Abstract
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In the era of major changes in medicine and public health, from individual clinical care to population health, there is very limited information about training and available career paths among PHPM physicians globally as well as in the United States. 1 –3 Peik et al 4 addressed career choices for PHPM physicians and the challenges facing PHPM in 6 countries (ie, Canada, France, Italy, Japan, the United Kingdom, and the United States). 4
In the current study, we examine PHPM physicians’ career paths in the United States. We describe the Johns Hopkins PHPM Residency Program-trained physicians’ career paths, characteristics of their jobs, and the factors that influence changes in their paths during the course of their careers. The program has trained more than 10% of PHPM physicians in the United States in the last 50 years and has a well-established network of more than 600 alumni.
To collect information, a survey was electronically administered to 264 Johns Hopkins PHPM Residency Program alumni in 2008 and 414 alumni in 2014. The survey tool was developed after review of other national and program-specific questionnaires, evaluation by national PHPM experts, and beta-testing by residents. We collected descriptive data on demographics of graduates and data on characteristics of their jobs and factors that influenced any changes in their career paths. Mixed modeling techniques were used to evaluate the decision to obtain PHPM board certification, to estimate the duration of remaining at a job, and overall job satisfaction.
The response rate was 62% (163/264) in 2008 and 42% (174/414) in 2014. A total of 337 completed questionnaires from 290 PHPM Residency Program alumni were included in this study. Of the 290 participants, 60% were male with a mean age of 47.2 years (standard deviation [SD] 11.5); 52% of participants completed a clinical residency and/or fellowship before or after undergoing PHPM Residency training, and 73% of participants were board certified in PHPM. Respondents who had no other residency and/or fellowship training beside PHPM had an odds ratio (OR) of 5.75 (95% confidence interval [CI] 0.15–225.83), those with international jobs had an OR of 0.44 (95% CI 0.04–5.29), and those with nonacademic jobs had an OR of 1.36 (95% CI 0.17–10.73) of being board certified in PHPM.
We evaluated the characteristics of physicians’ PHPM jobs; 75% of participants had a job in the United States and 25% had an international job, including working for international nongovernmental organizations and public health agencies such as the World Health Organization. Nineteen percent of participants held an academic position, and 43% of participants had governmental jobs (58% in federal government, 12% at a state level, 25% in local government). Additionally, 53% of participants remained at their job for less than 5 years, 84% practiced direct patient care for less than 50% of time, and 44% of participants had no budget management responsibilities in their job. Participants who practiced direct patient care ≥50% of the time had an OR of 1.18 (95% CI 0.67–20.95), those with budget management responsibilities had an OR of 22.4 (95% CI 0.16–3050.90), and those with nongovernmental jobs had an OR of 0.28 (95% CI 0.01–5.72) of remaining longer in their jobs.
We assessed factors that affected participants’ overall job satisfaction, which ranged from 1 (extremely satisfied) to 5 (extremely dissatisfied) with a mean of 1.75 (SD 0.90). There was a 0.10 (95% CI −0.07 to 0.27) increase in overall job satisfaction for those involved in direct patient care and a 0.07 (95% CI 0.24–0.09) decrease in overall job satisfaction for those who oversaw budgets of more than $500,000.
Despite ongoing discussions on broad goals for population health, there is a lack of consensus on its specific definition. Population health is a spectrum where at one extreme, the health outcomes of geographically defined populations are the main focus; for example, the health departments at the city, county, or state level are interested in the population health of the areas they serve. 5 These outcomes are determined by various underlying characteristics of the population and services that the health departments provide. At the other extreme, population health addresses health care delivery systems such as health plans and accountable care organizations. It reflects accountability for health outcomes in populations served by health care delivery systems. 5
There is an ongoing discussion about the most appropriate knowledge and skills necessary to prepare physicians for careers in public health, in the health of populations, and in direct patient care. 3,6 The training provided during PHPM residency and the PHPM physicians’ career paths in public and private sectors makes them the best equipped practitioners in population health. Several factors affect PHPM physicians’ career paths and their move between practice areas during their careers. This study describes the career paths and decision-making processes of PHPM physicians.
Response rates in the current study were 62% in 2008 and 42% in 2014, which were comparable with the first national surveys among preventive medicine physicians in 1980. 1 The low response rate among participants in the 2014 survey might make it more difficult to generalize the results. There might be a higher percentage of dissatisfaction among those who did not respond to the survey. The low response rate in 2014 also makes it more challenging to assess trends in career paths among the alumni. In addition, it limits the validity of the longitudinal data analysis and statistical modeling.
