The Pillars of Public Health – Protection, Prevention and Promotion

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I am very, VERY excited to be writing this post. If you follow me on Instagram (or Twitter) (I’m @theirishbalance) you’ll have seen a post I shared at the start of this week with a BIG announcement about my next career direction as a medical doctor. As many of you know, I completed my undergraduate medical degree in 2015, and then worked for 3 years in hospital medicine until July 2018, completing what’s called my ‘internship’ year and my two-year ‘Senior House Officer’ (SHO) training, in lots of different medical specialties – endocrinology, geriatrics, gastroenterology, general medicine, nephrology (kidney medicine) – I got to see a LOT of different areas in the hospital and work with some fantastic specialists, and meet MANY amazing patients, each with their own story.

As I’ve written about on the blog before, there comes a time as a doctor where you have to ‘pick your specialty.’ What will you dedicate your career to? What area of medicine (or surgery, psychiatry, paediatrics, obstetrics/gynaecology, general practice – there are many routes a doctor can pursue!) did I want to devote my specialist training to? As I tried each new specialty at the hospital, I tried to learn as much about it as possible and speak to those working in it, to learn what the day job was like at early and later years, and the future career directions in it. I particularly enjoyed my Endocrinology and Gastroenterology rotations – but something was missing. While I can definitely say I found them fascinating, I wasn’t passionate about them. They weren’t my why.

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Hospital-based medicine saves lives every single day. It’s the front lines of the healthcare service, and for the most part, by nature is what I would call ‘reactive‘ in nature. Patients attend for in- and out-patient care with various symptoms and signs, and hospital teams formulate a differential diagnosis and a plan of management/treatment. It’s busy, it can be stressful, but ultimately it’s a team environment, it’s exciting, and it does a darn good job. But during my training, I noticed that while I was getting a LOT of experience in this front-line aspect of healthcare, I wasn’t seeing or learning a lot about what lay upstream. What was causing the problems patients were experiencing in the first place? I found that I often didn’t have enough time with patients to explore (outside of asking about smoking and alcohol intake) their lifestyle and health behaviours that might be contributing to their presentation. I kept thinking about the phrase ‘Prevention is better than cure.’ That’s not an absolute statement (sometimes illness develops abruptly and the scope for prevention doesn’t preceed it), but it does have weight and power in a medical sense.

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I came across public health as a medical specialty not long after I started my blog in 2016, during the first year of my SHO training. I remember seeing Professor Niall Moyna (a Professor in the School of Health and Human Performance and a member of the Centre for Preventive Medicine in Dublin City University) speak at the first Public Health conference I attended, talking about the rising prevalence of childhood obesity in Ireland, the low numbers of children meeting physical activity guidelines, and the implications for their long-term physical and mental health. Really, given all I know now, this was just the tip of the iceberg, but I genuinely felt like shouting ‘Yes! This is the side of medicine I’ve bee looking for!’ after his talk. I kept reading more about public health training in Ireland, speaking to those in the specialty, and attending the twice yearly conferences in Dublin in the Royal College of Physicians (I attended 2 in my first SHO year, and presented research and audit projects I had done at the 2 I attended during my second SHO year). The more I read, the more I became convinced this specialty was for me.

So, as you guys know, I decided to pursue a full-time Masters in Public Health and Nutrition last year, which I started in September after finishing my hospital training. I’m about two-thirds of the way through it, and I couldn’t be enjoying it any more than I am. I’ve written about my learning from it so far on the blog (have a read of that here). And late last year, I decided to apply for the Public Health specialist training for doctors in Ireland (run by the Royal College of Physicians). It’s a four year programme – all medical specialist training in Ireland is about 4ish years to become a ‘specialist’ or ‘consultant’, whether that’s for public health, cardiology, respiratory, gastroenterology, etc. Public health is actually one of the lesser known specialties, but I’m pretty frickin’ delighted I found it.

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I applied, and got shortlisted for an interview, which took place about 2 weeks ago now, just after I turned 28. A week ago, I found out that after a competitive number of shortlist interviews for a small number of training programme places – I got in. I GOT IN! I won’t lie, the interview was tough and intense, and I spent the week waiting for the outcome in a little tense ball of worry, fear and self-criticism. I am my own worst critic, and I work on it everyday! I had worked really hard to prepare for the interview, but all the same, you have to perform on the day. And happily for me, I guess I said something right, because I’ve been offered a place. Over the moon doesn’t even COVER it. I literally felt a weight lift off my shoulders when I got the email of a programme offer. So I’ll start in July this year, pretty soon after my Masters finishes, and after I go on two much needed holidays! I couldn’t be more excited to start this new chapter of my doctor life, and I will of course be bringing the blog with me as I train and learn!

