Time Stamps

  • 01:00 Introduction
  • 05:07 Defining Public Health
  • 11:17 Pursuing a Public Health Career
  • 20:12 Politicization of Health

Transcript

Michael: If there’s ever a time when public health becomes sexy, becomes the thing to do it’s right after a pandemic. And that’s because people really feel it when there’s a failed public health response. In this episode, we’re going to be talking about how clinicians can gear themselves up for a public health career, or at least do work that’s public health oriented. How can we take the next step in thinking about our community, the population at large, the society that we serve, especially in light of this past pandemic year. So, I’m Michael Shen. Here it is.

INTRODUCTION

Michael: Dr. Maria Carney never planned to become the commissioner of health for Nassau County. That’s because she’s actually a geriatrician and palliative care specialist by training. And when I spoke to her, I asked her how it all came to be. I really, really was struck by your story. And I want you to just tell our audience. 

Dr. Carney: Sure, I might get actually a little emotional about it, but I remember I was on my way to work. And at 8:50 in the morning, I got a page. You know, this was before cell phones are the way they are now, but I got a page from my husband and I recognize his work number. And so I was parking… I went in, I called him back and it didn’t go anywhere. Just ended. Um, I had just heard on the radio, something was happening in New York City.

Michael: The date? September 11th, 2001.

Dr. Carney: And I hadn’t heard until hours later, what happened? It just turned around. I left work. I said, I have to go. I have to go home. I had to figure out where my kids were. My third child was a baby, two were in elementary school. And I just waited at home and waited and waited about five hours later. He came in the door with debris all over him and told us a story of what happened. 

Michael: What were you feeling? 

Dr. Carney: Um, I remember such relief. Uh, I remember being just confused. I remember feeling guilty that he came home and many of my community, their significant others didn’t part of me was, uh, angry that he called his mother didn’t reach me. I joke. Um, so it was, uh, a life altering for me, my husband, my family, um, in our community. I remember just kind of making a pact, you know, with God, with whoever and just say, all right, my family’s healthy. I am going to dedicate myself to good things. But then, next thing you know, our community was asking for people in healthcare to help with public health emergency… Would you help? And I said, all right, I’m going to help. This was like my deal. I’m going to give back in some way.

Michael: So she started public health planning, inner community, and other volunteers recommended she joined the medical reserve Corps, which I had never heard of actually. It’s pretty well known a network of volunteers from medical and public health backgrounds. They’re probably in your city or County too. And her branch was organized by the Nassau County Department of Health, which you would later come to direct.

Dr. Carney: And I found that I had a voice. Nobody was thinking about the older adult who was home, who maybe didn’t have family who could drive, how are they going to get in a hurricane clean water? How are they going to make evacuation plans? So I’ve done. I had this voice for vulnerable people based on my background as a geriatrician and palliative medicine physician.

Michael: And I think that’s really cool. She’s from a non-traditional background when it comes to public health. I mean, I also love palliative care and it’s cool to think that you can go from that to becoming Commissioner of Health.

Dr. Carney: And now looking back years later, I’ve always been public health minded, population minded. I think that’s why I went into the field of geriatrics, a growing aging population policies that are needed to help us age and live independently and keep us from harm and safety and so forth. I didn’t realize I was public health minded until I had that aha moment with my family.

Michael: This idea of public health mindedness resonates with me. It makes me wonder don’t physicians have to be inherently public health minded, thinking about the larger community and population that we serve, that kind of thing. And our clinicians by the nature of what we do providing public health. Well, the answer is: not necessarily.

THE PUBLIC HEALTH LANDSCAPE

Definition of Public Health

Michael: How do you define public health? 

Dr. Gounder: Public health is about improving the health and wellbeing of people at a population level. So your patient here is really the community, the society that you’re interested in.

Michael: This is Dr. Celine Gounder.

Dr. Gounder: I’m an internist infectious disease specialist and epidemiologist as well as a medical journalist.