The mean age of participants in our study was 47 years (SD 11.5), with the majority of them still actively working. Gender distribution among the participants was similar to the national survey of PHPM residents in 1987. 2 The number of participants with other clinical residencies before or after entering the PHPM program was higher than 36% among participants of the 1987 national survey. 2
About two thirds of our alumni were board certified in another specialty, which was much higher than the national level. 2 There were higher percentages of domestic and academic jobs held by our alumni when compared with PHPM physicians in the national survey in 1980. 1 Our survey showed that the PHPM physicians who had a higher probability of completing board certification in PHPM were influenced by the following factors: no other residency and/or fellowship training besides PHPM and domestic as well as nonacademic jobs. The higher rate of board certification among nonacademic jobs in comparison with academic jobs might be because many PHPM physicians in academia are faculty members of non-PHPM departments, which may not require PHPM board certification.
Dannenberg et al 7 reported on the percentage of PHPM graduates who had attained board certification, advantages of board certification, and barriers to board certification from a mailed survey of graduates from 1979 to 1989. They reported that as of 1991, only 45% of respondents were board certified in PHPM with the highest percentage of board certification among military PHPM residency graduates and the lowest among those from the Centers for Disease Control and Prevention PHPM residency. 7 There was a higher rate of board certification among those who served as the program director or on faculties in PHPM programs as well as those who devoted more time to administration and management. PHPM physicians with board certification earned higher income compared with those with no PHPM board certification. 7
The American Association of Public Health Physicians explored the value of PHPM residency training and board certification for physicians seeking jobs in the field of PHPM. 8 They reviewed 1427 job advertisements, only 1 (0.07%) of which required or preferred PHPM board certification. They also collected data on credentials, job search, and employment from 140 PHPM physicians; 78 physicians (55.7%) reported PHPM training as one of the major factors in securing their current employment. 8
We evaluated the characteristics of PHPM jobs and the factors that played a role in the decision to stay in a job; the percentage of time spent in direct patient care was similar among our alumni in comparison with physicians in the national survey. Less than one quarter of our alumni spent ≥50% of their time on direct patient care. 1 The number of participants with governmental jobs was higher among our alumni in comparison with respondents of the national survey. 1 Those with involvement with direct patient care for ≥50% of their time, budget management, and governmental positions were more likely to remain in their jobs longer compared with those with <50% time spent on direct patient care, no budget management, and nongovernmental positions. Budget management might be an indicator of a higher position, and governmental jobs might be more stable in terms of funding, future opportunities, and employee benefits, which may contribute to the decision to remain at a job. The national survey of PHPM physicians in 1980 also showed that governmental jobs were held the longest. 1
Overall job satisfaction among the participants in our survey was high (mean of 1.75). This finding is similar to the finding of the study evaluating burnout and satisfaction with work–life balance among US physicians relative to the general US population, in which PHPM physicians reported the highest rated satisfaction with work–life balance among different specialties. 9 PHPM physicians remained at lowest risk for burnout after adjusting for age, sex, call schedule, relationship status, primary practice setting, hours worked per week, and years since graduation from medical school. 9 PHPM physician satisfaction and its relationship with practice characteristics were assessed in a survey of 1979–1989 graduates of PHPM residencies. 10 Although our study revealed similar findings in terms of job satisfaction, caution should be exercised when comparing these results with other reports because factors taken into account to evaluate job satisfaction might vary among different studies. A more in-depth analysis of the different factors influencing overall job satisfaction, the method used to weigh those factors, and their impact on overall satisfaction might be necessary.
Peik et al 4 reviewed the career paths of PHPM physicians in 6 different countries. The career choices varied from traditional public health jobs such as medical officers or associates in local public health departments to working as salaried physicians within public hospitals and public health agencies in the domains of epidemiology or health information and academic practice, including research and teaching responsibilities. In the United States, PHPM physicians assumed a wide variety of employment from governmental jobs to public health departments, nongovernmental organizations, private sector, and research/academia, which was similar to our study findings. 4
PHPM physicians play critical roles in the movement in medicine and public health from individual clinical care to population health. PHPM physicians are well equipped to integrate population health with individual clinical approaches and to identify a standard definition of population health for health system leaders, academics, and those who hire population health professionals.
The current study provides valuable information about PHPM physicians’ career paths. A follow-up survey would help to compile trend data and offer a more in-depth evaluation of career trajectories of PHPM physicians. It will allow residencies and professional organizations to maximize career opportunities to address the well-documented shortage of physicians in population-based medicine. A national expansion of this survey will better describe the PHPM workforce in the United States.
Footnotes
Author Disclosure Statement
The authors declared no conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for this article.