Vol. 14, No. 4, pp. 399-401 Printed in Great Britain
Journal of Public Health Medicine
Doctors' understanding of the specialty of Public Health Medicine: a survey of general practitioners and junior hospital doctors Simon Voss
Summary
Method
The Acheson report recommended that the new name for Community Medicine should be Public Health Medicine and that a new group of doctors with responsibility for communicable disease control be established. Three years after the report general practitioners and junior hospital doctors in one health district were surveyed regarding their understanding of the specialty. This study identified some confusion about the titles and functions of doctors in Public Health Medicine. It is important to understand this problem and make efforts to rectify it.
A questionnaire was sent to every principal and trainee in general practice (n = 92) and every junior hospital doctor (n = 62) in the health district of Salisbury. The first question asked about the role of doctors in PHM. Six possible roles were given, and the respondent was asked to' answer 'yes', 'no' or 'don't know'. These particular roles were chosen because, in the author's experience, they have all caused some confusion. Further questions asked whether the doctor thought that there was a difference between Public Health Medicine and Community Medicine, whether they had heard of the term 'Consultant in Communicable Disease Control (CCDC)' or of the 'Acheson report on Public Health in England' and whether they had seen a copy of their Director of Public Health's annual report (which had been sent to all local practices). Finally, respondents were asked to name their Director of Public Health or a local consultant in Public Health Medicine and their local CCDC or Medical Officer for Environmental Health (MOEH). The questionnaires were sent with an explanatory letter and reply paid envelope. After two weeks, non-responders were followed up with a telephone call, and where necessary a further questionnaire was sent. After receipt of questionnaires, the identification numbers were removed to preserve anonymity and the results were collated and analysed.
Introduction The Todd report in 1968 recommended the establishment of a new medical specialty to be termed 'Community Medicine', and this term was changed to 'Public Health Medicine' following the inquiry into the future development of the Public Health function in England in 1988 (the 'Acheson report').1-2 The reasons given in the report for this new title were 'to avoid . . . confusion and to return to a term which we believe is more readily comprehensible to a wide range of people at home and abroad'. The authors also stated: 'We believe that use of this new title will make the specialty more comprehensible to those outside its ranks and enable potential recruits to identify more precisely what is involved in adopting it as their chosen career.' As a new entrant into Public Health Medicine (PHM) it became evident to me that, despite the objectives of the Acheson report, most of my medical colleagues seemed to have little idea about the specialty and its roles. I therefore undertook a survey of general practitioners (GPs) and junior hospital doctors in one health districtregardingtheir knowledge about the specialty of PHM.
Department of Public Health and Epidemiology, Odstock Hospital, Salisbury, WilU. SP2 8BJ. SIMON VOSS, Registrar in Public Health Medicine Address correspondence to Dr. Voss at Wessex Institute of Public Health Medicine, Dawn House, Highcroft, Romsey Road, Winchester SO22 5DH.
© Oxford University Press 1992
JOURNAL OF PUBLIC HEALTH MEDICINE
400
Advise the Health Authority on medical matters Work in well baby and community paediatric clinics Co-ordinate control of communicable disease Develop policy on prevention of illness Are responsible for inspecting sanitary facilities
GPs (incl. trainees) n=81 Junior Hosp. Drs. n=51
Perform pre-employment medicals _L
0
10
20
30
40
50 60 % 'Yes1
70
80
90
100
FIGURE 1 Public health functions identified by other doctors.
Results The overall response rate was 86 per cent (GPs 88 per cent, junior hospital doctors 82 per cent). Regarding the specialty, 58 (72 per cent) GPs and 30 (59 per cent) junior hospital doctors thought that there is a difference between PHM and Community Medicine. Twenty-eight (35 per cent) GPs and 21 (41 per cent) junior hospital doctors had heard of the term 'Consultant in Communicable Disease Control (CCDC)'. The 'Acheson report' had been heard of by 44 (54 per cent) GPs and 17 (33 per cent) junior hospital doctors. Only 21 (26 per cent) GPs and 4 (8 per cent) junior hospital doctors had seen (or remembered having seen) a copy of their Director of Public Health's annual report. The results regarding the functions of doctors in PHM are shown in Fig. 1. Fifty-seven (70 per cent) GPs and 8 (16 per cent) junior hospital doctors correctly named their local Director of Public Health or a consultant in PHM. However, only 36 (44 per cent) GPs and just 1 (2 per cent) junior hospital doctor could name their local CCDC or MOEH.
