The Education of Physicians—a

CDC Perspective

Denise Koo, MD, MPH

Director, Career Development Division
Office of Workforce and Career Development
Centers for Disease Control and Prevention
Duke University
January 9, 2008
 Learning Objectives

At the end of this session, the participant should be

able to:
• List 3 characteristics of a physician with a
population health perspective
• Describe 3 of CDC’s educational activities that
support development of such physicians
• Describe CDC’s Epidemic Intelligence Service
(EIS) program
• List 3 impacts of the EIS program on the field of
medicine
 Outline

• Medicine-public health continuum

• Role of physicians, particularly with population
perspective
• CDC activities that support development of such
physicians
• Epidemic Intelligence Service (EIS) program
• Impact of the EIS program on medicine (and
health)
• EIS case study (time permitting)
 What is Public Health?

• “What we as a society do collectively to

assure the conditions in which people can be
healthy”
• Functions:
• Assessment
• Policy Development
• Assurance

IOM, The Future of Public Health, 1988

 Medicine-Public Health Continuum
A guide to thinking about the determinants of population health

Living and working conditions

may include:

• Psychosocial factors
• Employment status and
occupational factors
• Socioeconomic status (income,
education, occupation)
• The natural and builtc
Over the life span environments
• Public health services
• Health care services

NOTES: Adapted from Dahlgren and Whitehead,

1991. The dotted lines denote interaction effects
between and among the various levels of health
determinants (Worthman, 1999).
Evans, Stoddart, 1990
 Population Health and Physician
Education
• Medical School Objective Project: Medical
Informatics and Population Health, 1998
• Institute of Medicine: Who will keep the public
healthy? 2003
• IOM: The Future of the public’s health in the 21st
century, 2003
• Healthy People Curriculum Task Force: Clinical
Prevention and Population Health Curriculum
Framework, 2004
• IOM: Training Physicians for Public Health
Careers, 2007
Famous Public Health Physicians?

“The function of protecting and

developing health must rank even
above that of restoring it when it is
impaired.”
--Hippocrates
Famous Public Health Physicians?

“The physician’s function is fast

becoming social and preventive,
rather than individual and curative…”
Doctors have the duty “to promote
social conditions that conduce to
physical well-being.”
--Flexner, 1910
 Critical Need for Physicians with
Population Health Perspective

• Public Health Physicians needed, as well as

• Partnering physicians within health care system:
– Quality assurance
– Infection control
– Clinical epidemiology
– Community health
– Health services research
– Health policy
– Informatics
– Etc.
 Characteristics of Physician with
Population Health Perspective* (1)

Ecological Model of Health

• Sees problem in context of broader
determinants
• Sees health as human right
• Considers the influence of home, work, and
environment on patient’s health
• Demonstrates systems thinking and actions

*Source: CDC Foundation Working Group on Population Health and

Medical Education
Characteristics of Physician with
Population Health Perspective* (2)

Community-Oriented Health
• Ability to identify and work with
community resources on behalf of patient
• Ability to zoom in and out from individual
to population
• Practices prevention, health promotion
and protection for individuals and
populations

*Source: CDC Foundation Working Group on Population

Health and Medical Education
Characteristics of Physician with
Population Health Perspective* (3)

Technical Skill Sets

• Ability to participate with public health
systems
• Ability to collaborate, work with, and
participate on interprofessional teams
• Ability to collect, analyze, interpret, and
disseminate quantitative and qualitative
health-related data

*Source: CDC Foundation Working Group on Population

Health and Medical Education
Needed: A Multipronged Approach to
Development of Population Health
Perspective

Multipronged, including practice…

• Academic (classroom)
• Experiential
• Role models (Faculty development)
• Research
• Conferences
Needed: A Multipronged Approach to
Development of Population Health
Perspective

At various stages…
• Prior to Medical School
• During Medical School
• During Residency and Fellowship
• In Research and Practice (particularly
Faculty)
The Basic Science of Population
Health

“Medical statistics will be our standard

of measurement; we will weigh life for
life and see where the dead lie
thicker, among the worker or the
privileged.”
--Virchow, 1849
 The Basic Science of Population
Health

“It is as important to know what kind of

man has the disease as it is to know
what kind of disease has the man.”
--Osler, 1849-1919
 Scientific Method Applied to the
Patient and Community
Step Clinician Epidemiologist
Data Gathering History, Surveillance,
Physical Exam Descriptive epidemiology