I wanted to write this post to tell you guys a little bit about public health, because as someone who has gone from never having heard of it to being fully immersed it, I think EVERYONE needs to know the role of public health medicine and public health physicians, for three reasons.

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One – more doctors in training should know about it as a potential career path, and doctors in other specialties should also be aware of it so we can collaborate to provide the best care for our patients. Twoour population is changing – it’s becoming bigger yes, but more importantly, older, and currently age is accompanied by increasingly prevalent chronic diseases. I’ll talk more about that in my points below, but as you’ll see, of the 4 domains of public health 2 in particular are central to how we need to plan for this change in population health status, and the expertise of public health physicians is and will be extremely valuable going forwardThree – Unfortunately, our 24/7, post-truth society often seeks answers to healthcare problems online or through social media before seeking advice of healthcare professionals. We see this especially with myths regarding vaccinations and food groups for example, which I wrote about last week on my blog (here). Its a HUGE bug bearer of mine, and I want the voice of public health in Ireland to be trusted and sought out in this technology-dominated world. So, with those points in mind, let me tell you a little bit about each of the 4 domains of public health – my chosen career path as a doctor!

Health Protection

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All pillars of public health are equally important, but health protection is the domain which takes up probably two-thirds of a public health physician’s work day to day. This realm focuses on infectious (also called ‘communicable’) diseases. It’s worth saying that in all of the talk on social and mass media about ‘non-communicable diseases’ (e.g. chronic diseases you can’t ‘catch’, such as type 2 diabetes, coronary heart disease, dementia and cancer) and their rising prevalence (along with obesity), we often forget about the infectious diseases. But actually, as we’ve seen for example with outbreaks of measles and mumps over the last year (largely due to sub-optimal vaccination uptake), as well as the rise in antibiotic resistance globally (and those are just two examples – there are MANY more that particularly affect developing countries such as malaria, Ebola and tuberculosis), we need a strong health protection service.

There’s a few key elements to it, which I’ll bullet point below. Please note that I’ve majorly simplified this list just for ease of your reading, to keep it relevant to all audiences and to keep my word count to the line too! Feel free to ask for more information or comment with your experience too if you’ve worked in public health.

  • Surveillance – this is essentially the collecting, analysis and monitoring of data specific to many infectious diseases both in Ireland and abroad. Ireland’s Health Protection Surveillance Centre co-ordinates this for our population, and liaises with the World Health Organisation, the European Centre for Disease Prevention and Control and the relevant health protection bodies of other countries. Using this data we can do many beneficial things, such as identify outbreaks and investigate and control these, respond rapidly to infectious disease threats, and plan and monitor disease prevention measures.
  • Prevention – This is largely through immunisation and vaccination, as well as raising awareness about specific issues (e.g. public health bodies in Ireland organise our childhood immunisation schedule, and are also currently actively involved in and co-ordinating the response to the ongoing mumps outbreaks among university students in Ireland).
  • Investigation and Response – This involves response at a national level (e.g. to measles and mumps outbreaks, outbreaks of infections in hospitals, and managing the influenza season each year) and internationally (e.g. at the peak of the Ebola and Zika emergencies, public health officials would have been actively involved in our response as a country and advised on appropriate protection measures at borders and regarding hospital protocols).

Health Improvement

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This pillar is probably the one I’m most passionate about, and is particularly relevant to our ageing population characterised by a high burden of chronic diseases. In Ireland, 65% of those over 65 have two or more chronic diseases, and that figure rises to 4 in 5 of those over 85! Essentially, the older we get, the more chronic disease that seems to accumulate. This issue is one of the big things that drives me as a doctor, to look at why these chronic diseases are so prevalent, what the drivers are at a wider societal level (the individual level is of course relevant too!), and how we can address these to improve the health of the population. So to make it easier to conceptualise, I’ll bullet point the big aspects of this realm.