Discussion The results of this survey are disappointing in that so few doctors seem to understand the title and roles of their colleagues in PHM or are able to name them. With the increasing involvement of PHM doctors in assessing need, advising on health policy, evaluating services-and in the control of communicable disease, they may well
be involved with the practice of doctors in other fields. This is therefore a significant finding. It is important that all doctors understand who PHM doctors are and their respective titles and roles. How many doctors in PHM have been told by medically qualified callers to their department that they had at first been directed to the Public Health Laboratory, or have had the same problem themselves when telephoning colleagues in other districts? This study identified some confusion between the roles of PHM doctors and Community Health doctors, occupational health doctors and environmental health officers. There was a common misapprehension that PHM doctors have clinical functions (in most districts they do not). The survey was conducted in a small health district where the Director of Public Health seems to be well known and respected by the local medical community. It may therefore be that the knowledge of PHM would be worse in other districts in England. The fact that junior hospital doctors were less aware of the names of the PHM doctors and CCDCs is not surprising, as they have been working in the district for a shorter time than most GPs. If hospital juniors had a better understanding of the function of PHM it would aid recruitment of high-quality doctors into the training schemes. How then can we improve the situation? Since the new NHS Act came into force, PHM doctors are becoming involved with purchasing and most Directors of Public Health have become members of health authorities. The specialty is therefore becoming more 'visible' to other doctors. Many PHM doctors have also
DOCTORS' UNDERSTANDING OF PUBLIC HEALTH MEDICINE
been involved in improving communication with GPs, in obtaining their views on secondary care services and in the formulation, jointly with clinicians, of shared protocols for the management of chronic conditions. These activities necessitate making personal contact, often in collaboration with other members of the health authority. Family Health Service Authorities (FHSAs) are now realizing the importance of obtaining Public Health advice. PHM doctors, either employed directly by FHSAs or working in collaboration with them, are developing further links with GPs. Initially, this has included discussions about health promotion clinic protocols and the use of information from practice annual reports. GP fund-holders may also require advice in the future from PHM on local needs. The specialty is well qualified to advise on this and will be aware of the problems of assessing needs based on small numbers. Having moved into PHM from general practice, I feel that many of the skills I have learnt would have been of great use to me as a GP. Some, but too few, vocational training schemes for general practice include short attachments to PHM departments. This approach should be encouraged, although it should form part of a properly designed training programme. Funding may be available from Regional Health Authorities, as has happened in West Dorset Health Authority (Dr. S. Bennett, personal communication), or from District Health Authorities. The latter may become a more attractive proposition if and when PHM is seen to provide a useful service locally. Clinical specialists are beginning to recognize the importance of some management training,3 but they would also benefit from some experience relating to PHM as part of their training. Applied epidemiology should be included more often in syllabuses for higher professional training, although facilities for attachment to PHM departments may not be available for more than a handful of clinicians. Undergraduate training usually consists of an introduction to epidemiology, but medical students would enjoy and benefit from attachments to PHM departments, as they do with any other specialty. This would help them to understand the role of PHM in the modern health service. This may not be a practical proposition, because of the current understanding of the specialty, but, as with any other specialty, any theoretical learning must be backed up with some practical application.
401
More involvement of service PHM doctors in teaching may be a way forward. As doctors in PHM learn more about the craft of management there is an increasingly common view that health service managers will need to develop some of the skills of PHM. The syllabus for the examination for membership of the Faculty of Public Health Medicine has a section on the organization and management of health care.4 With increasingly close links with our managerial colleagues, perhaps they too should receive some training about our functions, responsibilities and skills. There is potential for much closer partnership between management and PHM, and it is only by understanding our respective roles that this can be developed further. One of the aims of the annual report of the Director of Public Health should be to 'market public health'.3 This is an important method of showing the work done by departments, but the quality of reports must be kept high and the circulation wide. This study has shown that there is confusion about the titles of Public Health Medicine and consultants in communicable disease control. It is up to doctors in PHM to ensure that we become known as Directors of Public Health, Consultants (or trainees) in Public Health Medicine and Consultants in Communicable Disease Control in suitably named departments, and to make efforts to correct inappropriate terminology of the specialty.
Acknowledgements I am grateful to all general practitioners and hospital doctors who responded to the survey and to Drs. N. Armand Smith, K. Kimmance, H. Thomas and P. Old for their help and advice.
References 1
2
3
4
5
Todd AR. Report of the Royal Commission on Medical Education 1965-68. London: HMSO, 1968. Department of Health. Public health in England. (Acheson report.) London: HMSO, 1988. Gadd EM, Fletcher MF. Do senior registrars have adequate management training? Br Med J 1992; 304: 546-547. M.F.P.H.M. Part 1. 1992 Examination syllabus. London: Faculty of Public Health Medicine, 1991. Middleton J, Binysh K, Chishty V, Pollock G. How to do it: Write the annual report of the director of public health. Br MedJ 1991; 302: 521-524.