Michael: And she’s also on the Biden Harris COVID-19 advisory board. And what she’s saying is that public health is about serving groups of people. These groups can be as small as your local community or as large as countries and regions of the globe. And the thing is that clinicians play only a partial role in that larger system. One framework I found useful is to kind of see myself as a worker bee within the arm of public health, known as a clinical delivery system or a health delivery system. So while clinicians do serve the public, in a sense, most of us are treating individual patients at a time and thus not practicing public health, but as Dr. Carney says it doesn’t mean we can’t practice in a public health minded way.

Public Health Mindedness

Dr. Carney: I remember when I was at the Department of Health, I was at a conference and I heard this neonatologists presenting

Michael: This neonatologist to protect his patients implemented a flu vaccine program in his neonatal ICU.

Dr. Carney: He gave flu shots to the parents, the grandparents, the siblings, so that the babies went home were as safe as possible.

Michael: All of those babies and found that his flu vaccine program improved their survival.

Dr. Carney: That is a public health minded neonatologist!

Michael: He went beyond the individual patient. He saw a program, a pilot convinced leadership that this was important. He studied it.

Dr. Carney: And he impacted the public’s health without being part of the public health system.

The Landscape of Public Health

Michael: A number of us have probably dabbled or dived into systems level change in our own institutions, but what are some concrete paths to a public health career? And this is kind of selfish question because I personally am interested in a future in public health, and coming out of clinical training, I honestly don’t know where to start. What’s the lay of the land in terms of public health in America? It turns out it’s even more of a heterogeneous field than I thought. Now you’ll find different frameworks out there, but I’ve summarized it into four buckets.

The first being government level organizations, the second being non-government organizations, the third is research level infrastructure. And the fourth is actually media. So to start at the top, I think the largest bucket is the government level public health.

Dr. Carney: I think when people think about public health, they’re thinking about government.

Dr. Gounder: Which makes sense because public health is in service of people. Public service is a government function.

Michael: Largest government entity is the department of health and human services, which oversees 11 organizations. Some of which we’re really familiar with, including the FDA, the NIH, CMS center for Medicare and Medicaid services and the CDC.  

Dr. Gounder: The Centers for Disease Control and Prevention, where you’re really analyzing trends at a population level. You’re figuring out what’s the burden of disease. What are the risk factors for that disease, who’s affected and why?

Michael: And besides the CDC, other common careers are at your local or state departments of health, which is where Dr. Carney eventually found her calling.

Dr. Carney: But there are other ways to affect public health.

Michael: And this is our second bucket, which includes non-governmental organizations.

Dr. Carney: I think of March of Dimes. If you think about ARP.

Dr. Gounder: And Health or Care or Family Health International would be another example.

Michael: So, a lot of these are private non-profit organizations. And then there’s also community-based organizations.

Dr. Gounder: For example, the gay men’s health crisis in New York city as a public health organization, where they’re really historically have tried to scale up testing access to pre-exposure prophylaxis to prevent HIV. So you have all sorts of community-based organizations and some of them might, for example, work with women, who’ve experienced domestic violence. Um, they might be working with people who have been formerly incarcerated. So there’s a role to influence the public health through those careers. Doesn’t have to just be government public.

Michael: And the third bucket actually consists of, uh, the academic side, um, places where people do research for public health and population.

Dr. Gounder: So of course there’s academia. If you’re interested in studying and analysis of the problems, understanding what the drivers are, academia is another great way to pursue a career in public health.

Michael: And there’s one arm of public health that permeates our daily lives that may be overlooked. And that’s our fourth bucket. The media.

Dr. Gounder: I do think of medical journalism as another form of public health, where you’re illuminating, um, various health issues, communicating with the public. 

Michael: And if you think about, you know, how do you address these big systemic issues? A lot of that does occur through communication and information.

Dr. Gounder: And just having something published in the New England Journal of Medicine is great, but that’s not going to have an impact on policy. It’s not going to have an impact on how people vote or behave, or any of that.

Michael: And that’s a great point – it’s not making it’s way to the minds of the public, or to policy makers, if it’s just in the New England Journal. That’s where public health expertise can come in.

