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Indian J Community Med
Indian J Community Med
IJCM
Indian J Community Med
Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine
0970-0218
1998-3581
Wolters Kluwer - Medknow India

IJCM-49-561
10.4103/ijcm.ijcm_292_24
Editorial Commentary
Some Thoughts on Superspecialization in Community Medicine
Krishnan Anand
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Anand Krishnan, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India. E-mail: kanandiyer@yahoo.com
Jul-Aug 2024
09 7 2024
49 4 561563
04 5 2024
06 6 2024
Copyright: © 2024 Indian Journal of Community Medicine
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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pmcUNDERSTANDING COMMUNITY MEDICINE

I am often asked this question – What are the options for further study for anyone who already has a postgraduate degree in community medicine? At the same time, many departments of community medicines are looking to start advanced training to create superspecialists, and approach me for guidance. So how do we envision superspecialization or advanced training in Public Health/Community Medicine? I am writing this primarily from a community medicine perspective, even though this would also be applicable to public health. In general, public health looks at the issues from a broader perspective as compared to a more medicalized perspective of community medicine.[1]

Before we think about superspecialization, let me summarize what is core or basic community medicine as a specialty. Community medicine, unlike other medical subjects, straddles many disciplines and requires collaboration between them to create a cohesive curriculum or solve multifaceted problems. This subject in the medical curriculum bridges the medical-health paradigm gap by integrating many nonmedical competencies into a medical graduate. It is premised on the fact that improving people’s health goes beyond medicine.[23]

Core disciplines required for improving the health of the community are to it, measure it (epidemiology and biostatistics), understand it (social sciences), and modify it (social and health systems/policies) in addition to providing medical care (medicine). Each of these alone is insufficient to practice community medicine and while one’s primary qualification can come from any of the core disciplines (doctor, epidemiologist, statistician, social scientist, management) for someone to be called a public health professional they should have basic training in all the four core disciplines. This emphasizes the true inter or trans-disciplinarity of public health. Basic medical knowledge is not restricted to doctors alone but includes nurses, dentists, etc. Also, while a CM-trained person can become a public health professional by adequate training in other disciplines, a person from nonmedical background cannot become a community medicine professional.

What do we want to achieve in advanced training in community medicine?

Is superspecialization as a concept a complete antithesis for what community medicine stands for given that its strength lies in the breadth of the discipline and not depth? I do not agree with this. I believe that a deeper understanding of any one aspect is a desirable goal to have and is critical to expanding the frontiers of a discipline.

We typically describe advanced training as knowing more and more about less and less! In other words, a very in-depth knowledge about a very specific area. Typically, in medicine, this refers to an age (pediatrics, geriatrics), organ system (ophthalmology, orthopedics, cardiology, endocrinologist,) or a disease (infectious diseases) or a specialized procedure (radiology, etc.) as that is how the medical training is organized. However, this is not applicable to community medicine. If you look at any community medicine textbook, after covering the above four core subjects, it will move to applied aspects related to chronic diseases, infective diseases (by route of transmission), environment, etc., usually ending with global or international health. That may provide some insight into how to organize advanced training.

What is driving this need to initiate superspecialization in community medicine?

We also need to introspect as to what is driving this need to superspecialize. Is it fueled by the desire to be called one (power dominancy), or to address the growing or expansion of knowledge in the discipline that requires segmentation, a growing market or demand for specialists, or is it due to the specific needs voiced by health planners or community stakeholders.[45] The development of medical specialties is a poorly studied phenomenon and the example of the development of emergency medicine provides a good perspective on the issues involved.[6] In general, community medicine people have been critical of the trend of superspecialization and the narrow focus on an organ as market driven and not driven by the needs of the community.

Should we call it Doctorate of Medicine (DM)?

While many of us are enamored with the DM models in cardiology, neurology, etc. (sort of gold standard for superspecialization), it is important to understand that a DM degree provides additional clinical skills to the trainee and is practice oriented. I do not think that the DM model is appropriate for community medicine. Clinical aspects of community medicine have limited vertical growth opportunities as they will invariably encroach on other clinical disciplines and are not necessary for the improvement of population health. You cannot superspecialize in primary medical care! DM in epidemiology also does not make sense to me.

What are the possibilities for superspecialization or advanced training in community medicine?