Hypothesis
Assessment Differential Diagnosis Generation

Hypothesis Diagnostic studies Analytic Epidemiology

Testing

Action Treatment Community Intervention

 Education Prior to Medical School
Target: elementary/secondary school, college

• Excellence in Curriculum Integration through

Teaching Epidemiology
• Science Ambassador Program
• National Science Olympiad Disease
Detectives
• Young Epidemiology Scholars
• Science internships
• Undergraduate public health education (core
courses in Public Health, Epidemiology,
Global Health)
 Medical School
Target: medical students (and other health
professionals)
• CDC Experience Applied Epidemiology
Fellowship
• Epidemiology Elective
• O.C. Hubert Student Fellowship in International
Health
• Hispanic-Serving Health Professions Schools
Summer Internship
• Ferguson Emerging Infectious Disease Fellowship

• Regional Medicine-Public Health Education

Centers (RMPHECs)
 Graduate Medical Education
Target: residents/early postgraduates

• Epidemic Intelligence Service (fellowship)

• Preventive Medicine Residency/Fellowship
• Prevention Effectiveness Fellowship
• Public Health Informatics Fellowship
• Emerging Infectious Disease Lab Fellowship
• National Academies of Science Research
Associateships (occupational health)
• Fellowships in various areas, through the
Association for Prevention Teaching and
Research (APTR)
• Regional Medicine-Public Health Education
Centers (RMPHECs)—for residents
 Continuing Medical Education
Target: practicing clinicians (1)

• Clinical guidelines
• Morbidity and Mortality Weekly Report
• Vaccine-preventable diseases and vaccine
policy recommendations
• Regional Tuberculosis Training and
Medical Consultation Centers
• STD/HIV Prevention Training Centers
• Self-study STD Curriculum Modules
 Continuing Medical Education
Target: practicing clinicians (2)

• Training and education in certifying cause

of death
• 10-Day Seminar on Epidemiology and
Prevention of Cardiovascular Disease
• Fetal Alcohol Spectrum Disorders
Regional Training Centers
• Various conferences
 Research and Training
Target: faculty, institutions

• Research and training grants

• Research and training grants related to
occupational health
• Prevention research and training grants
• Ready-to-use STD Curriculum Modules for
Clinical Educators
 Training Model

• Sample Content
– Applied epidemiology
– Policy development
– Emergency response
• Methods of Training
– Structured courses, including case studies
– Exercises, Simulations
– Required activities on-the-job
– Mentoring
– Experiential learning
 Competencies for Applied
Epidemiologists

• CDC/Council of State and Territorial

Epidemiologists collaboration
• Defined for practicing (governmental)
epidemiologists--
Competencies for Applied Epidemiologists
in Governmental Public Health Agencies:
• www.cdc.gov/od/owcd/cdd/aec
Epidemic Intelligence Service (EIS)
• 2-year postgraduate “fellowship” program
• Started in 1951
• Applied epidemiology
• Training and service
• EIS class size = ~75-80 officers
• 25-30% assigned to state/local health
departments
 Who is Eligible for EIS?

• Physicians with at least 1 year

post-graduate clinical training
• Other health professionals such as
veterinarians, nurses, and dentists with an
MPH or equivalent
• PhD, DrPH, or other doctoral-degree
holders in epidemiology, biostatistics,
nutrition, or biological, environmental,
social, or behavioral sciences
 EIS Officer Assignments

• State or Local Health Department

• Broad, front-line public health experience
• Surveillance, investigation, and intervention
• Headquarters
• Specialized, disease- or problem-specific experience
(e.g., vaccine preventable disease, diarrheal disease,
injury, ectopic pregnancy)
• Surveillance, investigation, and policy development
 EIS Core Activities for
Learning (CALs)

• Conduct analytic epidemiology project

• Evaluate public health surveillance system
• Participate in acute public health response
• Make oral scientific presentation
• Present at annual EIS Conference
• Write scientific manuscript for publication
• Write Morbidity and Mortality Weekly Report article
• Respond to public inquiries
 EISO Backgrounds* (n=162)

• Physicians 86 (53%)
• PhDs 56 (35%)
• Veterinarians 16 (10%)
• Nurses 4 ( 2%)
• Physician Asst 2 (1%)
• Naturopath 1 (1%)

*includes dual degrees (such as MD/PhD, MD/DVM)

 EIS Officer Assignments
as of December 2007

• Infectious Diseases (n = 69)

