77: What is Preventive Medicine? A Look at Academic Prev Med

Session 77

Dr. Janani Krishnaswami talks about Academic Preventive Medicine including what drew her to it, and what she likes and doesn't like about prev med. Janani is a preventive medicine physician in University of Texas, Rio Grande Valley.

To learn more about preventive medicine, check out all the available resources at the American College of Preventive Medicine. Also, be sure to take a listen to all our other podcasts on MedEd Media Network.

[01:22] Her Interest in Preventive Medicine

Janani says a lot of preventive medicine physicians basically end up stumbling into the specialty. Relatively a nontrad student, she had a background in investment banking and her background was in economics, public health, public policy, and international studies. And she has always been interested in the systems level aspect of medicine.

When she started doing her third year clerkship, she saw the same patterns of patients coming into the clinic with conditions that didn't seem to be cured as well as who got the illness and who suffered the most. So she got interested in attacking that angle.

Then she found out about preventive medicine as she was scouring through different programs during third year. She saw a program in internal medicine - preventive medicine track, which she thought was perfect for her. She loves interacting with patients but there was that systems element that she craved. Then she hunted around to find out more about the specialty and she was just amazed about it.

"I just hunted around to find out more about this specialty and I was just so amazed. I felt I had found a diamond in the ruff as it were."

[03:14] Why is Preventive Medicine So Hidden?

Janani thinks that even on a national level, we talk about prevention and we all know the benefits of it. But at an actual practice level, we just don't have those opportunities. And she thinks it all comes down to the financial incentives. The way residency programs are funded and the residents are paid is tied to a certain type of funding. In short, hospitals are paid to have residents in hospitals and not in community settings, not really doing prevention. And Janani believes this is a huge part of the problem. Their incentives are misaligned with their verbiage about prevention. And if there were more aligned incentives, Janani thinks you would see preventive medicine as one of the most foundational medicines in medical school itself.

"Hospitals are paid to have residents in hospitals and not really in community settings, not really doing prevention, and I think that's a huge part of the problem."

[05:40] Traits that Lead to Being a Good Preventive Medicine Physician

Janani says you have to be comfortable switching the big picture of population health and the individual patient, which has a bit of tension between the two. You also have to be very enterprising and proactive. Janani explains that the path is not always clear-cut especially if you want to do some combination of clinical medicine, public health, and you want to tie those worlds together.

Additionally, Janani thinks you have to be an early adopter as there's not a lot of preventive medicine physicians out there. She really believes that this is something that is a foundational discipline in the future. But we're not there yet. So it takes somebody who have that vision, perseverance, and passion for the field and its components.

"Systems change is very difficult and it takes somebody with perseverance and willingness to see opportunities."

[07:38] Being Initially Pulled Toward Primary Care

As she was going through medical school training, Janani admits also being pulled by other specialties such as family medicine, internal medicine, and all those bread and butter primary care specialties. The reason is that she just loves to connect with people. And that there's evidence now that the way a doctor communicates is integral to the health and improvement of a patient. And she was fascinated by this aspect. Ultimately, she wanted to do preventive medicine knowing that she couldn't change systems one patient at a time. So she needed to look at the big picture, apply her skills in systems based thinking in upstream medicine to really make a difference.

She was just so troubled by the idea that somebody should be living years less on average of their lives or poor quality of lives as a function of their race or income status. This was what pushed her to keep going with the preventive world.

[09:30] Types of Patients

Janani explains that different preventive medicine physicians are doing slightly different things. But with her experience, she works with a primarily indigent, underserved, highly diverse community by design. She adds that the communities that are often helped by preventive efforts actually tend to be at relatively lower risk for disease. While people at a higher risk for disease often miss the benefits of these types of preventive efforts. So even if these efforts are well-designed, you can still potentially widen the gap between the health disparities between rich and poor, or the different socio-economic classes.

As a result, she intended to come to an area with a tremendous medical need such as border communities like Texas-Mexico. So the patients she sees primarily fall into this class. The theory of who tends to bear the burden of chronic disease that is on average underserved minorities, that bears out in this region. They have epidemic rates of diabetes and obesity which are very preventable conditions - not just in terms of incidence and prevalence, but also the severity of these conditions.

Much of her work is trying to create systems to better address the social determinants of health and promote the health behaviors that are conducive to prevention and optimizing the quality of life.

[11:40] Typical Day

In her role as program director of the Preventive Medicine Residency Program, a lot of her time is dedicated to refining the curriculum, making sure they're meeting their goals of promoting health equity and health literacy. They're focusing on building the program's network, designing optimal educational initiatives for her residents, leading didactic sessions, and a lot of education. She would also see patients in the clinic, working with lifestyle medicine and addressing chronic disease determinants. So her days would be a mix of administrative work, patient care, general strategic thinking, team meetings, and a lot of education.

