Attendees, please welcome to the stage AECOM President, Dr. Robert Bourgeois. Please be seated at this time. All right. Good afternoon, and welcome to the first in-person American Occupational Health Conference since 2019. I'm thrilled to see everyone here in beautiful Salt Lake City. This opening session marks the start of AOHC 2022. Appropriately, today is also International Workers' Day, known as Labor Day in numerous countries. On an interesting note, it's also World Laughter Day. So let's enjoy ourselves the next three days as we engage in a great mix of networking and educational activities. As of today, we have 818 in-person registrants and 366 virtual registrants for a total of 1,184 participants, making this one of the best attended AOHCs in recent years. As you know, AOHC is a premier professional meeting for physicians and other health professionals who have an interest in occupational and environmental medicine and provides a forum for connection, education, and networking. Our outstanding education program was assembled by our 2022 AOHC Program Committee, led by Dr. John Piacentino, Chair, Dr. Laura Gillis, Vice Chair. The committee members include Stephanie Estella, Dr. Zed Bernacki, Natalie Hartenbaum, Warner Hudson, Leslie Israel, Zeke McKinney, Kenji Saito, Yousef Saeed, Dallas Shi, and Brian Shizawa. I want to personally thank you all for all that you did this year in leading the team that planned this terrific event. Drs. Piacentino and Gillis, would you and any committee members in attendance please stand and be recognized? Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank You Dr. Davis that's gonna put your carry on your check bags overweight. Next is the Health Achievement and Occupational Medicine Award which recognizes an ACOM member for a specific unique achievement in occupational and environmental medicine. I'm pleased to announce that this year's award is presented to Dr. Marcia Issacari. Dr. Issacari is recognized for her commitment to diversity and inclusion in OEM and her outstanding work during COVID-19, specifically in March 2020 when the University of California at San Diego suffered one of the earliest mass COVID exposures in the country. Dr. Issacari within 36 hours successfully planned and launched a drive-thru post-COVID exposure clinic providing safe medical evaluations and testing. This model was used as a benchmark to launch mass vaccination clinics throughout the county of San Diego. Dr. Issacari please come forward to accept your award. Members of ACOM, it's a great honor to receive the ACOM Achievement Award. After such challenging past two years, it's an incredible feeling to be here with you all tonight. Thank you ACOM board for all the members and for the honor. I feel I'm standing on the shoulders of giants who inspired me to advocate for the safety of workers and seek excellence even during the most challenging times. I would have never imagined that I'll be here, the one leading a team to launch one of the first mass COVID drive-thru sites in America. But I need to give thanks to my great mentors I had in Brazil where I'm originally from, Japan where I did my residency, and to ACOM members who instilled confidence in me and made me believe that as an occupational medicine physician I could change the strategic direction on how we ensure worker patient safety. Now as a residency faculty member, I do not take lightly responsibility that I have to nurture the next generation occupational medicine physician and prepare them for the challenges ahead. I take pride that the next generation occupational practitioners that I'm working with are from diverse backgrounds and an increasing number of female and people of color. I would like to take a moment to especially thank my family for allowing to spend countless hours working and for being here today. Thank you Kent and Henry and thank you to my mom in Brazil. Muito obrigada. Thank you again for this incredible honor. Next is the Meritorious Service Award which recognizes an ACOM member who has provided outstanding service to the college. This year's recipient is Dr. Ishmael Nabil. Dr. Nabil is honored for his leadership in ACOM's COVID response, in particular for his part in the development of the COVID-19 peer reviewed Q&A forum, an invaluable resource for members and as host of ACOM's COVID conversations podcast, which has been a leading voice on COVID-19 related issues. In addition, he led the workgroup that produced the recent ACOM guidance document on mitigation and adaptation strategies for climate change. Dr. Nabil, please come forward to accept your award. So I started this journey as a junior member of the college in 2004. Since then, I've served in many capacities as vice chair of the underserved section and Council of Scientific Affairs. It's fast-forward 2020 when New York was engulfed with surging COVID-19 cases. We're confronting this unknown disease as we're all facing this unprecedented challenge. While I had more than 18 plus years in occupational medicine, I was like so many, felt ill-equipped to meet this challenge, but we persevered. A phone call from the incoming president of American College of Occupational and Environmental Medicine, Beth Baker, asked me the question, what do you want to do in this tumultuous times? I hesitated and pondered on the response. She again asked, who would be the expert if not for you? We launched the first ever Q&A series in April of 2020, looking at COVID-19 with a whole new perspective of occupational medicine. Work itself has become a pinnacle of diversity, strength, and expertise of what the American College of Occupational and Environmental Medicine had to offer. At the time, when we didn't have a clear understanding of the disease, no vaccine options were available, PPE was in short supply. Slowly and steadily, a team of experts started to build a repository of very pertinent questions, gleaned from emerging science, to inform the community of what can be done. We developed a year name to communicate more effectively with our members. AECOM official podcast, Ockpod, was launched in December of 2020, as the first shipment of messenger RNA hit the shelves. And again, healthcare workers rolled up their sleeves to become the first recipient of this experimental vaccine, which has now proven its worth for saving countless lives. The transformation happening in the college also burned brighter within myself. I looked at the question of climate change as an essential truth, and then got the privilege to lead the group of amazing individuals to construct a blueprint for OEM experts to tackle the century's biggest threat to workers' health. We do remarkable things. We are occupational and environmental medicine experts. I sincerely thank you for the privilege and for selecting me for this prestigious award. Thank you, AECOM, and thank you to my family and friends for being a rock by my side. Thank you. All right. Our next award is for Excellence in Education or Research in Occupational and Environmental Medicine. This Lifetime Achievement Award is presented to an individual who has made significant contributions to academic excellence or research in the disciplines of occupational medicine, environmental medicine, and or environmental