Like most people who go into medicine, Paul Spiegel assumed when he started out that he'd be treating individual patients. But after finishing his internship, he went to work for a year in a Sudanese refugee camp in Kenya and found he really loved working with whole populations.
"When I came back to Toronto," Spiegel recalled, "I tried to continue my internal medicine residency but felt suffocated by it. I was miserable and left after six months."
A sad tale of a medical career gone bust? Not at all. Spiegel, last year's chief resident of the Preventive Medicine Residency Program at the School of Public Health, is merely recounting an example of the circuitous path that many physicians specializing in preventive medicine must travel before finding their niche.
Even though the American Board of Medical Specialties has recognized preventive medicine as a specialty for the past 30 years, PM is still poorly publicized by most schools of medicine.
At the Hopkins School of Medicine, among the numerous electives residents and students may take in addition to the required core rotations is a one-month PM concentration.
A separate and autonomous two-year residency in preventive medicine is available at the School of Public Health, for those physicians who have completed a clinical residency but who decide on a career in public health. During the first year of the full PM residency, students complete a master of public health degree; the second year, they do rotations, each lasting two to three months, in epidemiology; administration and planning; and clinical PM or occupational medicine, or both. These rotations can take place anywhere in the world, but most residents stay within the United States.
"Eight medical students and two residents undertook a one-month elective in preventive medicine this year," Spiegel said, "only one of whom is from the School of Medicine here at Hopkins. The rest came from all over the country. This number has tripled from previous years."
In clinical medicine, the general paradigm is that a physician takes care of sick patients one at a time. The 4,200 board-certified preventive medicine physicians in the United States, however, consider whole populations as their patients--an urban community, for example, or a refugee camp, or a group of people living near a hazardous waste site--and work to maximize the health of the whole group.
"Although we in preventive medicine are physicians," said Spiegel, "we don't see most of our patients in the examining room. Clinically, I'm a general practitioner and I enjoy my patients, but my specialty is PM." The PM physician uses all the tools of public health--epidemiology, biostatistics and a knowledge of delivery systems--to help a well-defined population, such as an employee group.
Miriam Alexander, who directs the general preventive medicine residency at the School of Public Health as well as the school's master of public health program, took a roundabout route to her career as well. "I had a nutrition background," she said, "and had done research in maternal and child health. Preventive medicine allowed me to combine my interests in medicine, nutrition, and maternal and child health to develop a career that would address population-based health problems."
PM residents at Hopkins have the opportunity to volunteer in two community-based programs in Baltimore. The first is called the Shepherd's Clinic, a health service, located at North Avenue and St. Paul Street, that is meant to serve the working poor. "The indigent have Medicaid," Spiegel pointed out, "and many people who work have insurance, but there is little concern in this country for those working Americans whose employers provide no or inadequate health insurance."
All Hopkins PM residents volunteer at the Shepherd's Clinic one night per week doing regular clinical work and, because they are preventive medicine specialists, discussing lifestyle choices with patients. At the clinic, patients are eligible to be seen if they have a fixed address and are ineligible for Medicare and Medicaid. Those without jobs pay $4 per visit; those with jobs are charged a fee equal to one hour of their salary.
Since January 1998, the PM residents also have been operating a second community-based program, Reading for Life, which was started by a Hopkins researcher three years ago to help elementary school children learn to read. Every Thursday at 2:45 p.m., 40 volunteers converge on the cafeteria of the Preclinical Teaching Building in East Baltimore, where they pair up with 40 children from the Tench Tilghman Elementary School. Each volunteer, or "preceptor," commits to working with a single child for one school term, helping that child to read.
"We have a waiting list of people who want to be reading preceptors," Spiegel said, "but since we only have one school bus, we can only serve 40 kids. If we manage to find another bus, we'll bring along another 40 kids and so will need more volunteers."
At the end of their residency, PM candidates take boards as would any other specialist and are then deemed competent to manage whole populations. From there, graduates go on to careers as diverse as solving drinking water problems, developing breast cancer screening initiatives, running health departments and managing injured populations.
As U.S. health care sharpens its focus on preventing disease and promoting health, demand for the population-based medicine practiced by preventive medicine specialists is growing.
"The opportunities are endless," Alexander said. "And since you're both a public health practitioner and a clinician, the PM residency gives you the skills to become a leader."
Alexander is hoping to develop joint programs with primary care residencies in the School of Medicine so that physicians can combine complete clinical training in internal medicine or pediatrics with a full preventive medicine residency. This will allow students to blend the skills of clinical medicine with those of population-based medicine. Undergraduate premed students interested in learning about the preventive medicine residency can attend a course, organized by PM residents, which is given during intersession on the Homewood campus. Stephen Hill, of the School of Public Health, is the administrator.