As an academic physician, Janani works closely with medical students. She is also the director of student wellness so she inculcates the principles of preventive medicine and spread awareness of the field at the school of medicine as well.

[13:30] Three Major Directions for a General Preventive Medicine Physician

Janani describes their residency as being an uplift version of the traditional hospital-based residency.

Typically, most hospital-based residencies, despite being primary care, residents tend to spend about 80-90% of their time in the hospital, maybe 10-20% of their time in a clinic or a community setting. Janani explains that their residency is split on that. They are 80% in the community and 20% in the hospital, like a tertiary care setting.

"What preventive medicine physicians do is intimately connect to the community."

Generally, a traditional general preventive medicine job and career pathway would involve working in public health and county and state health departments. Part of the job may be doing surveillance of the entire populations and communities at a local district, county, or state level. Janani stresses the importance of understanding how is the health of the community improving and changing at a population health level.

In an academic setting, the major role for preventive medicine is as program directors or faculty in preventive medicine residency programs. The other hat for general preventive medicine is working in hospital systems as health administrators or in quality improvement, data analysis, data management, statistical analysis, journals, and research. This being said, a lot of preventive medicine physicians she knows are operating sizable research initiatives and grants.

[16:20] Beyond Epidemiology

Janani explains that a major asset an MD will add to your training is the ability to actually understand the clinical system and have that perspective and option of caring for patients. For instance, a regional director for Texas and a preventive medicine board-certified MD/MPH will routinely get cases of people with complex tuberculosis. And as a physician, she can write their management plan. She can prescribe the medications and mandate directly observed therapy. At the same time, as an epidemiologist, she's able to understand how the case fits into the general patterns of TB prevalent outbreaks in the community.

It's a great asset in that you can also care for patients. You can understand the symptomology, the complications, as well as understand the big picture population health dynamics of those conditions.

[17:42] Taking Calls

Janani says that the one situation that is a possibility for preventive medicine is this pathway of working in the Centers for Disease Control (CDC) as an Epidemic Intelligence Officer for public health. So if there's an outbreak of an illness and you need to figure out where it starts from, your work as an officer is finding and discovering like interviewing. Then this is the situation where you might be on call because if something is happening, then you're deployed to that site. But this is a specific career path.

Moreover, public health officers, especially if you're working in a county, state, or federal government level, national disaster is another big thing for preventive medicine. They would have a lot of training in emergency preparedness. So if you're skilled in that area of national disaster, then you'd more likely be called down to that site.

"National disaster is another big thing for preventive medicine."

Janani says that a class well-loved by their residents is Disease Detection where they simulate outbreaks and figure out where they started, which is a very systematic and interesting process.

[20:50] The Training Path to Preventive Medicine

You can go into preventive medicine as a pure primary care physician. It requires one year of an ACGME accredited by the residency. It could be a transitional year or a prelim year. Then you would then matriculate into a preventive medicine residency program. Janani explains this path has its pros and cons. The pro being that it's a two-year residency so the entire year of training is completed in three years. For somebody who doesn't really want to have clinical practice as their backbone then this could be a good option.

But if you see yourself in primarily clinical practice, another way to go into preventive medicine is a second residency or a fellowship or a combined program which was what Janani did. So you can finish any residency and then do a preventive medicine fellowship or residency on top of that.

For the combined programs, either of family medicine, pediatrics, or internal medicine can be combined with preventive medicine.

Choosing the right one among these three paths depends on what you want to do with your training after you graduate. Janani says that if you see yourself doing more than 20% clinic a week and you enjoy interacting with patients and likes that one-on-one patient care, she recommends doing additional training beyond just a transitional year.

"The ability to handle complex cases can be strengthened by additional clinical training."

Janani mentions another viable path. A preventive medicine field called Lifestyle Medicine is focused entirely on clinical care. This is a scenario where you could do a one-year transitional and two-year preventive medicine and then practice lifestyle medicine.

Moreover, if you see yourself working in health policy or at a local, state, federal, or county office and you see yourself doing the big picture activities, outbreak investigation, and working at CDC, then your traditional one year transitional and two years preventive medicine makes more sense.

If you have any chance to practice a lot of clinical medicine that is not lifestyle medicine, Janani recommends doing preventive medicine as a fellowship.

[24:40] Competitiveness in Residency Training

Janani says this depends on the location. There are very competitive programs that are hard to get into. You really have to have a background in public health or be able to demonstrate some type of vision and mission for your work in preventive medicine. Other programs are not as competitive. So it depends on the geographic locale and the prestige of the institution. All this being said, preventive medicine is a small field. So program directors tend to know who the top candidates are as a group. She also noticed that the competitiveness of the field is increasing each year.

