





American College of Preventive Medicine
American College of Occupational and Environmental
Medicine
Aerospace Medical Association
“Preventive Medicine and Public Health Workforce
Trends: Threats and Solutions”, a presented at
Prevention 2000 by Dorothy S. Lane, M.D., M.P.H.
CDC’s Ten Great Public Health Achievements –
United States 1900-1999
www.cdc.gov/epo/mmwr/preview/mmwrhtml/0005679
6.htm
Acknowledgements

Thanks to the members of the ABPM Client
Services and External Relations Committee for
their support and assistance with this presentation.

Thanks to Ms. Yolanda Rodriguez and Mr.
Michael Moskowitz, staff of the Boston University
Occupational Health Center for their
administrative assistance.