Preventive Medicine
PREVENTIVE MEDICINE
Preventive medicine is a specialty of medicine practiced by physicians devoted to health promotion and disease prevention. Physicians with expertise in preventive medicine are typically interested in health problems that have a significant impact on specific populations, such as those with multiple risk factors for cardiovascular disease, a highly prevalent condition. Conversely, a disease may become the focus of preventive medicine despite its low prevalence because it causes significant illness, disability, and death (e.g., a disease with a high case-fatality rate such as infection with the Ebola virus). Other health problems important to preventive medicine are those that disproportionately affect one narrow segment of a population, such as unintended pregnancies among urban adolescents.
Physicians who practice preventive medicine may work with individual patients in the delivery of clinical preventive services, or they may serve a defined population. In either case, the goal is to reduce the risk factors of the patient or the population that contribute to premature morbidity and mortality. Traditionally, in the United States, the medical and public health communities have assessed the diseases that cause the most mortality and have intervened to reduce their impact. Heart disease and cancers of all types remain leading causes of premature mortality. Recently, the emphasis has shifted from concentrating on diseases that are highly prevalent to a focus on the actual behaviors that cause these conditions. By approaching threats to good health in this way, behaviors such as smoking, unsafe sexual practices, dietary habits, and lack of exercise emerge as vitally important in determining disease or its absence. Preventive-medicine physicians embrace this approach to shape intervention strategies to target behaviors that cause disease.
The American Board of Medical Specialties recognizes preventive medicine as one of the twenty-four distinct medical specialties. Since 1950, the American Board of Preventive Medicine (ABPM) has certified over 7,800 physicians as specialists in preventive medicine. Of the living diplomates (physicians board certified by ABPM) in 1999, 2,752 were in public health/general preventive medicine, 2,442 were in occupational medicine, and 897 were in aerospace medicine. The American Medical Association database on physicians who designate themselves as preventive-medicine specialists reveals a decline in this specialty practice from 2.3 percent of all United States physicians in 1970 to 0.9 percent in 1997; the greatest decline has been in the area of public health and general preventive medicine. Although the needs of the public health work force have not been fully elucidated, and many factors determine physician specialty choice, the following contribute to declining participation in the field: the lack of awareness of the field of preventive medicine, the absence of requirements for certification in many public health and general preventive medicine positions, and inadequate funding during residency training. Despite their small numbers, experts in the field, as well as the collective action of professional societies that bring preventive-medicine specialists together, have been in the forefront among all medical specialties in clearly defining the knowledge and skills needed to master and the professional competencies to be used as the basis for residency training in preventive medicine.
Physicians who become diplomats of the American Board of Preventive Medicine are uniquely trained in both clinical and population-based medicine. Residency training requires a minimum of one year of training in an accredited clinical program, an academic year that almost always leads to a master's degree in public health (M.P.H.), and a practicum year that provides trainees with experience in the application of the knowledge and skills of preventive medicine in diverse settings.
The didactic component of preventive-medicine training provides the core knowledge and skills that encompass the major public health disciplines. The areas of public health in which a preventive-medicine physician must become competent are epidemiology; biostatistics; environmental and occupational health; planning, administration, and evaluation of health services; the behavioral aspects of health and disease; and the practice of preventive medicine in clinical settings. The first five areas represent the core of public health and are required of M.P.H. programs for certification by the Council on Education in Public Health. Epidemiolgy and biostatistics are the fields that define, describe, and quantify diseases and disease patterns; environmental and occupational health and the behavioral sciences cover major determinants of whether diseases flourish, diminish, or exist at all in populations; and planning, administration, and evaluation of health services encompass the competencies needed by programs and health care systems to address specific diseases and/or population-based health programs and evaluate the effectiveness of interventions.
Preventive medicine physicians must be skilled in the clinical practice of health promotion and disease prevention. They must also understand evidence-based medicine in order to know what screening tests and interventions are appropriate for their patients. Evidence-based medicine is a method for determining the content of clinical care that involves evaluating the scientific evidence supporting a particular diagnostic test or therapy and deciding whether the evidence is sufficient to establish the efficacy and effectiveness of an intervention. Preventive medicine physicians must have a good knowledge of this approach to medicine and must be able to incorporate the findings in their practices in order to evaluate their patients and provide appropriate counseling, testing, and preventive therapy.
Preventive medicine physicians have numerous employment opportunities. Many primarily practice population-based medicine and work for local, state, federal, or international health departments; the military; or large employers such as managed care organizations. Consulting opportunities exist for specialists in epidemiology; disease management systems; and program development, implementation, and evaluation. Preventive-medicine physicians also teach and conduct research in schools of public health and medicine and deliver direct patient care.
Miriam Alexander
Robert S. Lawrence
(see also: Clinical Preventive Services; Evidence-Based Medicine; Health Promotion and Education; Healthy People 2010; Prevention; Preventive Health Behavior; Primary Prevention; Secondary Prevention; Tertiary Prevention )
Bibliography
Lane, D. S. (2000). "A Threat to the Public Health Workforce: Evidence from Trends in Preventive Medicine Certification and Training." American Journal of Preventive Medicine 18(1):87–96.
McGinnis, J. M., and Foege, W. H. (1993). "Actual Causes of Death in the United States." Journal of the American Medical Association 270(18):2207–12.
Woolf, S. H.; Jonas, S.; and Lawrence, R. S., eds. (1996). Health Promotion and Disease Prevention in Clinical Practice. Baltimore, MD: William and Wilkins.