1. Sava, Saverio MD
  2. Armitage, Karen MD
  3. Kaufman, Arthur MD

Article Content

We are in a time of economic crisis amidst a growing realization that our US health care system is broken-too expensive, too short on access, and too low in value. We invest heavily in fragmented, subspecialized care and unbridled use of technology for some, instead of public health, basic prevention and primary care for all. The Affordable Care Act addresses aspects of this problem-more emphasis on primary care, integrated care, and prevention. However, our systems of public health and primary care remain mostly in their own silos at a time when the nation needs them to collaborate in a common purpose.


At one time, US physicians were core members of the public health workforce. They joined public health nurses, hospital staff, sanitation officers, and elected leaders to battle epidemics with little more than quarantine, hospitalization, and palliative care as interventions. The scourges that endanger health and shorten life in the 21st century present new and formidable challenges-epidemic obesity and increasing levels of inactivity and poor nutrition now predict the first generation in history with a shorter life span than the generations that came before them. Traditional medical care, miraculous drugs, and technologically advanced surgical techniques will not eradicate these risk factors, or the chronic diseases they foster, nor will they address the overwhelming impact of social determinants of health and resulting health disparities on health outcomes. Ironically, the public health system, which houses the programs and the workforce needed to address social determinants, is currently facing substantial funding cuts and a shrinking workforce.


We believe that it is time for the "curative system" of health care, which absorbs 97% of health care dollars, to broaden its focus and impact by integrating public health into its education, training, and service components. To achieve this, we must educate the next generation of physicians differently, preparing them to carry out public health roles in all venues in which they work-hospital wards, emergency departments, clinics, and communities. They must adopt the public health system's team-based culture and rich network of community partnerships to improve health outcomes and reduce health disparities.


Integration of Education

The University of New Mexico integrates public health into medical education by requiring all medical students to complete a Public Health Certificate (17 transferable credits into an MPH program).1 The curriculum focuses on social determinants of health and essential roles physicians play in improving the health of communities, beyond caring for individual patients. In the first 2 weeks of medical school, students are immersed in communities, mapping community strengths and challenges and learning from community leaders and community-oriented physicians. In the subsequent 4 years, biostatistics, epidemiology, health policy, evidence-based medicine, and the health needs of special populations are woven into medical school curricula, both off and on campus.


Integration at the Clinical Service Level

There will be little impact on future physician behavior if integration of public health into medical education is not followed by its integration into clinical practice. The "Patient Centered Medical Home" (PCMH) model2 is an opportunity to begin this transformation, offering great improvement in quality, efficiency, and access within the 4 walls of the primary care practice. Adding a community-oriented, public health focus to the PCMH would amplify the impact of those practices on community health. Efforts to expand beyond the PCMH can be guided by lessons learned from past innovations including the origins of the community health center movement rooted in social determinants and Community-Oriented Primary Care's use of community health assessment to drive clinical programs.3


A new, integrated service model has emerged in New Mexico that incorporates lessons from these innovations: the "Health Commons." This model unites a local health clinic, a state health department, and a department of family medicine to mine the essential link between clinic, public health, and community.4 Common patients obtain services in primary care, behavioral health, oral health, social services/case management, health education, and public health in a single visit-"One stop shopping." Public health staff and community health workers (promotores) are housed in the Health Commons, and data generated by the health department and input from community boards ensure that decisions are evidence-based and reflect the priorities and values of the community.


Challenges to This Integration

The integration of public health into medical education faces resistance from both traditional medical schools and schools of public health. Both schools have established separate identities and lost their common language, mission, and goals.5 Each may fear a loss of core functions, power, influence, and jobs. Sharing successful models and pilots, offering consultation with veterans of such a transition, and providing technical and financial support to integrate public health both into medical education and practice could help address resistance and encourage innovation both in medical schools and schools of public health.


National Strategy

We recommend that the integration of public health and primary care education and practice be adopted as a priority by existing, academically linked, national health initiatives. These entities already embrace many aspects of the integration of public health and medicine and are kindred spirits-aligning around this priority would amplify their impact on the health care system. These national health initiatives include the Association of Academic Health Centers' "Social Determinants of Health;" the Association of American Medical Colleges and Centers for Disease Control and Prevention's "Regional Medicine-Public Health Education Centers" (involves 30 schools); The Affordable Care Act's Section 5405 "Primary Care Extension Program" funded by the Agency for Healthcare Research and Quality (involves 17 states); the W.K. Kellogg-funded "Beyond Flexner: Social Mission of Medical Schools" (involves 6 schools); and the AAMC/Urban-Serving Universities/National Institute of Minority Health's"U-Health" initiative (involves 5 schools).


We see this time in history as a unique window of opportunity to address the shortcomings of our health care system and to achieve substantial improvements in health outcomes for our patients and our communities. Creating a seamless partnership between public health and medicine is essential to achieve these goals.




1. Geppert CMA, Arndell CL, Clithero A. Reuniting public health and medicine: the University of New Mexico School of Medicine Public Health Certificate. Am J Prev Med. 2011;41(4)(suppl 3):S214-S219. [Context Link]


2. Kilo CM, Wasson JH. Practice redesign and the patient-centered medical home: history, promises and challenges. Health Aff (Millwood). 2010;29:773-778. [Context Link]


3. Nutting PA, ed. Community-Oriented Primary Care: From Principle to Practice. Washington, DC: U.S. Department of Health and Human Services Public Health Service; 1987 HRSA Publication No. HRS-A-PE 86-1. [Context Link]


4. Kaufman A, Derksen D, Alfero C, et al. The Health Commons and care of New Mexico's uninsured. Ann Fam Med. 2006;4(suppl 1):S22-S27. [Context Link]


5. Lasker RD. Medicine and Public Health: The Power of Collaboration. New York, NY: The New York Academy of Medicine; 1997. [Context Link]