key: cord-0745472-pzwh25fx authors: Jadotte, Yuri T.; Lane, Dorothy S. title: Core functions, knowledge bases and essential services: A proposed prescription for the evolution of the preventive medicine specialty date: 2020-10-14 journal: Prev Med DOI: 10.1016/j.ypmed.2020.106286 sha: 74dc98647922a2075f9f1918e453558c26601bba doc_id: 745472 cord_uid: pzwh25fx The pandemonium from the 2020 pandemic calls for a greater emphasis on prevention, public health and population health. Yet the role of preventive medicine specialists, ideally qualified to lead this charge, remains difficult to situate within the houses of medicine and public health. To overcome this challenge to its identity and evolve to better tackle novel and on-going public health and population health problems, the authors propose that the specialty of preventive medicine should assert 3 core functions within preventive care; expand and modernize its knowledge base; and enhance its residency training accordingly. The authors also propose 10 essential services, not otherwise systematically provided by other specialties, that the preventive medicine specialty can optimally fulfill as its unique contributions within medicine and public health. It is the authors' view that the pandemonium created by the 2020 pandemic was a call for medicine and public health to prioritize prevention and health over treatment and disease. Medical schools and healthcare institutions aim to improve human health, 1 yet medicine is neither health-nor population-centric despite longstanding calls to adapt. 2 Primary, secondary and tertiary prevention are all grounded in the pathogenic viewpoint, i.e. the prevention of risk factors, diseases, disabilities and deaths, respectively. 3 Prevention denotes the avoidance of disease or disability, but only connotes the pursuit of health and well-being. Health still lacks a formal accepted definition that fully excludes the term disease 4 and a clear scientific understanding of its nature; yet it is the mantra of many stakeholders (ex. health coaches, public health practitioners) and socio-professional movements (ex. population health, health and wellness). Existing public health and healthcare system approaches, even in developed nations, fail to mitigate much less contain pandemics or address ongoing population health crises. Although politics, economics and policies have long undervalued and underfunded public health and population health, this lack of a cohesive approach to health promotion and protection is rooted in medicine and public health's disease-centric modus operandi. 5 A unified specialty area of Public Health and General Preventive Medicine, herein referred to as Preventive Medicine or PM, ought to lead medicine and public health to adopt more healthcentric approaches. Unfortunately, the continued self-segregation of PM specialists based on their designation as public health, population health, or health and wellness physicians 5 diminishes intuitive recognition of the specialty by other physicians, public health professionals and the public, further perpetuating the specialty's perceived identity problem. 6 The specialty's perceived equivalence problem, thought to chiefly reside in the lack of distinctiveness in the structure and content of its residency training relative to other specialties, 7 further sows confusion. To overcome these challenges and help PM specialists emerge as recognizable leaders of the science of health in medicine and public health, the authors propose that the specialty should assert 3 core functions within preventive care, expand and modernize its knowledge base, and enhance residency training accordingly. The authors also propose 10 essential services, not systematically provided by other specialties, that the PM specialty, thus evolved, would optimally fulfill in medicine, public health and society. J o u r n a l P r e -p r o o f Journal Pre-proof Core functions serve as an articulation or operationalization of the mission of a profession or specialty, particularly when this mission is unclear to the general public, relevant organizations or members of the profession or specialty itself. 8 Preventive Medicine still needs to clearly situate itself within the houses of medicine and public health to facilitate simple recognition of who PM specialists are and what they do. The 2020 pandemic provides an opportunity and mandate to address this need. Preventive medicine physicians are experts in preventive care, as compared to primary, secondary and tertiary care. Using this known continuum of care, PM should highlight its unique qualifications to perform 3 proposed core functions that the authors believe cover the spectrum of practice of PM specialists: community medicine, 9 population medicine, 10 and clinical preventive medicine (CPM). 5 Community medicine, which entails the preservation and restitution of health for persons and social groups within geo-politically designated communities, 9 could convey the core function of PM specialists within public health systems (i.e. macro-level preventive care such as health policies, laws and regulations). Population medicine, a term for the epidemiologic approach to the management of clinical services, 10 could designate the indirect patient care core function of PM specialists within healthcare systems (i.e. meso-level preventive care such as quality improvement and patient safety interventions). Clinical preventive medicine, which consists of direct patient care, could denote the core function of PM specialists in clinical care (i.e. microlevel preventive care such as clinical preventive services and lifestyle medicine interventions), and may be provided both within and outside the bounds of a given public health or healthcare system or practice setting. Although primary care specialties clearly do some preventive care, PM possesses a multisystems perspective that is otherwise woefully lacking in preventive care and is ideally suited to the task of integrating primary care and public health. 