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Physician executives, communities and public health.

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Learn how approaching a community without any sense of entitlement and acknowledging the community's point of view in health matters will allow for the growth of trust and, consequently, solid health improvement.

Involved in a raging debate about the quality and price of health care, Americans are realizing that our hospitals, health centers, and physicians, alone, cannot prevent the predicted rise in such harmful conditions as obesity, diabetes, hypertension and cancer.

Doctors, pressured by time requirements, pharmacy advertising and rapid medical advances, seem to be relying increasingly on medicines over behavior change counseling. Patients, now taking record numbers of medicines, are unable to keep up with scheduling, side effects and costs.

As Americans struggle with health insurance and drug prices, they are looking increasingly to improve their health without depending on doctors and hospitals. Through grant funding and public health laws, federal, state and local governments are supporting community efforts to organize and provide healthy choices to residents with regards to nutrition, exercise, air, water and safety.

The Centers for Disease Control and Prevention (CDC) supports community-level efforts to reduce chronic diseases with Community Transformation Grants. The National Institutes of Health (NIH) encourages the partnering of academic institutions and communities through Community-Based Participatory Research (CBPR) grants.The Affordable Care Act funds community approaches to obesity prevention, smoking cessation, improved behavioral health, nutrition and HIV prevention.

The U.S. Department of Health and Human Services (H HS) recently released Healthy People 2020, a health roadmap for the nation to follow over the next decade. Its is leading health indicators are community and prevention centered. Presumably, federal grants will be available to help attain Healthy People 2020 goals. Private foundations such as the California Endowment have strengthened focus toward improving community health. Currently, physician executives have a prime opportunity to partner with communities and be an influential voice in optimizing health.

Physician executives, often employed in large institutions, tend to have little experience working directly with community groups. Engaging communities requires meeting the right players, showing empathy, keeping promises and gaining acceptance.

The first step to fruitful collaboration is to build a trusting relationship between the institution and the community. To show that you have the best interests of that community, consider the following:

* Define "community"--While it remains easiest to think of community in geographic terms, communities come in an array of types. Ethnic, religious, homeless, elderly and lesbian-gay-bisexual-transgender (WET) communities, for example, often comprise people who live far from each other. Specifically defining the community you and your institution want to target will prevent you from over-reaching and trying to accomplish too much. As you nurture your relationships, your view of what the specific community is may evolve, but start with defined parameters.

* Understand public health--While physician executives have trained in medicine, few understand its sister discipline: public health. Medicine involves healing sick individuals; public health centers on disease prevention for populations. Examples of successful public health achievements include vaccines, reducing industrial pollution, fluoride in tap water, personal hygiene, seatbelt mandates, cooking meats at high temperatures, indoor smoking bans, condom use and infants sleeping on their backs.While those may be among the most popular, there exist numerous public health findings that may be less known to physicians and the public. These include obesity, diabetes, hypertension and high cholesterol. For well-nourished populations, like most Americans, taking a multivitamin per day does nothing to improve health--in fact, recent studies show it may be harmful; there exists little evidence that drinking milk prevents bone fractures--a lifetime of drinking cow's milk may be the cause rather than the cure of osteoporosis. (1-3) (Note that medical procedures like colonoscopies and mammograms, which stand at the intersection of medicine and public health, are considered preventive medicine in that they prevent the spread of disease but do not prevent initial disease.) Public health also evaluates a community's circumstances with regards to factors like poverty, education, employment, housing, food insecurity, condition of roads, etc. These "social determinants of health" often concern communities more than having access to health care providers, facilities and medicines.


* Address community concerns--While physicians, conditioned to see the world through disease, may want to reduce diabetes in a certain group, for example, that group may be more concerned about the lack of area grocery stores and the plethora of fast-food restaurants.Addressing the community's concerns first will earn trust, respect and gratitude--all of which will allow you to present your suggestions to improve health with less resistance.

* Acknowledge community distrust--Because of poor past relationships between institutions and communities, many may hold strong suspicion of doctors and hospitals.Communities have seen academicians come, experiment and leave without making any substantial improvements. Officials make major environmental alterations without asking for community input. A community's fear and distrust of medicine has only increased as numerous studies confirm that providers may stereotype their patients based on race or ethnicity and not provide the same intensity of health care to all. (4) These health disparities are being addressed through cultural competence training, educating more minority health professionals, removing language barriers and emphasizing optimum quality universally. Show that you are connecting with the community to collaborate rather than dictate.

Every community has its central, trusted members. Appealing to them first may ease your entry into the community's world.

* Understand health care around the world--While politicians love to extol how America has the "best health care system in the world," our outcome and cost data forcefully contradict that belief. The countries of the developed world have all experienced the same problems we do and have instituted a variety of ways to solve them. All have established some form of universal insurance, whether private or governmental, to prevent the societal drain and expense of having a substantial uninsured population.Other countries have made great progress in decreasing high costs, inequality, dangers and inefficiencies seen plaguing America's system. Internationally, public health is prioritized with regards to meal size and quality, building walkways and bicycle paths, decreasing safety risks, and improving air and water quality. Understanding how the world has dealt with its health care issues will give the physician executive tools to help American communities determine their own health standards.

* Become an advocate--Once you start working with a community, it will expect you to represent the community's views to the institution you represent. It will also view you as the liaison to the community when any member accesses services at your institution. While you learn and understand the community's needs and wants, be wary of the natural reaction to compare it to other communities.Rather than viewing life as a zero-sum game, teach the community that exchanges and partnerships with other groups and building allies will lead to improvements and more resources.

* Get over yourself--Physician executives have been conditioned to believe that, because of their education, income, and position, they stand atop the social ladder.Communities, however, can immediately sense an over-inflated ego.When working with communities for interventions that will lead to positive health outcomes, you must arrive and remain as an equal.

With public and private funders emphasizing community-level approaches to health, partnerships between physician executives and communities can mature into fruitful, symbiotic associations. Initial moments of unease and suspicion are typical for the start of any relationship. Approaching a. community without any sense of entitlement and acknowledging the community's point of view in health matters will allow for the growth of trust and, consequently, solid health improvement.


Medicine involves healing sick individuals; public health centers on disease prevention for populations.


(1.) Campbell TC and Campbell TM. The China Study. Dallas, Texas: BenBella Books, zoo6

(2.) Mursu, J., and others. Dietary Supplements and Mortality Rate in Older Women: the Iowa Women's Health Study. Arch Intern Med. 171(18):1625-33, Oct. 10, 2011.

(3.) Feskanich D, Willett WC, Stampfer MI, Colditz GA. Milk, Dietary Calcium, and Bone Fractures in Women: A 12-Year Prospective Study. American Journal of Public Health. 87(6): 992-7. June 1997.

(4.) Smedlley BD, Stith AY, and Nelson AR (Eds). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press, 2002.

Chandak Ghosh, MD, MPH, is a board-certified ophthalmologist and health policy consultant in New York
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Title Annotation:Public Health Care
Author:Ghosh, Chandak
Publication:Physician Executive
Geographic Code:1USA
Date:Jul 1, 2012
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