Looking Upstream With a Preventive Medicine Physician

Session 150

Want to change the world, or at least the world around you? Dr. Michael Brumage tells us why preventive medicine in the community might be the way to do it!

Preventive medicine is a very underappreciated specialty that has the ability to be fulfilling for you as a physician and has a much bigger impact on the world than working one-on-one with patients every day.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:53] Interest in Preventive Medicine

Michael’s initial interest in preventive medicine came from his time in internal medicine. He trained originally as an MD Internal Medicine Physician after completing medical school.

He went overseas for a year and studied at the University of Heidelberg in Germany. Then he came back to the University of Florida where he did a three-year internship and residency in internal medicine which he really loved.

Michael was introduced to the concept of preventive medicine when he was in the military. Part of it came from a curiosity about Preventive Medicine in terms of Biostatistics and Epidemiology. But he was also working with his patients who had end-stage disease, heart disease, hypertension, diabetes, kidney disease, and liver disease. So he was thinking about what he could do to go upstream to try to make a difference in their lives.

“Preventive medicine trains physicians to look at the bigger picture, to take a step back, and look at things like the social determinants of health.”Click To Tweet

Many physicians look at health through the healthcare lens, working in clinics, working in hospitals, and we see that as healthcare. When you really take a bigger step back, health is a lot of things other than healthcare.

Looking at the possibilities of training in a way that he might be able to impact patients’ lives in a fundamentally different way was one of the things that really drew him into preventive medicine. Especially, with all the deeper issues in health and medicine today.

“Our healthcare system is a disease diagnosis and management system, not a health system.”Click To Tweet

Under the public health 3.0 model, they look at preventive medicine physicians as community health strategists, which is a really great way to look at this. So if you’re a physician out there, who is interested in taking that step back, you don’t have to get into preventive medicine, but it is a discipline focused in on that health strategist role.

[05:25] Why Preventive Medicine is Not More Intertwined with Internal Medicine Family Practice

Their residency director at the University of Florida, Dr. Craig Kitchens, talked about this in terms of being lumpers and splitters. Think about how we’ve looked at medicine before in the past. We have different disciplines to address different body parts in medicine – neurology, gastroenterology and so forth. It’s a way that we fragment things to focus on one part of the body and become a specialist in that.

Family Medicine, Internal Medicine, and Pediatrics are great specialties that would be well intertwined with Preventive Medicine. Personally, Michael would like to see more of that go on. But from his own internal medicine training, there was so much focus on making the diagnosis using the proper diagnostic modalities – the thought process that goes into a diagnosis and treatment.

“We don't think about the bigger picture at that point because we're so focused in on that individual patient and unraveling the riddle of the diagnosis in that particular person.”Click To Tweet

Michael wishes there would be more of an emphasis on preventive medicine, and that preventive medicine fellowship be offered to primary care specialties, rather than a residency. Because many people become curious after they begin to practice about what they could do differently but you don’t have time to do that. So a fellowship would ideally be another pathway into preventive medicine.

[07:13] Traits that Lead to Being a Good Preventive Medicine Physician

Michael stresses the importance of having a curiosity about the world. You have to be able to pick up a newspaper and begin to see the different pieces of the world and how it affects health. See how economics, housing, transportation, and all those affects health.

Understand how they’re instrumental in synthesizing an idea about how we can change the health of populations as well as individuals.

“The ability to take a step back and see the bigger picture seems to be a critical skill set to be able to become a successful preventive medicine physician.”Click To Tweet

[08:34] Preventive Medicine’s Role in Restarting from the COVID-19 Pandemic?

From 2005 until 2008, Michael was the chief of preventive medicine at Tripler Army Medical Center in Honolulu, Hawaii. But he worked a couple of other different hats at the time. He was the public health emergency officer for the Pacific Regional Medical Command.

He was also the public health emergency officer for Joint Task Force Homeland Defense. That included all the U.S. affiliated Pacific Islands, places that a lot of people have never heard of.

At that time, the threat was influenza H5N1, the bird flu, the highly pathogenic avian influenza that threatened to which, by the way, had a very high mortality rate. And if it jumped into acquiring the person-to-person spread, it would have become the next pandemic with much more dire circumstances than what we currently see with COVID.

That background helped Michael to think in a more holistic way about systems of care, about disruption of staff and hospital, disruption of food supplies, of supply chains. That kind of skill set is absolutely needed at this moment.

What we’re really not thinking about is that this pandemic has become a great magnifying glass for watching what’s happening with other aspects of health. So we see these huge chasms. Now, with inequities of health care for people of color, specifically African American populations. We see that our mental health crisis in the United States is growing.

And unfortunately, in West Virginia where he practices, which is maybe the greatest preventive medicine laboratory in the entire world because of all the different things that go on in West Virginia. It has the highest rates of Hepatitis B and C in the country. West Virginia is still leading the nation in overdose deaths, diabetes, smoking, you name it – West Virginia’s got it going on. All of these things are magnified.