Dr. Gounder: And so if you want to see knowledge translated into action, you know, the, the medical journalism piece is definitely an important one.

Michael: So, to summarize the public health landscape of the U S includes: One, government health departments at all levels, as well as federal agencies, like the FDA and CDC. Two, a slew of non-governmental organizations ranging from hybrid health delivery systems to nonprofits, to community-based organizations, three academia or institutions that produce public health research and for media and medical journalism, by which we communicate science to the public. 

HOW TO PURSUE A PUBLIC HEALTH CAREER

Michael: Now, we want to take a step back and give you some practical tips for pursuing a public health career. What are the next steps for physicians who are solely clinically based to kind of gear them towards a future in public health?

Public Health Degree

Dr. Gounder: I think the most obvious route is to do a degree in public health

Michael: Masters in public health or MPH is probably the most common degree that you’re going to see, but what advantage does it give over the practical knowledge that I’ve already gained as a clinician?

Dr. Gounder: So you don’t really learn that much in the way of epidemiology, biostatistics in medical school.

Michael: And even in residency, it’s about preparing journal clubs and applying that knowledge to specific clinical scenarios.

Dr. Gounder: So the point here is to develop your analytical skills, your quantitative skills, especially about how do you collect data, how do you analyze data? What do you do with that data to inform public health work?

Michael: And one sense that I got from speaking to some of my colleagues with MPHs are that curriculums really tend to vary.

Dr. Carney: But masters of public health would include statistics, group dynamics, healthcare, advocacy, environmental health, so nature climate, um, mosquitoes, uh, water, supply safety.

Michael: And then you have more of the administrative side of things.

Dr. Gounder: But that you get into questions of budgets and human resource management and those kinds of issues, which again, you don’t learn any of those skills in medical school.

Fellowships

Michael: And definitely not in residency, either. Some related programs might include masters of public policy, public administration, or health administration. Another very common and spoken about path is the CDCs epidemiologic intelligence service program, or EIS.

Dr. Gounder: EIS is a more hands-on way of learning epidemiology. And you really do get sent on some of the cooler outbreak case investigation projects. It’s also one of the most important ways people start on the ladder of a career at the CDC. So a lot of people who work at the CDC as well as other federal agencies have gotten their start through the EIS program.

Michael: But if you can’t be a “disease detective” – which is what they call EIS fellows in the movies – there are a lot of other fellowship opportunities out there. There’s the Robert Wood Johnson Clinical Scholars program, as well as the National Clinician Scholars program. But lemme just stay this – look at your local institutions – theres probably a fellowship experience there. All you need to do is ask.

Dr. Carney: I mean, I’ve seen other people take these fellowships. Here at Northwell, we have a physician administrative leader fellowship where you go around to the different entities of the health system to really understand how they’re working.

Informal Experiental Learning

Michael: If there’s one thing I learned from Dr. Carney and Dr. Gounder it’s that there’s nothing as valuable as some hands-on experience – even if it’s not formal training or a formal degree.

Dr. Carney: Even if it’s just for two weeks, just to see how a department of health works is worthwhile. Different departments of health have different responsibilities. They may have tuberculosis clinic. So you could rotate in that, the STD clinic, the HIV clinic. So I think trying to understand what are the different programs, what are your interests and see if you can have an experience within one of those. 

Michael: In other words, find your own crash course. And I think it’s worth it to say that there is some flexibility here, and you can see it on the application for the CDCs EIS program, where they recommend either a public health degree or a year of experience doing some kind of public health work.

Dr. Carney: I don’t think most people understand the breadth of a department of health and the importance of a department of health. My advice to young physicians are find their interest, find their passion, find their niche, that they can take that knowledge beyond an individual and learn how to influence groups and what a masters of public health, a master’s in healthcare administration, a leadership program help that.

Clinical vs Public Health Work Split

Michael: If we draw from Dr Carney’s experience, maybe we should also look at some of our own careers and see glimmers of that public health mindedness that she was talking about.

