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Join us as we speak with Donna Grande, CEO of the American College of Preventive Medicine. We discuss the urgent need to overhaul the broken health care system in the U.S., addressing issues such as the high cost of health care and disparities in care among marginalized communities. Donna emphasizes the importance of involving preventive medicine-trained physicians in decision-making processes, highlighting their unique skills in health systems thinking and public health. Discover the ethical imperative and practical benefits of inviting these physicians to the table, as we explore potential solutions and legislative changes to fix our health care infrastructure.
Donna Grande is CEO, American College of Preventive Medicine.
She discusses her KevinMD article, “Here’s how to fix the public health system in the U.S.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Donna Grande. She is CEO of the American College of Preventive Medicine. Her KevinMD article is titled “Here’s how to fix the public health system in the U.S.” Donna, welcome to the show.
Donna Grande: Hi, thanks so much, Kevin. So glad to be here.
Kevin Pho: So we’ll get into the article a little bit. First off, just briefly share your story and journey to where you are today.
Donna Grande: Sure. I think I’ve had an incredible journey to get to the current position with the American College of Preventive Medicine. When I think back on what influenced me in my early formative years, my grandmother always said, “If you don’t have your health, you have nothing.” That was always a very important statement, and it resonated with me.
My first job out of college, as a writer, was working on the first report to Congress on tobacco and health. It was actually smoking and health at the time, because it was all about smoking and sidestream smoke and the impact of smoking on the population. Dr. Koop was the surgeon general at the time. Dr. C. Everett Koop was very inspirational, and he had a goal of creating a smoke-free society by the year 2000. That really resonated for me.
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Kevin Pho: So for those who aren’t familiar with what exactly preventive medicine is, tell us, what’s the formal definition of that?
Donna Grande: Well, Preventive Medicine, with a capital P, capital M, is a specialty in medicine. It is one of the 24 specialties within the American Board of Medical Specialties. It is a certified specialty within medicine.
Preventive medicine physicians are those physicians that have first-year clinicals in their residency training, either in internal medicine, family practice, pediatrics, or some other specialty, and then they enter into a residency training program for two years, at least two years of additional training in public health. They receive a master’s of public health. They acquire competencies in systems thinking, health systems finance. They do rotations in public health departments to gain on-the-job experience working with health departments and in that public health infrastructure, which differentiates their skills and expertise from other MDs who happen to also acquire a master’s in public health.
Kevin Pho: So tell us about some of the challenges facing the field of preventive medicine today.
Donna Grande: Oh my goodness, where do I begin? One of the key challenges has to do with funding and the pipeline. The funding for residency training for preventive medicine is not the traditional pathway for graduate medical education that is supported predominantly by the Centers for Medicare & Medicaid Services. It actually comes from HRSA, the Health Resources and Services Administration. Many physicians that are not in preventive medicine are surprised to hear and to learn that.
With the HRSA funding, we have to, year over year, fight the appropriations process to try to increase the funding for those slots at the various programs across the country. For just the preventive medicine public health part of the specialty, we need $52 million to fund all of the slots. Notoriously, ACPM has fought the good battle, engaged our advocates, and aligned our strategic partners, and for over a decade the line item has been flat, anywhere between $7 million and $8 million.
As you know, and as anybody who works in federal appropriations or understands the congressional budget cycle knows, $52 million would be the size of a nit on a gnat, let alone the $7 million to $8 million we get. So 50 percent of the approved slots to build this important specialty of medicine, 50 percent of the slots, are unfilled because we can’t secure the resources to pay for those important roles and residency rotations.
Kevin Pho: Now, for those medical students who may be listening to you on this podcast, what are some questions they should ask themselves if they were to consider preventive medicine as a career?
Donna Grande: Well, more than anything, we get med students that are so passionate about making a difference. In their first-year clinicals, if they go in and select preventive medicine, or select another residency at first, they have the experience of doing clinical care. What we’ve heard more than anything from our residents is that during that first-year experience, they saw patient after patient with chronic conditions that are preventable. They’ve seen chronic conditions such as diabetes, hypertension, COPD, or other aspects of individual patient health, and they want to have a bigger impact. They want to swim upstream and really look at the population as a whole, and they really want to make a difference.
So if you are a med student and you are frustrated, or interested and encouraged by having greater impact at the population level, please consider a residency in preventive medicine. Reach out to us through our website, and we’ll be happy to share more about how you can get involved and engaged and start a career path that’s going to be very meaningful.
Kevin Pho: All right, let’s talk about your KevinMD article. It’s titled “Here’s how to fix the public health system in the U.S.” Big topic. So tell us, how did this article come together?
Donna Grande: Well, there are many ways to fix it. I think that the premise of my article at the time, back in April, was really around getting physicians at the table. There’s a lot of discourse about physicians not understanding the health system or understanding how to fix this broken system. It was absolutely imperative that physicians who are trained in systems thinking, who have experience from the federal government all the way to state and local government, as well as in the care for individual and population health, and in particular in looking at diversity, equity, and inclusion, really looking at the marginalized, be at the table. And so preventive medicine physicians need to be at the table.
Our health care system is a sick care system. It focuses on treating illness, not on preventing the disease and the illness at the start. If the Congressional Budget Office could change its scoring methodology around prevention, number one, we might be able to have more investments in prevention and show the long-term return on investment in investing in upstream prevention in order to reduce health care costs. Almost 20 percent of our GDP is spent on health care, and yet the population is not getting better. It is not healthier than any other industrialized country around the world.