To be competitive, students must have some type of commitment. Experience doesn't have to be extensive, but you should be able to demonstrate a commitment to public health. In their program, they have a very strong emphasis on underserved medicine and health equity. So they're looking for somebody who has done work in underserved populations and is knowledgeable about the topics of community engagement, participatory research. They should be able to show aptitude in biostatistic epidemiology either through coursework or work in medical school.

"Research is a big cornerstone of what we do in preventive medicine... but the interview for us is key because that's where you can really tell if somebody understands the field."

Additionally, Janani reveals that the interview is key for them because this is where you can tell if somebody understands the field.

[27:20] Opportunities to Subspecialize

Aside from general preventive medicine, other subspecialty opportunities include occupational medicine, environmental medicine, aerospace medicine, addiction medicine, and lifestyle medicine. Many times general preventive medicine can be a stepping stone to these.

But what's interesting about preventive medicine is that a lot of times, they will take the equivalent experience to be able to certify in some of these added specialties. You don't necessarily have to do general preventive medicine first for many of these types of disciplines. Lifestyle medicine, and to some extent, addiction medicine, lends itself well to the general preventive medicine track.

If one is interested in environmental medicine, which includes toxicology, exposures, pesticides and workers, plastics in the environment, several colleagues completed a general preventive medicine residency and then gone on to do an environmental health fellowship.

That being said, the path is not that linear so if there's a specific interest, there are likely different pathways to get to that outcome.

[29:15] Working with Other Primary Care Physicians

There's an argument whether preventive medicine is primary care or not.

What bothers her tremendously as the director of student wellness is the rising rates of physician burnout, physician substance abuse, physician suicide, and the opioid epidemic. She thinks primary care physicians are burned out because they feel like they can't really help their patients to the extent they want to.

"I think, increasingly, primary care physicians are burned out because they feel like they can't really help their patients to the extent that they want to."

And the system of medicine is part of the problem and this can really precipitate the cycle of burnout. So Janani wishes that primary care physicians knew about their work. For lifestyle medicine practice, the goal is to help patients adhere to and comply with some of these evidence-based prescriptions for better health like diet, exercise, and emotional wellness. In that end, they're actually helping their primary colleagues get to the goal they want of healthier patients. But the problem is they tend to work separately. Public health systems are often quite separate from clinical systems and that makes it hard on both the public health and the primary care physician. So if they only had knowledge and information exchange between both entities, then there could be a healthier physician workforce.

"Public health systems are often quite separate from clinical systems and that makes it hard on both the public health and the primary care physician."

If people knew that this field of preventive medicine and lifestyle medicine existed and had opportunities for collaboration, you would see dramatic changes in the rate of chronic disease in the country, the epidemics of opioid addiction and physician burnout, and overall would just be a lot healthier.

Lifestyle is responsible for 80% of the disease. It's a staggering figure that even outweighs genetics. And we all know this stuff works but we just need to set up the communication channels and realize that each other exists. We must learn how to collaborate for better health for all.

[32:00] Working with Other Specialties

Janani they have partnerships in their school with the Department of Pediatrics, as well as those of internal medicine, obstetrics and gynecology, and family medicine. They work with issues including childhood obesity, child abuse, healthy pregnancy and postpartum care, and connecting women to contraception and promoting women's health and women's rights. They work with ensuring a healthy and safe pregnancy. So there's a variety of programs and specialties they're working with.

[33:15] Special Opportunities Outside Clinical Medicine

Janani says many of the public health workforces are part of the US Public Health Service Corps. These are physicians who work on promoting the health of the military, Air Force, etc. In terms of completely nonclinical, you could work at a state, local, or county public health departments. Your title is usually Regional Director or Local Public Health Officer or State Public Health Officer, or County Official. Janani describes these as very eye-opening roles for a new graduate. You get to learn so much from those roles.

Although many times too, a lot of the job openings can be in more small, rural communities scattered across the nation. This way, you can really have the ability to shape the health of your community. This is rewarding because your decisions, your understanding, the research that you do, and the initiatives you recommend can transform health.

"You really can have the ability to shape the health of your community."

[35:40] What She Knows Now That She Wished She Knew

Janani shares that she wished someone would have told her that change comes slowly and it doesn't mean your initiative is wrong or is not working. But patients would be the most important thing as a preventive medicine physician. It took two decades for smoking, which was once regarded as healthy and doctors recommended it, for that needle to shift. Now, we understand smoking as a harmful habit that creates lots of diseases. So the needle may move slowly but the evidence will come out in the end.

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