Dr. Carney: I think for me, geriatrics provided that. It gave me a population-based approach. A lot of people didn’t understand what a geriatrician is capable of. That I’m an internist. I knew policy, I knew advocacy. So I had to tell individuals that as a geriatrician, I’m really capable of this. I mean, I know how to do this.

Michael: Dr. Carney alludes to one of the largest problems she sees in healthcare today, which is that the healthcare delivery arm and the public health arm are very separate from each other.

Dr. Carney: And it’s very hard to link them. So I, by chance got an opportunity because my experience volunteering and with the Medical Reserve Corps, that I was approached to throw my name in the hat, to be involved with the department of health, to be Commissioner Department of Health. I was not a traditional path. But what came out of it was once I was in the Department of Health, they in the public health system thought, “Oh, she’s not public health trained or experienced.” But I think what they saw was. I had credibility with my colleagues – with the frontline physicians, the community healthcare workers.

Michael: She brought a linkage to hospitals and physicians into public health, which doesn’t really exist. It often has to just decide one path or another. 

Dr. Carney: So I think the future of public health to be sustainable has to link with healthcare delivery better. And we haven’t done that.

Michael: State department of health ultimately accepted Dr. Carney’s two year geriatrics fellowship as equivalent to a master’s in public health.

Dr. Carney: Which a proud state to say, two years of a specialty in a population based specialty should be recognized as somewhat equivalent.

Day in the life – County Health Department

Michael: So this wouldn’t be a complete careers podcast if I didn’t ask Dr. Carney what a public health job entails and what challenges come with it. Can you describe your job at Nassau County?

Dr. Carney: My role as commissioner was to run the department of health. That could be as simple as, um, the bread and butter of public health, communicable diseases, environmental health, child, maternal services. There was management of emergency response and emergency preparedness. It was talking to community organizations trying to drive discussion or awareness of issues. It was advocating for resources to communities.

Michael: So sounds like the bread and butter is a lot of infectious disease, like foodborne pathogens, probably things like Rabies, West Nile; as well as environmental stuff like air quality and water; as well as community advocacy and emergency preparedness. This she says was all work that she loved, but there are some challenges and barriers to public health work as well.

BARRIERS AND CHALLENGES

Challenge: Fear of losing clinical skills

Dr. Carney: One of the struggles is some of the career paths keep you out of clinical work. I found in my first two years in that role, I was losing my clinical skills.

Michael: You know, as a trainee, it is scary to think that I went through all these years of training, and I’m proud of my clinical skills. Uh, I’d be scared of losing them. So Dr. Carney ended up advocating for herself to be in the clinic. Again,

Dr. Carney: Even if it’s voluntary pro bono, somehow keep your hands in it. And it feeds your ability to create policy because you’re seeing the challenges people have with healthcare. The public health system needs to encourage people to stay clinically active because, um, it links, it won’t be such a divergence of the world of healthcare delivery and public health. We need to create linkages liaisons along the way. So I think that’s something that the public health system needs to work on.

Challenge: Government moves slowly

Michael: Another issue that a lot of us are probably aware of from going to the DMV and waiting in line, is that government sometimes move slowly.

Dr. Gounder: The local and state health departments sometimes do move less quickly than you would like. Uh, some of that’s also related to budgets. Unfortunately, public health has been really historically underfunded.

Michael: Since the 2008 financial crisis, public health departments have suffered really massive budget cuts, and we’ve lost over 50,000 public health workers across the country since then.

Dr. Carney: So when you have strapped budgets, when you are short staffed, things are just not going to happen as quickly. You’re not going to be able to do everything that you want to do as quick.

Challenge: Limited funding and resources 

Michael: And perhaps the toughest challenge of a career in public health is the limiting funding, which means there are limited resources.

Dr. Carney: And it’s shrinking funding for public health has shrunken over the last 10 years dramatically. And it’s actually, COVID has been an example of a public health failure in that the response has been hospital based. 

