Lawrence Loh: Public health and why terminology matters

Lawrence_Loh_picAs younger generations of physicians develop a newfound interest in the social determinants of health, public health has increasingly become a buzzword for providers to throw about. In the medical community, it is now more and more common to find someone who is “practising” public health. But are they?

Having worked as a public health physician for five years, I am slowly beginning to notice subtle distinctions between practising public health and incorporating a public health issue into one’s practice. Many conflate the two, but these are not the same thing.

A recent conversation with a friend who does short term medical service trips abroad in remote areas comes to mind as an example. This friend was proudly sharing his recent success in incorporating a cervical cancer screening programme into his group’s work. He excitedly explained to me that this was public health practice in rural and remote settings: that he was providing pap smears and screening to people who otherwise wouldn’t get it, and referring them on to the district hospital for follow-up.

“But that’s not public health practice,” I said.

“You’re telling me that doing cervical cancer screening doesn’t count as public health practice? It’s not a public health issue?” he said.

“I’m not saying it’s not a public health issue, no. It is. What I’m saying, though, is that the actual work that you’re describing is clinical—it’s clinical preventive medicine. It’s not public health practice.”

I didn’t have the heart to tell him that public health practice in cervical cancer goes much further than the simple provision of the service. Teams of public health practitioners would start by reviewing evidence and conducting appropriate population assessments to determine whether a screening programme is even needed, and, if it is, they would put together proposed plans for what a programme would look like, accounting for stakeholder input, resources, culture, and context. These practitioners would oversee programme implementation together with service partners, focusing on logistics (for example, staffing, intake processes for referrals, and continuous quality improvement), as well as monitoring and evaluation to ensure that the programme is having the desired impact.

None of this, of course, took away from the fact that my colleague was certainly a service partner who recognised and was willing to support work on a public health issue. Many public health programmes would flounder without the dedicated work of colleagues who provide the actual preventive service and relay the data that our surveillance and assessment systems rely on. But for individuals to tell funders that they “practise public health” in rural and remote areas abroad on the basis of providing a clinical service made me pause. They do great clinical work, yes. But is it public health practice?

In my role as a public health physician, I am tasked with working with a multidisciplinary team to assess evidence and incorporate input from various groups and stakeholders, all of whom have their own vested interests and are advocating for them—sometimes in diametrically opposed positions. Commonly serving in a governmental role, public health physicians have to consider what is the best programme or policy for the community in light of these conflicting views, constrained resources, precedent, public opinion, and best available evidence.

Conversely, a physician with a keen interest in a public health issue might do amazing research or serve as a convincing advocate. But to suggest that they do the equivalent work of public health physicians takes away from the highly specialised practice undertaken by public health physicians, which sees them protect and promote the health of their community by managing competing considerations. To put it another way, a family doctor might diagnose and cast a complex fracture, and refer their patient to a fracture clinic for surgery. However, no one would say that the family doctor is doing orthopaedic surgery; although, certainly, the family doctor has acted on an orthopaedic issue.

There are other important reasons to recognise the unique and valuable work accomplished by public health physicians practising as medical officers of health and as provincial and federal leaders. Given that public health initiatives are almost always silent in success, using appropriate terminology is critical to avoiding further confusion around the role of public health physicians and misunderstanding by non-physicians, particularly policymakers, as to who does what.

A good example of how the ongoing conflation of public health with aspects of acute care goes awry was demonstrated in the recent Patients First paper put forward by the Ontario government. The one proposal in it specific to public health suggested that health units in Ontario should report to the acute care system’s coordinating body and use their limited resources to collect and analyse data in improving the acute care system. This demonstrated a fundamental misunderstanding of the important, broader roles that public health physicians have beyond healthcare in improving and protecting population health.

It is certainly exciting that public health is in vogue—especially given the potential that prevention and a determinants of health approach have for the health of our nation and the sustainability of the healthcare system. But in our rush to transition to this new paradigm, let’s not forget that there are unique roles that exist. Much like there is a difference between orthopaedic surgeons, physicians who work on orthopaedic issues, and physicians who provide important services that support orthopaedic care, there will always be those who practise public health, those with a passion for public health issues, and those who provide important services that support public health initiatives.

All of the above are important roles, but they are not one in the same.

Lawrence Loh is a Toronto based physician, certified in family medicine and public health, serving as associate medical officer of health for Peel region in the Greater Toronto area and adjunct professor at the Dalla Lana School of Public Health, University of Toronto. He also practises urgent care medicine and volunteers as director of programs for The 53rd Week, a Brooklyn based non-profit that aims to optimise the outcomes and minimise the harms associated with short term volunteer work abroad through research, advocacy, and innovative programmes.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.