# The Schism Between Medicine and Public Health | Patrick Remington | TEDxUWMadison

**Channel:** TEDx Talks
**Source:** https://www.youtube.com/watch?v=Hh-y2QuaLJ8
**Transcript page:** https://www.withtranscript.ai/video/Hh-y2QuaLJ8

## Chapters

- 0:13 — Origins of the Medicine Schism
- 4:35 — From Clinical Care to Public Health
- 8:45 — Teaching Students Both Disciplines
- 13:22 — Why Reuniting Medicine Matters

## Transcript

**[0:13]:** well thank you I'm really honored to be here first to hear the speakers this morning I feel humbled to be on the same stage what I'd like to talk with you about this morning is medicine and I wonder if this may be I grabbed the wrong one it's medicine and public health and before I do that I'd like to define a word a really important word in my talk today and that is a schism a schism is a split or a division between strongly opposed sections or parties caused by differences in opinion or belief and what would you think if I told you there's a schism between medicine and public health and that this schism is not just a few years old but more than a century old and that it goes on in nearly every school and university across the country and that everybody pretty much everybody working in medicine and public health knows

**[1:23]:** about it but we almost never talk about it well it wasn't always there in fact medicine and public health were joined seamlessly in the 1800s when physicians like John Snow diagnosed a cholera epidemic using fundamental tools of Epidemiology when Robert Koch discovered infectious diseases through microbiology and Edward Jenner experimented and discovered vaccines in in the late 1800s these were physicians leaders at their time who really worked with Public Health seamlessly in their communities but something happened in the early 1900s as medical schools were being developed across the country there was concern that they weren't up to the standards expected of university programs and so Abraham Flexner gathered experts together and published what is now a seminal report in medical education the Flexner report in this report called upon medical schools to have a four year curriculum two years of basic science and two years of clinical science and as a result almost 200 medical schools

**[2:43]:** around the country either closed or were merged to bring the quality of medical student education up to snuff but what it did was jam-packed the medical school curriculum so there was little or no room for the public health sciences things like environmental science for psychology or sociology and so sensing that the doors to the medical school were closing experts began to meet across the country to talk about how to educate people in public health since that opportunity didn't appear to exist in medical schools and in 1915 the now-famous Welch Rose report was published and talked about how schools and universities should develop standalone independent schools of Public Health on campuses not affiliated with medical schools and in fact William Welch the author of this report became the first Dean of the first School of Hygiene and public health at Johns Hopkins University and over the next 50 years schools of medicine and schools of Public

**[4:00]:** Health were established on nearly every campus across the nation but these schools of medicine and public health oops these schools of medicine and public health I'm gonna animate that took me a long time to do that animations I need to stank you and I figured that out by myself I'm proud of that schools of medicine and public health really grew apart during the ensuing 50 years so that Dean's not only worked in parallel but often competed

**[4:35]:** for the scarce resources that are available on campuses when I was growing up I had no idea what public health is I wanted to be a doctor I went to medical school here this is the old medical school where I began my medical school training and as seen with the gentleman with his head in the books I memorized my way through the first two years of basic science and I enjoyed nearly every clinical rotation that I had during the clinical years well maybe not surgery wasn't my strongest suit but then when I graduated and started my internship as a practicing physician I saw patients who were really sick kids at Children's Hospital at the University of Washington in Seattle or adults at Virginia Mason hospital and while caring for these patients my mind began to wander I thought why did this child have to be here in this situation in the ICU a result of

**[5:34]:** a car accident when he wasn't wearing a seat belt well why does this individual have to be in the ICU after a lifetime of smoking when we know the harms of smoking and the risk of developing cancer or heart disease and in fact why did he have to spend the last few days of his life hooked up to a ventilator when it would have been better for him to spend those last few days and hours with his family at home I found the answers to these questions in a textbook Harrison's textbook of medicine with the heading epidemiology I was intrigued to learn that we not only knew the causes of most of the problems I was seeing in the hospital but we also had evidence-based strategies to prevent them and yet almost never did we talk about epidemiology and prevention in the clinical setting we had to take care of very sick patients so I

**[6:33]:** personally took a little detour in my training and I went to the Centers for Disease Control I joined a two-year training program called the epidemic intelligence service it's boots on the ground grassroots epidemiology diagnosing problems in communities I then took advantage of a preventive medicine residency where I specialized in preventive medicine and even did my master of public health degree on a career development program at the CDC and at the end of six years I felt fully trained in public health but I realized that I had officially left medicine behind and joined the public health profession well I had the good opportunity to come back to Madison to actually practice preventive medicine that the Wisconsin Department of Health Services you can see my office in the state office building they're second to the right down on the third floor in cubicle actually not my office and I spent 10 years not seeing patients individually but

**[7:40]:** working with communities thinking about how we could improve air quality and restaurants by banning smoking how we could reduce youth smoking by increasing the cigarette excise tax how we could help women survive breast cancer by promoting mammography or even learn more about firearm injuries by developing a surveillance system for firearm injuries and so at the end of those ten years I have learned about the practice of Public Health and I also had the opportunity to work with medical students who would come up during their fourth year of medical school and they would work on a project with me and I was struck that this was the first exposure in their medical school training that they had to public health and epidemiology so when the opportunity arose to come back to the medical school I jumped at it and I joined the faculty of the Department of and medicine and the first thing I did was