Michael: That’s true, we’re in a pandemic and for the majority of the country, it was hospitals that were the first responders for a public health emergency.

Dr. Carney: So why is our health system that I’m in now really providing the public health role for our region? We’ve had a public health failure and it’s not a discredit to my colleagues in public health. They just have not been supported, we’re not linking with healthcare delivery. And so we really need to rethink this.

Michael: And I certainly hope that moving forward, we’ll invest more in our public health system.

Challenge: Politics

Michael: One thing that came up for me, especially with COVID is the politicization of health. That seems like very, a difficult thing in my mind. I’m wondering how you approach that.

Dr. Gounder: It’s an interesting one…

Michael: One final challenge I want to address today when it comes to public health is that of politics.

Dr. Carney: …I think sometimes in our training, um, we are told health is not political. Um, and I think we sometimes hide behind the science. Um, and I think that’s disingenuous because health is by definition political, which is different from politicization, but it is by definition political because you’re talking about the distribution of skull scarce resources, and you’re talking about disproportionate impacts on different people and that is political. Um, so that is distinct though from politicization where you make something political, where it did not need to be. So for example, masks, um, you know, that is not inherently political. Um, it was defined as a cultural symbol that made it political. So I think that, I think that distinction is important. You’re dealing with a wide variety of individuals and politics, and the very polarizing right now. If you like that, then you’re built for it, but it can be overwhelming.

Michael: But I think talking about politics head on is crucial. Doctors are known to be, and historically have been very apolitical. Just take a pre-2020 study that showed that doctors vote 9% less than the general population. And I think it’s time to change that. It’s harder and harder now to ignore the social and political context in which we work, especially with all the things that have happened in the past year with COVID-19.

PHYSICIANS ARE BUILT FOR ADVOCACY

Dr. Gounder: I think we, whether it’s as clinicians or public health workers, we bear witness, and not only do we bear witness, but we are often more empowered to speak up about what we see then our patients are for any number of reasons.

Michael: Sense that I got from speaking to both our discussions today, it’s really that physicians are geared for advocacy and being able to take it to the next step in a public health career will help you make more impact.

Dr. Gounder: If you are interested in having an impact at a population level, at a community society level, that by definition would mean a career in public health. 

Michael: I think a lot of that has to do with what we find rewarding. Um, is it alleviating pain? Is it preventing disease? Is it fixing a condition? Or is it tackling some huge societal issue?

Dr. Gounder: You know, a friend once told me it’s sort of like force equals mass times acceleration, and you have only so much force and the bigger the mass you take on the slower your acceleration is going to be. And so your timescales are going to be different. You know, doing a cardiac catheterization or an appendectomy on a patient is a much shorter timescale than addressing some of these huge public health issues. But then you’re impacting many, many more people. And so I think it’s really a question of figuring out what your personality is, what your values are and what makes sense to you.

Michael: I love physics. Um, I think we should throw in the, uh, the coefficient of friction in there somewhere.

Dr. Carney: You actually you should, uh, broaden the metaphor.

Michael: So why am I thinking about a public health career so much now? Obviously it’s cuz we’re living in what Dr. Fauci literally calls his greatest nightmare – a global pandemic. And I’m having all of these feelings about what we could have done better – it makes me want to do something about it.

The next time something big happens, and it WILL happen. The next pandemic. I want to be prepared, I want to know that I’ve done something or have thought about the bigger picture. I’m wonder if others feel the same way. 

So thanks for tuning in. I wanna thank the American College of Physicians for partnering with us on this careers series. 

If you found it helpful, please share it with your colleagues, give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us. And special thanks to our supervising editor Dr. Shreya Trivedi, co-producer Sofia Kennedy. Thank you to Preeyal Patel for the accompanying graphic, especially because it goes over somethings we didn’t get a chance to cover like potential leadership trajectories. And thank you to our listeners. We love hearing feedback, as always, so please email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.

References

  • Grande, D., Asch, D. A., & Armstrong, K. (2007). Do doctors vote?. Journal of general internal medicine, 22(5), 585-589.