11 Emergency preparedness failures in healthcare and public health systems during the COVID-19 pandemic confirm this lack of integration. Aside from mastery of actionable core functions, the possession of a unique knowledge base also distinguishes a specialty. In addition to general preventive medicine and public health as foundational fields of knowledge shared with other specialties and professions, PM should achieve expertise in salutogenesis, 12 evolutionary sciences, 13 human ecology, 14 lifestyle medicine, integrative medicine, 15 and advanced research methodologies. This would build upon the PM specialist's knowledge of biostatistics, epidemiology, social and behavioral sciences, health services administration and environmental health sciences, to further distinguish PM from other medical specialties. Table 1 Similarly, robust quality improvement, clinical epidemiology, communicable disease control and surveillance, and public health field deployment opportunities should be developed and expanded locally, regionally and nationally, and supported by residency funding agencies and healthcare systems. This would sustain a pipeline of highly qualified PM specialists to further increase national capacity to meet local or regional needs, providing adequate coverage to systematically tackle population and public health issues everywhere. In the realm of direct patient care, many PM residency programs have implemented lifestyle medicine clinics or consult services, while others have trained residents to deliver clinical preventive services via telehealth. To achieve widespread expertise in this realm, such rotations should be replicated, scaled up and adopted by all PM programs nationally. Essential services are practical functions performed by a specialty/profession in response to societal needs. 18 Achievement of an essential service reflects complex interactions between training competencies and contextual factors (ex. technology, organizational culture, and community characteristics). 19 Although the PM specialty's residency training competencies are partly informed by the essential public health services, 6 Within healthcare systems, where the PM specialist would perform the population medicine core function, PM specialists would be credentialed and privileged to provide clinical epidemiology and medical quality improvement services, including expert guidance on patient panel management, thereby freeing up other physicians to do additional direct patient care. They would develop, implement and innovate in the healthcare system's emergency preparedness plans to assure that business and financial decisions are counterbalanced by medical and public health evidence as guidelines and best practices change. They would also provide direct patient care, when desired, as a specialty service for lifestyle medicine, clinical preventive services, and evidence-based integrative medicine (ex. acute and chronic inpatient or outpatient care) in certain employment settings to be able to sustain their clinical practice productivity and meet their expected relative value units and volume-driven reimbursements. 22 This would help eliminate common misconceptions about PM doctors and practicing medicine. 23 J o u r n a l P r e -p r o o f Journal Pre-proof Among PM specialists with clinical practices, the essential services tied to the clinical preventive medicine core function would take place via lifestyle medicine, clinical preventive services, and evidence-based integrative medicine. In addition to the preventive patient care services already mentioned, PM specialists would become sought-after consultants to primary and specialty care providers, and collaborators for integrative medicine 15 and other health professionals. They would oversee evidence-based integrative medicine therapies to facilitate safe and holistic health and wellness services, a critical role in the context of novel, painful, incurable or terminal illnesses, when people eagerly seek integrative medicine therapies without a definitive source of sound medical guidance. They would also serve as consultants for clinical preventive services and lifestyle medicine within primary care or multi-specialty practices where such expertise is desired. This is crucial to patient safety as other physicians without population or public health training increasingly try to address the social determinants of health, a service that PM specialists are optimally trained to perform. By taking these proposed prescriptions, PM should no longer be searching for a cure to its perennial purported identity and equivalence problems. Although many of the proposed ideas are new to the specialty and need to be further evaluated and validated prior to their adoption by the specialty, the authors believe that PM should evolve as prescribed to become a more distinct and recognizable specialty, if it is to lead population health and public health efforts. The authors propose that PM specialists boldly expand their fields of knowledge, embrace their 3 core functions in preventive care, and be prepared to optimally deliver 10 essential services as their unique contributions to medicine, public health and society. J o u r n a l P r e -p r o o f A single mission for academic medicine: improving health A perspective on educating physicians for prevention An operational classification of disease prevention What is the WHO definition of health. Frequently Asked Questions Web site The Emerging Identity of the Preventive Medicine Specialty: A Model for the Population Health Transition Preventive Medicine's Identity Crisis. American journal of preventive medicine Preventive medicine's equivalence problem Defining Public Health Practice: 25 Years of the 10 Essential Public Health Services A dictionary of epidemiology Primary Care and Public Health: Exploring Integration to Improve Population Health. Committee on Integrating Primary Care and Public Health Board on Population Health and Public Health Practice The Handbook of Salutogenesis Evolutionary medicine: its scope, interest and potential Human ecology theory Preventive Medicine, Integrative Medicine & the Health of the Public. Paper presented at: IOM Summit on Integrative Medicine and the Health of the Public Evolving health: the origins of illness and how the modern world is making us sick The essential services of public health The ghost map: The story of London's most terrifying epidemic--and how it changed science, cities, and the modern world. Penguin; 2006. 21 Using normalized RVU reporting to evaluate physician productivity: one physician organization demonstrates how innovation can result in a substantially better tool for measuring physician productivity Do preventive medicine physicians practice medicine? Preventive medicine