**[8:45]:** develop a public health elective I called it physicians in public health and this elective was one credit optional elective we met in the evenings after classes were over and we talked about public health issues that was my plan unfortunately only a couple of students signed up so I reposted the description of what the selective would be like it was still talking about physicians at public health but I offered free pizza and 20 or 25 students came to the elective I brought in my colleagues from the health department who were leaders in environmental health infectious disease maternal and child health epidemiologic researchers all physicians all working in public health and the medical school students listened intently but I actually think they came for the pizza until one day a colleague came in a colleague came in who was a family medicine doctor she had a busy clinical practice but she also worked in the community in an underserved community she also worked overseas in Uganda working on better sanitation to improve health in

**[10:10]:** a developing country and as she told to her story about doing medicine and public health the students were captivated they listened intently long after the pizza was gone they met with her after the lecture and asked if she could work with them and maybe they could shadow her in her clinical work or in her public health work she said that the public health experiences that she had made her a better doctor and the clinical experiences that she had made her better at practicing public health so I had what I called my public health and medicine epiphany that night and I decided the next year to changed the name of the course and how we structured the course I now called it physicians in medicine and public health and the result was amazing over a hundred students signed up the first year for this course first and second year medical students and I invited busy clinicians

**[11:15]:** to come to tell their story a surgeon who ran the trauma unit at UW Health but also developed global guidelines on disaster preparedness a pediatrician who saw kids in his office during the day but nights and weekends developed the program called reach out and read where kids are provided books by the in the doctor's office to improve child literacy an internist who saw very complex medical cases but she was also the president of the Wisconsin Medical Society and students were amazed that people could be both clinicians outstanding clinicians and public health doctors so over the next 20 years the school of medicine transformed its educational curriculum to not only have courses on basic science biology and clinical science but also public health and in fact about 15 years ago we changed the name of the medical school it is now the School of Medicine and public health it's a medical school that embraces public health

**[12:24]:** not only in its mission but in its name we also transformed the curriculum for medical students we offer to all medical students I should say we require of all medical students that they take courses in public health and primary care throughout their four years we've woven the curriculum for all medical students we had a medical student come and he complained that he thought there was too much public health education and we said you should have looked at the top name of the school and you should have read the webpage before coming and not be surprised about this we also developed a tier of Public Health called the public health path of distinction for students some students who want to do more for example take the elective than I offer or do a project in a community involving public health and then finally the third tier is for those students who want to be fully trained

**[13:22]:** in public health and get a Master of Public Health degree we call that the md mph dual degree program so we've significantly changed the curriculum but the cold dark reality is that the schism between medicine and public health is real and present pervasive medicine continues to focus on diagnosis and treatment often in a for-profit setting where the incentives are for more care with rising costs public health on the other hand is focused on prevention in a non profit setting where our goal is better health and yet we have crumbling infrastructure no more apparent today as we confront a potential coronavirus pandemic so this schism is a challenge for us in moving forward and I'd like to tell a story that I heard from a physician a busy emergency room physician who was seeing kids in New York City who were coming in with asthma exacerbation and he did a further study and he found out

**[14:31]:** that they're coming from homes that weren't as clean as they could be that had a lot of allergen from mites and and cockroaches so he simply prescribed vacuum cleaners and after vacuum cleaners were provided once the people had the opportunity to clean the home 30% reduction in emergency visits due to asthma exacerbations and he published this story presented it and it was great news except one day he was visited by the chief financial officer of the hospital who said that they had a significant problem that the revenue generated by seeing these kids in the emergency room was now missing and this hospital was at risk of not staying open they depended on kids having asthma and the revenue generated from that exacerbation and having to come for care clearly a schism between medicine and public health and it's no Lourdes parent today than than the everyday practice of clinical medicine imagine a primary care physician

**[15:44]:** talking with the patient who's struggling with obesity what does she have to offer brief advice maybe a pill for diabetes management if it gets really serious refer to a surgeon for gastric bypass surgery but when that patient leaves the office they are confronted by Western society of constructs things like spent how much time we spend in a car television fast food our workplace which is focused on the laptop now we have a sedentary society even now there's a term called obesogenic lifestyles so despite wanting to solve this problem physicians are stressed with confronting them in the clinical setting and not being able to do anything about the community setting so clearly we need to bring back medicine in public health this schism has been present for over a century it won't go away overnight but I think with the future physician future physician or the current physicians in training and future physicians that we have

**[16:59]:** an opportunity to be optimistic young people today see that we need to redesign the healthcare system from one that is incentivized to provide more care to more people to one that is rewarded for improving health in communities we have that opportunity but it's going to be a challenge medicine has the money but Public Health has the mission imagine what we could do if we brought the money of medicine together with the mission of public health and I'd like to end with a quote it comes from Bobby Kennedy and I've modified it a bit some people see things as they are and ask why but I think of things that once were and asked why not again why not medicine and public health thank you