The Specialist Public Health and Preventive Medicine Physician: System Roles and Training Challenges

By Dunkley, Geoffrey | Canadian Journal of Public Health, March/April 2013 | Go to article overview

The Specialist Public Health and Preventive Medicine Physician: System Roles and Training Challenges


Dunkley, Geoffrey, Canadian Journal of Public Health


In their commentary, Lawrence Loh and Bart Harvey have described the evolution of the medical specialty in Canada currently named public health and preventive medicine. However, the role of this specialty within the larger public health system is still not clear in Canada. There remains lack of consensus about the role and necessary qualifications of the public health physician within the public health system. This lack of consensus is both within government and in the broader public health community. There is not even consensus among physicians currently in public health practice, who understandably regard their own path into the discipline as well as their particular level of training as adequate.

The future of the specialty and its ongoing role within public health in Canada will depend on developing a common response to the following inter-related issues:

The requirement for specialty certification to exercise regulatory authority under public health legislation

Specialty certification, i.e., FRCPC, is not the minimum qualification for being a medical officer of health (MOH) or provincial chief MOH in most provinces in Canada. Most jurisdictions require a medical licence and a 1-year Masters of Public Health (MPH) or equivalent. The fact that this policy is changing slowly, if at all, is due to a number of factors, including difficulty in recruiting specialists - particularly in rural areas - and a belief among many politicians and even many practitioners that most public health decisions are mostly common sense and that the necessary expertise can be acquired on the job with a minimum of formal training. The argument that the job now requires a stronger scientific and technical base has not yet won the day. Many larger urban units with greater ease of recruiting do require specialty certification for their positions.

The tension between technical/scientific vs. administrative/leadership functions

The greatly differing roles of public health physicians in the different provinces and territories have led to challenges in designing training objectives and a curriculum for a Public Health and Preventive Medicine (PHPM) specialist program in Canada. In some provinces/territories, the role is predominantly a technical consultant; in others, there is an additional leadership/management role.

The vesting of public health regulatory authority in physicians

In most jurisdictions, there is recognition that the MOH's regulatory role and obligation to inform the public about threats to public health and safety are a professional responsibility, not requiring prior bureaucratic or political approval. Thus, an MOH has some defined independence even if their position is nested well down in the bureaucracy. This delegation of authority and decision-making assumes expertise, judgement and professional ethics which will put the public interest and safety before any institutional or political self-interest.

Historically, society has judged the medical profession as having the appropriate training and professional approach to play this role. The recent emphasis on the CanMEDS roles of collaborator, communicator, advocate and professional in medical training suggests the continuing appropriateness of this delegation. This presumes that the physician also has adequate scientific and practical training to inform population-based decision-making.

Clinical training vs. public health training

Currently, most PHPM training programs in Canada consist of two years of clinical training leading to certification in Family Medicine, one year of academic training and two years of applied public health training. These last two years represent a short period of time to achieve mastery over the many domains of public health practice. Population practice is fundamentally different from clinical practice, requiring an entirely different toolkit. Even with recent revisions of the undergraduate medical curriculum, the vast majority of undergraduate training is in the clinical domain. …

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