  • Monitoring the health status of the population – we can consider this to be similar to surveillance used in health protection, but for non-communicable diseases. It involves again, using data and statistics to look at how healthy (or unhealthy!) our population is, the specifics of the different chronic diseases (e.g. cancer surveillance, monitoring diabetes, heart disease, etc) and more importantly, explore why that might be, so that we can plan intervention and prevention measures.
  • My personal favourite – promoting healthy behaviours and making the healthy choice the easier choice. That statement is powerful in it’s simplicity, but of course anything BUT simple to do, because it requires the whole of society to engage with it, from government to individual levels. As leaders in healthcare, we need to set an example for society by promoting health bebaviours around for example diet and physical activity (e.g. by working with colleagues to produce healthy eating and exercise guidelines), smoking cessation, and awareness about our low-risk alcohol guidelines and cancer screening programmes. We also have to address the environment that we live in which MASSIVELY affects our health behaviours and lifestyle choices – for example, implementing regulations around tobacco availability such as the workplace smoking ban and smoke-free university and hospital campuses, or regulating pricing of alcohol, and sugar-sweetened beverages.
  • Health improvement is about getting EVERYONE involved in the process – it’s about collaboration with every level of society to engage them on this mission.

Health Service Improvement

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In Ireland, the future of our healthcare service is has been the topic of much discussion over the past few years, after the government published their 10 year plan for it’s reform to a universal single-tier health service (based on need, not ability to pay) – known as Slaintecare, and many of you may have heard of it. It’s ambitious, is all I will say, but it’s vision is definitely admirable. It makes the domain of health service improvement in public health more relevant than ever going forward , and I believe we need public health physicians at the forefront of this reform, shaping and advising on it. Let’s break this down into quick bullet points again.

  • Health service improvement sounds pretty self-explanatory, but although there is more to it than meets the eye, I won’t over-complicate it. It’s about assessing many aspects of the services we provide to the population – accessibility, equity of distribution, efficiency, effectiveness, relevance and accountability for example.
  • On that train of thought, a key aspect of improving health services is ensuring that they are reaching those who need them the most – hard to reach populations such as those in lower socio-economic groups or migrant populations for example.
  • It’s also about rolling with the times and ensuring our services are up to date in terms of how they are delivered and the evidence that informs them. For example, technology becomes more and more advanced every single day, and we know that we do need to figure out the best ways to integrate it into our healthcare services. There is a lot of work going on in Ireland at the moment around the concept of eHealth and telemedicine – for example, looking at how we change transition over time to online prescribing of medicines in hospitals, online patient documentation and integrating that between primary and secondary care. It’s going to a slow process (and expensive) but it is necessary.

Health Intelligence

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This domain of public health is one I know the least about so far being honest, but I have learnt a little bit about it through my Masters of course, and it’s so, so interesting. Really though we only hit the tip of the iceberg. Health intelligence is all about healthcare-related data – how we record it, how we use it, and how best to use it to inform our healthcare services. From metrics like length of in-patient stays in hospital to waiting times for out-patient services to the monitoring of the health of the population I mentioned above, it’s all so relevant and so useful. In the GDPR era it of course needs to managed and monitored in a confidential, sensitive protected manner too. More on that as I learn about it!

And that brings me to the end of this little summary! I want to finish by saying three things:

  • I will dive headfirst into my public health doctor training scheme in July (not in Dublin – eek! More on where I’ll start soon!) for the next 4 years, and I cannot WAIT. That means I will learn a LOT as I go, and I am so, so excited to do so, and share my journey and learning with you all!
  • Public health to me is about teamwork, communication, collaboration, leadership and passion. I count all of those as strengths of mine as a doctor, and I plan to bring them with me to my work every single day. It will mean working more without my stethoscope than with – instead, it will be about using these skills to interact and collaborate with government officials, healthcare professionals, patients and other sectors to address the health of patients at a population level.
  • I want to be a leading voice in the field of public health medicine. I want to be a trusted voice, one that is heard over media myths and misinformation. I want to contribute to this field throughout my career, to improve the health of the Irish population, and I would also love to work internationally later in my training too to gain insights into how other countries approach public health, and use that insight in my own work.

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And I can’t wait to get started. I have a thesis to write, a Masters to finish, exams and assignments to do, and fun to have in between (HELLO LISBON AND COPENHAGEN IN JUNE!). And I say bring it, because life outside of my comfort zone has taught me nothing but growth so far on this journey, so I’ll keep trusting my gut instinct every step of the way.

I would love to hear your thoughts on this post guys – you know where to find me, @theirishbalance on Instagram/Twitter/Facebook! And thank you to everyone for such lovely messages, comments and kind words about my new job and career path, I am so grateful for all of your support!

Ciara 🙂 x

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