Journal of Public Health Medicine
Doctors' understanding of the specialty of Public Health Medicine: a survey of general practitioners and junior hospital doctors Simon Voss
Summary
Method
The Acheson report recommended that the new name for Community Medicine should be Public Health Medicine and that a new group of doctors with responsibility for communicable disease control be established. Three years after the report general practitioners and junior hospital doctors in one health district were surveyed regarding their understanding of the specialty. This study identified some confusion about the titles and functions of doctors in Public Health Medicine. It is important to understand this problem and make efforts to rectify it.
A questionnaire was sent to every principal and trainee in general practice (n = 92) and every junior hospital doctor (n = 62) in the health district of Salisbury. The first question asked about the role of doctors in PHM. Six possible roles were given, and the respondent was asked to' answer 'yes', 'no' or 'don't know'. These particular roles were chosen because, in the author's experience, they have all caused some confusion. Further questions asked whether the doctor thought that there was a difference between Public Health Medicine and Community Medicine, whether they had heard of the term 'Consultant in Communicable Disease Control (CCDC)' or of the 'Acheson report on Public Health in England' and whether they had seen a copy of their Director of Public Health's annual report (which had been sent to all local practices). Finally, respondents were asked to name their Director of Public Health or a local consultant in Public Health Medicine and their local CCDC or Medical Officer for Environmental Health (MOEH). The questionnaires were sent with an explanatory letter and reply paid envelope. After two weeks, non-responders were followed up with a telephone call, and where necessary a further questionnaire was sent. After receipt of questionnaires, the identification numbers were removed to preserve anonymity and the results were collated and analysed.
Introduction The Todd report in 1968 recommended the establishment of a new medical specialty to be termed 'Community Medicine', and this term was changed to 'Public Health Medicine' following the inquiry into the future development of the Public Health function in England in 1988 (the 'Acheson report').1-2 The reasons given in the report for this new title were 'to avoid . . . confusion and to return to a term which we believe is more readily comprehensible to a wide range of people at home and abroad'. The authors also stated: 'We believe that use of this new title will make the specialty more comprehensible to those outside its ranks and enable potential recruits to identify more precisely what is involved in adopting it as their chosen career.' As a new entrant into Public Health Medicine (PHM) it became evident to me that, despite the objectives of the Acheson report, most of my medical colleagues seemed to have little idea about the specialty and its roles. I therefore undertook a survey of general practitioners (GPs) and junior hospital doctors in one health districtregardingtheir knowledge about the specialty of PHM.
Department of Public Health and Epidemiology, Odstock Hospital, Salisbury, WilU. SP2 8BJ. SIMON VOSS, Registrar in Public Health Medicine Address correspondence to Dr. Voss at Wessex Institute of Public Health Medicine, Dawn House, Highcroft, Romsey Road, Winchester SO22 5DH.
© Oxford University Press 1992
JOURNAL OF PUBLIC HEALTH MEDICINE
400
Advise the Health Authority on medical matters Work in well baby and community paediatric clinics Co-ordinate control of communicable disease Develop policy on prevention of illness Are responsible for inspecting sanitary facilities
GPs (incl. trainees) n=81 Junior Hosp. Drs. n=51
Perform pre-employment medicals _L
0
10
20
30
40
50 60 % 'Yes1
70
80
90
100
FIGURE 1 Public health functions identified by other doctors.
Results The overall response rate was 86 per cent (GPs 88 per cent, junior hospital doctors 82 per cent). Regarding the specialty, 58 (72 per cent) GPs and 30 (59 per cent) junior hospital doctors thought that there is a difference between PHM and Community Medicine. Twenty-eight (35 per cent) GPs and 21 (41 per cent) junior hospital doctors had heard of the term 'Consultant in Communicable Disease Control (CCDC)'. The 'Acheson report' had been heard of by 44 (54 per cent) GPs and 17 (33 per cent) junior hospital doctors. Only 21 (26 per cent) GPs and 4 (8 per cent) junior hospital doctors had seen (or remembered having seen) a copy of their Director of Public Health's annual report. The results regarding the functions of doctors in PHM are shown in Fig. 1. Fifty-seven (70 per cent) GPs and 8 (16 per cent) junior hospital doctors correctly named their local Director of Public Health or a consultant in PHM. However, only 36 (44 per cent) GPs and just 1 (2 per cent) junior hospital doctor could name their local CCDC or MOEH.