• Chronic Disease, Maternal/Child Health,
Genomics (n = 15)
• Environmental/Occupational Health, Injury
(n = 19)
• Health Statistics (n = 4)
• State and Local Health Depts (n = 52)
• Office for Global Health (n = 1)
• Food and Drug Administration (n = 1)
 Field EIS Officers, 2007
Hanson1
Laney2
2 Tongren1
Gulati 2
Andrews1 Holzbauer

1
Blaney2
An
Jaeger1
1 Guh1
Nett1 Finks
Anderson1 T. Chen2 Gutelius2
Nguyen1 Nair1
Dufficy2
2 Cooper2
Buss
Langer2
Katz1
Trevino2 Glenshaw2
1 1 2
Yu Calanan Hall Palekar1
Boehmer2 Kurkjian1
Kim 2 Aghoghovbia1
Beavers2 Chai2
1 2
Karon Moore

Wendelboe2 MacFarquhar1
Ehrhardt2 Piercefield1 Christian2
S. Chen1
Sircar1 IHS Diana Bensyl
1
Melstrom
Sugerman1 Dubray2 Sheryl Lyss
Wiersma2
Randolph Daley
Su2 Julie Magri
Brunkard2
Park1 Kris Bisgard
2
Fagan DePasquale1

1 = 1st year EIS Officers (n=26)

2 = 2nd year EIS Officers (n=26)

Cities listed: Seattle, San Francisco, Los Angeles, San Diego, Denver, Washington D.C., Philadelphia, New York City
 Where do EIS Officers Train?
Copper in Cryptosporidiosis
drinking water
Monkey Pox

E. coli

West Nile Virus

WTC Bombing
Forest
Fires

Hanta
Virus Hurricane Hugo

Cyclosporiasis
TB in
immigrants

Norwalk Virus from Norovirus

Malaria oysters
Lead screening Hurricane
Katrina Legionnaires' Disease
 EIS History – Highlights
1951 - 1959
• Contamination of killed poliovirus vaccine
with live virus

• Asian influenza epidemics

• Nosocomial staphylococcal epidemics

• Childhood lead poisoning from peeling paint

 EIS History – Highlights
1960 - 1969
• Cases of poliomyelitis associated with
oral vaccine

• Smallpox epidemics through 1977

• Hong Kong influenza epidemics

• Hurricane Camille response

• Salmonellosis in commercial chicken

 EIS History – Highlights
1970 - 1979
• Salmonella in pet turtles
• Bacteremia from contaminated intravenous fluids
• Childhood lead poisoning from environmental exposure
• Vinyl chloride-associated liver cancer
• Legionnaire’s disease
• Ebola virus in Zaire and the Sudan
• Aspirin-associated Reye Syndrome
• Cancer and steroid hormone study
• Three Mile Island investigation
 EIS History – Highlights
1980 - 1989
• Heat-wave associated morbidity and mortality
• Toxic Shock Syndrome
• AIDS
• Accutane-associated birth defects
• Escherichia coli O157:H7 epidemics
• Eosinophilia-myalgia syndrome
• Toxic oil syndrome in Spain
• Teen suicide clusters
 EIS History – Highlights
1990 - 1999
• Hantavirus pulmonary syndrome
• Health effects of Hurricane Andrew
• Cryptosporidiosis from contaminated Milwaukee public
drinking water
• Acute renal failure in Haiti from contaminated
acetaminophen
• Pandemic cholera
• Rotavirus vaccine recall
• West Nile virus epidemic
• Cardiac valvulopathy associated with fenfluramine
(fen-phen)
• E. coli O157:H7 and undercooked hamburger
 EIS History – Highlights
2000 - 2007
• Diethylene glycol poisoning in Panama
• Alfatoxin poisoning in Kenya
• 2001 anthrax terrorist events
• Cochlear implants and meningitis
• West Nile Virus and blood transfusions
• West Nile Virus and transplants
• Health effects of Hurricane Katrina
 Career Paths for EIS Graduates

• Academia

• Clinical medicine

• Clinical epidemiology

• Health services research

• Preventive Medicine

• Public health
 EIS Graduates in Public Health

• 25 of 54 (46%) State Epidemiologists are

EIS graduates*

• 7 of 11 CDC Coordinating Center/Office

Directors (direct reports to Dr. Gerberding)
are EIS graduates

• Steve Galson, Acting Surgeon General

*includes NYC and DC, and 2 States have 2 State Epis

 EIS Graduates in Clinical
Medicine
• Hospital Infection Control: Society for Healthcare
Epidemiology of America co-founded by EIS grad
(and 12 of 1st 13 Presidents were EIS grads)

