Framing the Future Task Force report, "A Master of Public Health Degree for the 21st Century" calls for a significant shift in emphasis for the MPH degree away from a generalist, core curriculum in favor of a greater emphasis on areas of specialty.1 Given the potential for this report to greatly influence MPH accreditation standards, this call needs to be carefully examined. Is this the right direction for the MPH degree? Four statements in the report summarize this recommended shift:
1. The MPH should be designed as an advanced degree focused on specialist education that is directly responsive to the needs of students and their prospective employers.
2. An in-depth concentration should be a distinguishing element of a 21st century MPH degree.
3. The core should typically comprise no more than a third of the content or credits of a newly designed PH degree.
4. The practicum and the culminating experience in the MPH degree should be considered primarily as elements of the concentration rather than as elements of the core.
This recommendation threatens to undo the small amount of progress that has been made since the 1988 Institute of Medicine report in making academic preparation relevant for practice.2 It ignores how essential the core competencies are to practice as well as the time and effort needed to teach and learn them. Furthermore, it loses sight of what is special about public health generally and the MPH degree specifically. And although public health academia still has some distance to go to be as relevant to practice as it should be, it is those MPH programs that have focused on teaching core competencies through experiential learning in partnership with practice agencies that have come the closest to closing the academic/practice gap. The report, rather than urging that the academic community learn from and expand on best practices from these programs, has instead suggested that academic public health move further away from teaching core competencies needed for practice. The public health practice community needs to make its voice heard, in the face of such a proposed change, to preserve and improve on the intent of the MPH degree to serve as a practice-oriented professional degree.
The 1988 Institute of Medicine report defined the substance of public health as, "Organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology."2 Public health practice is mission driven and outcome oriented, and the disciplinary toolbox it uses, always in conjunction with epidemiology, is essentially whatever works for the problem at hand. Skillful and successful practice, whether done in traditional agencies or in private community settings, comes from developing constructive partnerships, identifying the necessary tools, and using them creatively and flexibly to bring about change in the context of agencies, communities, and systems.
Although specialized skills are frequently needed, they must be properly identified and properly used in a specific practice context. In 2013, the Association of State and Territorial Health Officers "convened 31 national public health leadership groups to collectively assess the priorities, needs, and characteristics of the governmental public health workforce."3 In the consensus that emerged, the top training needs and attributes of future public health workers were identified (see Table 1).
This list is similar to the core competency domains listed by the Council of Linkages on Linkages Between Academia and Public Health Practice,4 the cross-cutting competency domains used by the ASPPH competency project that is used as a framework by many MPH programs,5 and even by the Framing the Future expert panel itself. The panel provides a list of "critical content of the core," which is a mix of knowledge areas, conceptual understanding, and competencies.1Table 2 provides a partial list of this critical content that includes all those judged to be competencies.
The expert panel list clearly resonates with those put forward by the Association of State and Territorial Health Officers, the Council on Linkages, and ASPPH. It speaks to the kinds of jobs held by MPH graduates: as program and project support staff, managers, analysts, and evaluators in both public and private settings. The problem? To make room for the increased focus on specialty education, the expert panel applies a different standard of competency attainment for core and specialized competencies. While the specialized competencies must be used in the practice and culminating experience to "focus on higher levels of learning including analysis, synthesis, and evaluation," the learning objectives for the core competencies should be "focused on learning at the level of knowledge and comprehension."1 Really? MPH graduates need to know about, but not how, to work in organizations, teams, and diverse communities? Clearly the core competencies are the very competencies that MPH graduates must be able to perform, not just comprehend! The writers of the report either missed this point entirely or assume that these are competencies that can be acquired without being taught, practiced, and developed.
It is also of concern that the report fails to identify what problem this casual dismissal of the core competencies is designed to solve. The report provides no evidence of a population or practice call or reason for such a change. Furthermore, public health education already has an MS degree, which provides the very framework of less focus on core practice skills and more room for specialized training that the report says is needed. Agencies that need someone more highly trained in a specialty area at the master's level can already hire someone with an MS. This report, then, is not a call for something we do not have. Rather, it is a call for dismantling the unique aspects of the MPH.
We are not the only profession that has been seduced by calls for more specialization and more "professionalization" (as distinct from professionalism) and that has lost sight of the reality that the real world needs well-trained generalists. Overspecialization in medicine has been a serious problem in the United States for 50 years.6,7 Numerous studies have documented better patient and population outcomes where systems and the profession are more oriented toward primary care.8-10 Although the specialty of Family Medicine, as well as numerous policy efforts, have attempted to redress this imbalance, it persists in the US health care system, and academic medicine continues to socialize students in ways that favor specialism.7 Social work schools, in the name of professionalization, have shifted away from training programs that emphasize social change and community organizing, and instead they concentrate on preparing clinical therapists through the teaching of psychological theory.11 The pattern in both medicine and social work was a shift toward specialization and professional roles that could demand more respect and remuneration, without adequate reference to the needs of the population. Although economic forces also contributed to these shifts, the academic institutions accelerated then and resisted efforts to reverse them.
This should hardly be surprising. Academia seeks new knowledge, and so its hierarchy is based on the degree to which its practitioners can push the envelope in specialized areas of new knowledge development. Practice, however, focuses on making a difference in the real world, and the challenge is to use judgment to properly apply both developing and existing knowledge appropriately in a particular context. There will always be a need for the practice community and those seeking to protect public interest to rein in the tendency of academia to focus too heavily on specialization at the knowledge frontier. It is disappointing, however, for this to happen in public health. Of all the professions, ours should be the one best able to maintain a focus and commitment directed to public interest and population need. This report fails in that regard. It should be rejected, and the public health practice community should voice its support for an MPH degree that focuses on professional development through the teaching and practice of the generalist core public health competencies at a high level.
The real challenge for the MPH of the 21st century will be how to "flip the classroom" so that students can master or at least have access to the ever-expanding knowledge base in the core content areas and in related disciplines, so that the faculty, both academic and practice based, can use the available contact time to teach and evaluate acquisition of the practice-based core competencies at a level that will allow new graduates to function as independent practitioners. The expert panel of the Framing the Future Task Force missed the opportunity to face this challenge. Others will need to step forward.
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