Discussion The results of this survey are disappointing in that so few doctors seem to understand the title and roles of their colleagues in PHM or are able to name them. With the increasing involvement of PHM doctors in assessing need, advising on health policy, evaluating services-and in the control of communicable disease, they may well
be involved with the practice of doctors in other fields. This is therefore a significant finding. It is important that all doctors understand who PHM doctors are and their respective titles and roles. How many doctors in PHM have been told by medically qualified callers to their department that they had at first been directed to the Public Health Laboratory, or have had the same problem themselves when telephoning colleagues in other districts? This study identified some confusion between the roles of PHM doctors and Community Health doctors, occupational health doctors and environmental health officers. There was a common misapprehension that PHM doctors have clinical functions (in most districts they do not). The survey was conducted in a small health district where the Director of Public Health seems to be well known and respected by the local medical community. It may therefore be that the knowledge of PHM would be worse in other districts in England. The fact that junior hospital doctors were less aware of the names of the PHM doctors and CCDCs is not surprising, as they have been working in the district for a shorter time than most GPs. If hospital juniors had a better understanding of the function of PHM it would aid recruitment of high-quality doctors into the training schemes. How then can we improve the situation? Since the new NHS Act came into force, PHM doctors are becoming involved with purchasing and most Directors of Public Health have become members of health authorities. The specialty is therefore becoming more 'visible' to other doctors. Many PHM doctors have also
DOCTORS' UNDERSTANDING OF PUBLIC HEALTH MEDICINE
been involved in improving communication with GPs, in obtaining their views on secondary care services and in the formulation, jointly with clinicians, of shared protocols for the management of chronic conditions. These activities necessitate making personal contact, often in collaboration with other members of the health authority. Family Health Service Authorities (FHSAs) are now realizing the importance of obtaining Public Health advice. PHM doctors, either employed directly by FHSAs or working in collaboration with them, are developing further links with GPs. Initially, this has included discussions about health promotion clinic protocols and the use of information from practice annual reports. GP fund-holders may also require advice in the future from PHM on local needs. The specialty is well qualified to advise on this and will be aware of the problems of assessing needs based on small numbers. Having moved into PHM from general practice, I feel that many of the skills I have learnt would have been of great use to me as a GP. Some, but too few, vocational training schemes for general practice include short attachments to PHM departments. This approach should be encouraged, although it should form part of a properly designed training programme. Funding may be available from Regional Health Authorities, as has happened in West Dorset Health Authority (Dr. S. Bennett, personal communication), or from District Health Authorities. The latter may become a more attractive proposition if and when PHM is seen to provide a useful service locally. Clinical specialists are beginning to recognize the importance of some management training,3 but they would also benefit from some experience relating to PHM as part of their training. Applied epidemiology should be included more often in syllabuses for higher professional training, although facilities for attachment to PHM departments may not be available for more than a handful of clinicians. Undergraduate training usually consists of an introduction to epidemiology, but medical students would enjoy and benefit from attachments to PHM departments, as they do with any other specialty. This would help them to understand the role of PHM in the modern health service. This may not be a practical proposition, because of the current understanding of the specialty, but, as with any other specialty, any theoretical learning must be backed up with some practical application.
401
More involvement of service PHM doctors in teaching may be a way forward. As doctors in PHM learn more about the craft of management there is an increasingly common view that health service managers will need to develop some of the skills of PHM. The syllabus for the examination for membership of the Faculty of Public Health Medicine has a section on the organization and management of health care.4 With increasingly close links with our managerial colleagues, perhaps they too should receive some training about our functions, responsibilities and skills. There is potential for much closer partnership between management and PHM, and it is only by understanding our respective roles that this can be developed further. One of the aims of the annual report of the Director of Public Health should be to 'market public health'.3 This is an important method of showing the work done by departments, but the quality of reports must be kept high and the circulation wide. This study has shown that there is confusion about the titles of Public Health Medicine and consultants in communicable disease control. It is up to doctors in PHM to ensure that we become known as Directors of Public Health, Consultants (or trainees) in Public Health Medicine and Consultants in Communicable Disease Control in suitably named departments, and to make efforts to correct inappropriate terminology of the specialty.
Acknowledgements I am grateful to all general practitioners and hospital doctors who responded to the survey and to Drs. N. Armand Smith, K. Kimmance, H. Thomas and P. Old for their help and advice.
References 1
2
3
4
5
Todd AR. Report of the Royal Commission on Medical Education 1965-68. London: HMSO, 1968. Department of Health. Public health in England. (Acheson report.) London: HMSO, 1988. Gadd EM, Fletcher MF. Do senior registrars have adequate management training? Br Med J 1992; 304: 546-547. M.F.P.H.M. Part 1. 1992 Examination syllabus. London: Faculty of Public Health Medicine, 1991. Middleton J, Binysh K, Chishty V, Pollock G. How to do it: Write the annual report of the director of public health. Br MedJ 1991; 302: 521-524.