• Numerous infectious disease researchers

(including Allen Steere, discoverer of Lyme
disease)

• Leaders in clinical epidemiology (including Bob

Lawrence, Sheldon Greenfield), chairs of
preventive medicine

• Al Sommers--Hopkins Chair of Ophthalmology

then Dean of School of Public Health
 EIS Graduates as Health
Leaders
• David Fraser—former President, Swarthmore College
(“Epidemiology as liberal art,” NEJM)

• Steve Schoenbaum—Commonwealth Fund

• Steve Schroeder—former President, Robert Wood Johnson

Foundation (Professor of Health Policy, UCSF)

• Ron Davis—Henry Ford Health System and current

President, AMA

• Jerry Barondess—first salaried, full-time President, NY

Academy of Medicine

• Roger Glass, Director, Fogarty Institute, NIH

 EIS Graduates in Quality
Assurance
• Don Goldmann—Institute for Healthcare
Improvement

• Andy Wiesenthal—Kaiser Quality Assurance, now

in charge of EMR purchases for all of Kaiser

• Peter Gross—Medical Director of Hackensack

Medical Center (major driver of IDSA clinical
guidelines)

• Gordon Moore—Chief Medical Officer at Harvard

Community Health Plan
 Graduates in Clinical Roles

• More effective clinicians

• Medicine-public health continuum

 Graduates in Clinical Roles

• More effective clinicians

– Evidence-based medicine
– Increased analytic skills
• Practice-based learning
– Question why this person, this illness,
now?
– Question: how to prevent?

• Medicine-public health continuum

 Graduates in Clinical Roles

• More effective clinicians

• Medicine-public health continuum
– Obligation to look beyond health care
system
– Responsibility as MDs within (public)
health system
• Systems-based practice
– Potential action outside health system
EIS Case Study?
Thank you for your attention!
dkoo@cdc.gov
 Preventive Medicine
Residency/Fellowship
• Physicians (R) or veterinarians (F) with EIS
or similar training
• Leadership/management and policy focus
• MPH holders do practicum year
(switch HQ/state from where did EIS)
• Others are sponsored for MPH then do
practicum and payback
• 6 - 10 residents/fellows per year
 PMR/F Assignments

• Leadership and management focus

• Integration into senior management teams
• Project and human/fiscal resource management
• Systems-based practice and learning
• Community intervention
• Program evaluation and management
• Policy analysis and development
• Grant review and/or writing
 PMR/F Assignments
as of December 2007

• MA Department of Public Health, Boston, MA

• CA Department of Public Health, Sacramento, CA
• DeKalb County Board of Health, Atlanta, GA
• Emory School of Public Health (extramural
training)
• National Center for Chronic Disease Prevention
and Health Promotion, CDC
• National Center for Environmental Health, CDC
• National Center for Zoonotic, Vector-borne, and
Enteric Diseases, CDC
 Selected PMR/F Activities
• Conduct a policy analysis of national,
state, and local quarantine and isolation
policies to guide development of
standardized policies for urban area
• Enhance pandemic flu preparedness for
small businesses
• Propose legislation regarding HIV testing
and surveillance data
• Manage and implement an outcomes
evaluation of a Center for Torture and
Trauma Survivors
 The CDC Experience
Medical Student Fellowship
• 10-12 month fellowship in applied
epidemiology for medical students
• Focus on applied hands-on training
experience in epidemiology and public health
• Assigned to a program at CDC Headquarters
• 8 fellows per year
• Funded by Pfizer through CDC Foundation
 Who is Eligible?

• Medical students completing second or

third year of medical school, with some
clinical experience
• Currently enrolled in an allopathic or
osteopathic LCME-accredited school of
medicine
• U.S. citizen or permanent resident
The CDC Experience Current Assignments

All in CDC Headquarters: disease- or problem-specific

experience

• Asthma and Air Pollution/Respiratory Diseases

• Rotavirus efficacy
• Human Papillomavirus vaccine implementation
• Tuberculosis Outbreak Investigation Team
• Birth Defects (n = 2)
• Influenza
• Viral Enteric Diseases
 Examples of Recent
The CDC Experience Projects
• Study of the prevalence of heart disease in the
United States
• Evaluation of performance measures of STD
control programs
• Descriptive Study of Prescription Medication
Sharing Behavior among Women of
Reproductive Age
• Analysis of fetal alcohol syndrome data