“The pandemic is robbing us from paying attention to these other issues.”Click To Tweet

Michael believes that the pandemic has sucked all the oxygen out of the room. It has taken away all the light and when you take away oxygen and light, things begin to ferment. So we’re watching these underlying health issues begin to ferment. And these will be major issues, which they were before the pandemic and they’ll get worse during the pandemic.

“Having someone with a preventive medicine background is going to be absolutely essential to help people understand what health really is and where we need to focus our attention.”Click To Tweet

[13:05] Myths Around Preventive Medicine

Michael admits that most people including him did not know much about preventive medicine and didn’t understand what they did. They seem to be a sort of disembodied aspect of medicine.

And in many institutions, like Madigan Army Medical Center where he trained, it was in a totally separate building. When you’re in a separate building away from everything else that’s happening, it’s easy to maintain that illusion that preventive medicine is something that other people do in the dark corners of medicine.

In that regard, Michael wishes that preventive medicine was more integrated with clinical medicine or they could add prevention into the practice of these guidelines. But the misconception that preventive medicine is only done in offices in front of computers is a mistake.

Getting involved with the community getting your hands dirty is one of the aspects of preventive medicine.

One of the ways he likes to think about this is when you have a computer on your screen, you have a lot of icons about what programs are important. And when we think about medicine, the icons are surgery, medicine, pediatrics, and so on – and preventive medicine just runs in the background that you never find out about until the crash.

“The misconception that preventive medicine is only done in offices in front of computers is a mistake.”Click To Tweet

[15:06] How Much Patient Care is Involved in Preventive Medicine

Under the ACGME, it is a requirement to have at least two full months of patient care during your PGY-2 year. Most preventive medicine residency doesn’t start with an internship in preventive medicine. It starts with an internship at either a transitional year of surgery, medicine, or something else.

Then you begin your PGY-2 year in a preventive medicine program. Even in that PGY-2 year, you’re still expected to have clinical rotations, which are very important things.

General ambulatory medicine clinic rotation is really important in infectious disease.

“In order for you to be a good physician of any type, it's important to have a strong clinical background.”Click To Tweet

You can do clinical care, but you can also do so many other things with preventive medicine other than routine clinical care. Some physicians in preventive medicine model their practices with something relatively new, called lifestyle medicine, where you have wellness clinics and see people that way and have a sort of clinical practice that is really focused on wellness rather than the disease identification and treatment.

[16:33] Typical Day

“One of the beauties and one of the curses is that there is no typical day.”Click To Tweet

Michael does clinic twice a week. He also holds residency meetings along with a number of other meetings.

They want people who have the burning passion within them to come into this field. So he appears on podcasts to advocate for the field. He also writes articles for different publications and journals, being the voice for issues that are happening in our community.

He recently wrote on The Atlantic talking about rural health issues including the opioid crisis as well as adverse childhood experiences (ACEs).

A lot of people don’t understand that what happens to you during childhood has lifelong impacts.

“People with an ACE score of six or more are 40,800% more likely to use injection drugs, 40 times more likely to use injection drugs, and will live on average 20 years less.”Click To Tweet

ACEs are one of the many things that he talks about in his day-to-day as he gets asked to speak around the state. He has worked with the Maryland Department of Health and others around ACEs.

Michael likes to tell people they’re the Forrest Gump of public health as they end up showing up at different places at different times with the major events that are happening.

Preventive medicine can be very interesting. You can be a health officer in a local health department. But that can lead to all kinds of really interesting things if you’re willing to go outside your office. You’re able to get your hands dirty, meet people, and bring all the resources together since you need to tackle the really meaty public health issues.

[21:22] If You Have Big Aspirations of Changing the World

Michael sees the importance of really reaching out to medical students through different platforms including this podcast because so much attention is paid to clinical care.

“It's really hard to compete for attention against things that are well established.”Click To Tweet

Most people understand internal medicine or if you’re a surgeon. But preventive medicine suffers from a little bit of an identity crisis in terms of exactly what they do and how do you explain that to people. It’s something he has had conversations with folks at the American College of Preventive Medicine.

Getting out there and being able to talk about yourself come in two ways. First, people talk about themselves. There are people who do it from a narcissistic perspective that they want to promote themselves and things like that.

And that goes against the grain of many physicians who feel that they just have got to put their nose down to the grindstone. They don’t want to self-promote and self-advertise because they see it as sort of being egotistic. But if you don’t get out in front and start to talk about what you do, people are never going to figure out what you do.

“If you don't get out in front and start to talk about what you do, people are never going to figure out what you do.” Click To Tweet

At the end of the day, Michael explains that sure, you can talk to national media sources. You can learn about risk communication. You can get involved in big meaty issues around natural disasters and manmade disasters and about populations. But it’s hard to do that from an office where you’re expected to see a patient every 15 minutes.

[24:09] Taking Calls

Michael describes the call as not being a traditional call. You’re not on one every three or every four or every six, where you’re sharing it with your partners. You’re either on or you’re off. And so for public health crises like this, you are on all the time. There is no off time.

Now, that doesn’t mean you’re up on 24 hours a day or that you’re dragged into the middle of the ICU. But things happen unpredictably and you need to be able to respond to those things.