Kevin Pho: So when you say you need more physicians trained in systems-level thinking, what exactly do you mean by that?
Donna Grande: The health care ecosystem is complex. Value-based reimbursement: Our country has been based on a medical system which is based on fee-for-service. If we are truly going to look at changing the paradigm, looking at the systems and the infrastructure and the connected systems that are going to change the financial outcomes as well as health outcomes is truly important.
Preventive medicine physicians are trained with that systems thinking, not looking at one patient exclusively at a time, but really looking at what are those social determinants, or social drivers of health, that really truly impact a patient population, to really truly achieve optimal health for all.
Kevin Pho: Now, do you have a case study or an example of a preventive medicine physician using that systems-level training to make a measurable difference? Maybe a story that would illustrate that?
Donna Grande: Oh my goodness, what a great question. I think if you talk to any of our program directors across our residency training programs, you will probably see case study after case study. Through COVID-19, many preventive medicine physicians worked in and through and with health systems, specifically working with marginalized populations, to see how systems thinking would apply to ensuring that EHR systems and data analysis and the epidemiology really looked at how we could increase the number of vaccines available to, accessible by, and delivered to marginalized populations across the country. That’s one example.
Kevin Pho: So you mentioned, of course, that health inequities contributed to disproportionate rates of preventable chronic conditions. So any statistics or numbers that can really drive that point?
Donna Grande: Well, when you think about 96 million prediabetics that are undiagnosed in our country, I mean, that’s an incredible data point that should make everyone fearful about what the downstream implications of that are. And when you look at how patients one-on-one are having interventions or conversations with their physicians, prediabetes may not be part of that.
And so if you look at family history and the likelihood of having prediabetes move into type 2 diabetes, glucose monitoring systems, as an example, are not readily available to marginalized populations to really look at tracking, tracing, and managing or monitoring their glucose level, to actually look at how lifestyle changes might change or influence the decisions and the choices they make and how they live their life, whether it’s the food they eat, the exercise they get, the sleep, so many factors of lifestyle that impact the potentiality of acquiring full-blown type 2 diabetes.
Kevin Pho: So you mentioned previously that we want to get more preventive medicine physicians at the decision-making table to address some of these public health concerns. What about the majority of the clinicians that are out there listening to you now? Is there anything that we can do to get trained in systems-level thinking and make that population-level difference after practicing?
Donna Grande: Absolutely. We would love for all physicians to actually consider a second board, or a third board, or a fourth board. So many physicians care deeply and are lifelong learners, and so preventive medicine is an opportunity for them to actually acquire and gain that additional skill and mindset, coming and attending any of our annual conferences, seeking out and purchasing our lifestyle management core competency course.
There are a whole host of ways in which the additional skills could sharpen the edges of physician practice, to think through and to actually acquire population health-level insights into delivery of care, and change their voice and use their voice to influence practice and policies in their community.
Kevin Pho: And when you talk about physicians getting another board, how many years of training typically would one need?
Donna Grande: Two more years.
Kevin Pho: And again, drawing the distinction between a preventive health residency versus a master’s of public health degree, what’s the distinction?
Donna Grande: I think more than anything, it’s the skills that you acquire by actually working in and rotating through public health departments. It’s really on-the-ground training from that perspective, in addition to the types of case studies and projects that are part of the curriculum and the training.
Kevin Pho: So if you were the public health czar, able to make whatever changes that you want in your ideal world, what would you like to see happen?
Donna Grande: I would love to see that every single city, county, and state health department across this country would have a trained, board-certified preventive medicine physician among the ranks of their employee population. Whether it’s the health commissioner, whether it’s their chief epidemiology officer or chief medical officer, I don’t really care. But I do think that every single health department would have incredible value if they had a medical professional trained and boarded in preventive medicine leading the way and being at the table to help interface with the hospital, federally qualified health centers, and other clinicians, to help truly bridge public health and health care in each and every community across this country.
Kevin Pho: And tell us, what are some of the major obstacles that you see preventing this vision from happening?
Donna Grande: The key one has to do with funding. And so, number one, if each and every health department looked within their own assets and thought through their new grants on workforce from the Centers for Disease Control and Prevention. If they also talked with each and every one of their elected officials and advocated strongly for additional funding in the HRSA line item for residency training.
Again, there are a lot of compromises that are being made on Capitol Hill right now for funding decisions with the recent appropriations, and we certainly hope that preventive medicine is not cut, but more than anything, is actually increased, so that we can, in fact, train and build up the pipeline of public health physicians across this country.
Kevin Pho: We’re talking with Donna Grande. She is CEO of the American College of Preventive Medicine. Her KevinMD article is titled “Here’s how to fix the public health system in the U.S.” Donna, tell us some of your take-home messages that you want to leave with the KevinMD audience.
Donna Grande: More than anything, that there is hope, there’s possibility, and there’s an opportunity to really encourage elected officials to embrace political will. If there is an opportunity to influence policy for good, we need to all exercise our voice and put it into practice.
Kevin Pho: Donna, thank you so much for sharing your time and insight. Thanks again for being on the show.
Donna Grande: Thanks for having me, Kevin. I appreciate the opportunity.
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