I classify advanced training into three types – academic, applied, and practitioner.

Academic training programs would help in developing/validating/refining new concepts, methods, or approaches in any of the four core areas, in other words pushing the frontiers. This could include advanced epidemiological and statistical concepts/approaches related to public health like disease modeling, bioinformatics, data sciences, newer approaches for community engagements, understanding health behaviors, health technology assessments, etc. These could be one-year specific advance certificate courses like for disease modeling, or any specific statistical technique. For more detailed and in-depth, especially conceptual work, Doctor of Philosophy (PhD) would be preferable, which emphasizes research skills and scholarly accomplishments. PhDs generally prepare students to become scientists or scholars, in roles such as professors, research directors, etc.

In Applied training programs, we apply the known approaches and skills of the discipline (eligible persons should already be competent in them before coming for these trainings) to a specific area like nutrition, environment, infectious diseases, chronic diseases, genetics, occupational health, and so on. Each of them has some specificities that require deeper knowledge and maybe some additional skills. For these, we could use Fellowships of up to two years duration.

The third is for existing public health practitioners who want to develop certain skills that they think are relevant to their current work. For them, Doctor of Public Health (DrPH) is the global norm. The course would typically focus on operational and implementation research, program monitoring and evaluation, policy development, etc. Indian Universities, to the best of my knowledge, currently do not offer this option.

Who should be eligible for superspecialty courses in Community Medicine?

If one agrees to what is written earlier, then we must also see the eligibility as not only restricted to postgraduates in community medicine but also open to others. For example, DM infectious diseases should be open to physicians, microbiologists, community medicine, and pediatricians. Likewise, we need to have a broader criterion for intake. For example, why should a MD medicine not get trained in occupational health or nutrition. The list can go on… It is acceptable if medical colleges restrict their training to medically trained people. That is their choice and possibly best suited to the expertise available to them. However, that should not be defined as the only model for advanced training for people with postgraduate degrees in community medicine.

I take few specific examples to further illustrate my thinking. These have been asked or proposed to me for starting:

Family Medicine (FM): I do not consider FM as a career advancement for community medicine postgraduates. For me, a typical FM specialist should be able to manage community health centers (handle all basic emergencies including doing cesarean section, neonatal emergencies, setting fractures, giving spinal anesthesia, myocardial infarction, shocks, etc.) independently, or an all-in-one secondary level doctor. So, this can be considered as horizontal growth (with larger focus on the medical aspect) and not vertical growth. Incidentally, MD in FM will also probably grapple with the issue of superspecialization!

Preventive Medicine: Preventive medicine is the specialty of medical practice that focuses on the health of individuals, communities, and defined populations. It is obvious that if one wants to practice primordial or primary prevention, then community medicine knowledge is essential. Both given our ancestry of Preventive and Social Medicine (PSM) and the course focus, preventive medicine can legitimately be part of the applied aspect. So, I would say fellowships in preventive medicine should be a definite possibility.

Disaster Management: Disaster management needs transdisciplinary teams (surgeons to engineers). There are very few institutions that are equipped to provide such training, including medical colleges. The core competencies required for this align very well with that of community medicine and this could be another area that is very relevant to national needs where we can take the lead. Again, a Fellowship in Disaster Medicine/management which is open to a wide variety of people would be welcome.

These examples demonstrate the need for community medicine departments to collaborate with other relevant departments in the medical college while offering advanced training. This will ensure that the training is interdisciplinary, which is at the core of community medicine. We need to change our thinking in the way we conceive superspecialization in community medicine.

What are the career prospects after these trainings?

I see many career choices after specialization depending on the course opted for:

PhD candidates can aspire to join academic disciplines to teach and research in medical colleges, schools of public health, and research institutes.

People with fellowships would be useful to many international agencies that focus on specific areas of work and would be glad to have people trained in those areas.

DrPH is an excellent way to strengthen our health system.

I do not claim that my views expressed here are definitive. However, I have penned these in the hope that this will initiate discussion and dialogue on this aspect of our discipline. We need to reach a consensus on at least a few of these areas and move to develop the necessary curriculum and training. It is high time we gave serious thought to advanced training in community medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

I acknowledge the comments on the earlier version of this paper from Dr. Akhil Goel and Dr. Rakesh Kumar which helped in revising it.
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