Medical Officers of Health, Public Health and Preventive Medicine Specialists, and Primary Care Physicians: How Do They Fit?

Article excerpt

In discussing Loh and Harvey's article,1 I will focus on the medical officer of health (MOH)* role and training for this role, and also comment on how these relate to primary care practice and practitioners. I note that public health practice as an MOH is only one of many potential career paths for public health and preventive medicine (PHPM)[dagger] specialists.2,3 Positions in the provincial or federal health ministries or centres of disease control, academic positions as a researcher/teacher, or a career in global/international health or occupational/environmental health, to name the more common ones, can be attractive options.[double dagger]

Role

For a physician trained in population health,§ wouldn't it be great to have a job in which you work with local decision makers (from a Board of Health or Municipal Council) and direct a range of public health professionals to plan and implement evidence-based, agreed-upon programs? The fact is, the Medical Officer of Health positions in all the major urban centres of Canada are filled.

I believe there are advantages to having a population health physician in the MOH role, for the following reasons: a) their knowledge of disease - the disease process, potential for spread, treatments, etc. - fits well with disease prevention and health protection roles; b) their training in diagnosis, which emphasizes a specific approach to detecting causes, is well suited to analyzing assessment and surveillance information; c) medicine has a focus on curing the health problem, which is essential to success in improving health; and d) a physician often starts with an advantage of being respected by the community and by other health professionals, which is important for effective collaboration and advocacy.

Of course, to be effective in such a complex environment, one needs more than education - one needs some experience in dealing with communities and politicians, as well as leadership and management abilities. One must also be credible with the politicians and with the community - i.e., have a degree of (small p) political accountability.

Working in a public forum can be messy. The issues one faces may be quite removed from "scientific" diagnosis and treatment in a controlled setting. However, when a leading politician and the MOH share common goals and have mutual respect for the role and abilities of the other, significant policy and program advances can be made (e.g., non-smoking bylaws, heart health programs, needle exchange programs, etc.) and the rewards, in terms of community health, can be substantial.

To gain experience for the role of MOH, a population health specialist can become an Associate MOH, working under the MOH and responsible for some part of the overall mandate. This also allows him/her to spend relatively more time on technical issues and to be more "hands on" in terms of program implementation. And it can be a permanent career choice.

The rural experience has some important variations from the urban one. The MOH is less likely to have the support of an associate MOH. Also, one's counterparts in dealing with local politicians are likely to be chiefs of police and fire department, municipal planner, finance and transportation directors, etc. They are likely to have moved through the ranks and have years of experience. As the PHPM fellowship program is more oriented to attracting physicians immediately after medical school,1 PHPM specialists are more likely to be relatively advanced in technical areas, such as data collection and analysis, but less experienced in understanding a community, or working in partnerships or in the policy-making environment.

In such an environment, it may be more desirable for the municipality or Board to have as MOH a local physician (usually a family physician) who understands the community and goes back to university to obtain the knowledge and competencies to practice public health. The need for a fellowship may seem less obvious in this situation as the prospective MOH has already had years of clinical practice experience. …