The last time he was involved other than the pandemic was in 2016 where they had a major flood in West Virginia. It was a 1000-year flood that sent people out of their homes. They had to open a shelter in a high school gymnasium. It was the first time that’s ever been done in this county.

So he was on all the time during that entire crisis. He was sleeping three or four hours a night and then getting up the next day and going out and beating the streets. And then of course, it tapers off over time as other organizations jump in. But some really important decisions need to be made really early on. The same way with a pandemic, you have to be able to respond right away.

But in terms of other kinds of calls, you’re with your family most of the time. It’s very fulfilling. And you can do a lot of other things on the side. In preventive medicine, you have this ability to do all these things, and many of them are at your choosing, and not being chosen for you by somebody else.

“It's a very family-friendly specialty of medicine.”Click To Tweet

[26:57] Training Pathway

After the internship year, there are two more years of training. The first the PGY-2 year is really more clinically focused but you begin to transition into more population health and preventive medicine responsibilities.

When you get your PGY-3 year, you’re expected to do rotations with a local health department, and in their case, with the state health department as well. So you have that broader background doing other rotations and getting involved in other sorts of projects two years after the internship year.

Then you can do all the board prep to sit for the American Board of Preventive Medicine’s examination which is a comprehensive examination as it is in many other specialties.

[28:05] Message to Future Primary Care Physicians

What Michael would tell the person who is in a primary care residency is that you need to become a good physician, just a good clinician overall.

But many primary care physicians will find themselves soon frustrated by the grind by the administrative responsibilities of being a physician. And these are all things that have to do with compassion fatigue and burnout.

If you still have that flame within you and most physicians do in wanting to change the world around you, stop and think you have another pathway. You are not trapped into primary care. You can go out and take a step back and do preventive medicine after residency.

This is exactly what Michael did after 10 years in the military. He was able to do a preventive medicine residency. Now he had an advantage in that he still got paid at the time as a lieutenant colonel so he didn’t have to take a financial hit.

“This avenue is still open for you anytime throughout your career.”Click To Tweet

So if you find yourself reaching that point where this is not what you set out to do, or this was not the original reason you came into medicine in the first place, take a step back. Preventive Medicine is always here for you as another pathway in your career, and you will find it immensely rewarding.

[29:49] The Most and Least Liked Things About Preventive Medicine

Michael likes that every day is a different day that he gets to do so many different things and be involved with so many different kinds of activities. He is everywhere from addressing the opioid crisis to a nuclear power plant meltdown to a flood, to just trying to make a community better overall.

It’s rewarding to have an opportunity to work with college athletes and division one athletes. He’s able to give them a life skill that hopefully will help them with their performance, but also with their daily lives, with their relationships with their studies.

At the end of the day, it’s not about the paycheck for him, it’s about the ability to have a fulfilling life.

“You don't have to be trapped into a career that you just don't find fulfilling. There is a better life for you. And preventive medicine is one of those ways to a better life.”Click To Tweet

On the flip side, what Michael doesn’t like about the specialty is that when you’re a local health officer, which he was at one point, you can get caught up in politics. And you’re dealing with elected representatives. It can be very frustrating, especially in times when expertise in science is called into question. And when you see a lot of conspiracy theories, you have to bat those down. In West Virginia, they have some of the strongest vaccination laws in the country. In fact, they do better with school children than any other state in the United States. And the community spewing out misinformation and really getting people to do and make really bad decisions is one of the frustrating things.

[33:15] Major Changes Coming into the Field

Michael mentions talking with a buddy from ACGME about the other ways you can get into preventive medicine other than doing a fellowship. A lot of people who are working as primary care clinicians will work as a local health officer without really any specific training. And some of those experiences can actually help you.

If you want to sit for the boards later on, you may still need to complete necessary education and didactics toward a Master’s in Public Health which is one of the other advantages he loved about this specialty.

You have the opportunity to go back to school and get a Master’s but also getting physicians to be able to find other alternative pathways into the specialty. So you don’t have to make this decision after your internship year. Although he wishes more medical students would think about it coming out of medical school. This alternative pathway is another way that primary care physicians can go into preventive medicine.

But he’s also hoping that more and more physicians will just see the value in preventive medicine and that they find it as a personally rewarding alternative for themselves.

[34:54] Final Words of Wisdom

If he had to do it all over again, Michael would still have chosen to be a preventive medicine specialist.

For him, it was without a doubt, the best thing he ever did with his life in terms of professional development. It’s rewarding to have the opportunities that he has had, showing up at really interesting moments in history and being able to have an answer to make a difference.

How many physicians have had the opportunity to think about pandemics until February of this year in the United States? Very few. Again, it’s something Michael has been doing for almost 15 years.

Finally, his advice to premeds or medical students who might be interested in preventive medicine is that when you see the seduction of clinical medicine, of the big dollar signs around procedures, think that you still have a pathway to do what you want to do – to make a difference for your community. And think about preventive medicine as one of those pathways into a rewarding career.