health. I'm pleased to announce that the 2022 Award for Excellence in Education or Research is presented to Dr. Christopher Martin. Dr. Martin is honored for his years of service in multiple areas of medical education, including more than 20 years as program director for West Virginia University's Occupational Medicine Residency Program. His research includes 18 peer-reviewed articles and numerous contributions to OEM textbooks. His work has appeared in MedPage Today and The Atlantic. He has actively collaborated with NIOSH in his research on its safety and occupational health study section, special emphasis panel, and as an external reviewer for the Office of Extramural Programs. Dr. Martin is unable to join us in person, but recorded an acceptance speech ahead of time. Dr. Martin. Thank you, Dr. Bourgeois. I'm disappointed not to be able to join you in person and appreciate the opportunity to join you via technology. Thank you, ACOM, deeply for honoring me with this award in 2022. Like many of you, I feel that occupational medicine has given more to me than I've given to it. So it's been a wonderful joy to have such a wonderful career and to work with colleagues such as you. As I look through the list of past recipients of this award, towards the top of the list are great colleagues and friends that I've had the good fortune to work with for many years. Further down the list, you see names that are true giants in the field like Harriet Hardy. I can assure you that in my wildest dreams, I never thought that my name would appear on the same list as Harriet Hardy's. So it is a deep, deep honor to receive this award. Thank you, ACOM. And I'm very grateful that in my absence, Dr. Bourgeois is able to accept this award on my behalf. He's been my friend for many years, and he has been a great supporter of our educational programs throughout his career as well. I wish all the attendees a wonderful AOHC 2022 in Salt Lake City. Thank you, Dr. Martin. Our final award is the College's Lifetime Achievement in Occupational and Environmental Medicine, the highest award in Occupational and Environmental Medicine. This award recognizes a distinguished career in one or more disciplines of occupational medicine, environmental medicine, and or health care. This award recognizes a distinguished career in one or more disciplines of occupational medicine, environmental medicine, and or environmental health. This year's award goes to Dr. Jennifer Christian for her advocacy for better outcomes for injured or ill workers. Dr. Christian is president of Webility Corporation, a catalyst for positive change in workers comp and disability benefits. She has chaired ACOM's work, fitness and disability section, and led the development of ACOM's guidance document on preventing needless work disability by helping people stay employed, which made specific recommendations for improving the stay-at-work and return-to- work process, and founded the nonprofit 60 Summits Project to promote it. Her program proposal was credited with inspiring and providing a vision for the 180 million dollar federal demonstration project retained. Dr. Christian, please come forward to accept your award. Thank you, everybody. I'm very grateful to receive this award, and it makes me feel acknowledged and happy, and I want to thank everyone who played a role in making it happen. And I want to, I feel so grateful for being part of this community. Thank you to all my colleagues in ACOM who've inspired me, mentored me, collaborated with me, and befriended me since 1982. For those of you who are new to ACOM or are still learning the ropes, I want to point out with considerable gratitude that I was the beneficiary of a tradition in ACOM in which existing leaders look for talent and encourage new people in order to latch on to their energy. So that was certainly true for me, and in particular I want to mention two men whose early belief and support for me was really formative. First was Kent Peterson. While Kent was president of ACOM, he recruited me to take on my first ACOM job and lead the development of a short position paper for the college. He also recommended that I take a short personal and professional development course called the Landmark Forum. I eventually did so, and I'm still actually taking landmark courses because they keep recharging my batteries. They keep reminding me that I, as a regular old human being with foibles and frailties, and the president of a teeny two-person consulting company, can make a positive system-level contribution to the world. That's where I found the nerve to propose that idea that provided a vision for Retain. I heartily recommend that you consider taking the Landmark Forum too. And Ted Emmett is the other person. He recruited me to lead the committee of 22 OCDocs that produced that position paper, Preventing Needless Work Disability by Helping People Stay Employed, which the multi-stakeholder audience recognized as articulating ACOM's work disability prevention model. I'll always be grateful for Ted's steadfast support. And David Sickberg is the other person I want to thank. He's my business partner and husband of nearly 25 years. David and I have worked together out of our home since 1998. We're the two-person teeny consulting company, and he's been my intellectual partner in all of our projects, both Webility and the 60 Summits project. We call ourselves the Odd Ducks and Matching Puzzle Pieces. We are most definitely not twins, and yet we're definitely very compatible. Thank you, dear. And I'd also like to thank my dad, Donald Harding, MD, MPH. I didn't even realize what a role model he was until I was 40, and I noticed that I had the same degrees he had, that I had in fact become a little chippette off the old block. I absorbed his commitment to a life of public service, to public health, to intellectualism, and his fascination with solving system-level problems. I also need to mention that I'm grateful to the changes in US society since the 1970s that benefited me and all women, especially in medicine. I graduated from college the year that the women's movement began. That environment inspired my former husband, Bill Christian, to support my dream of becoming a doctor. I found, luckily, nurturing mentors in medical school and in residency, almost all of them men. And to those of you who feel divided now by your commitment to your children and your profession, I spent more than 15 years on a modified mommy track. I couldn't really spread my wings and feel free to go full blast professionally until I was 48 years old, and yet I have achieved great professional satisfaction since then. I'm so grateful I found the courage to start my own company in 1998. It feels wonderful to look back and realize I've been free to notice problems that are really worth solving and devote my energy to them. And don't you just love that new diverse AECOM leadership team? And lastly, I want to thank the first four clients in our Maze Masters program, a program that I developed, a tutoring and coaching program for patients who had had very poor outcomes. These people, Peggy, Pete, Helen, and Ernest, taught us so much about what it takes to restore a life of fulfillment and satisfaction to people stuck in the health care and work comp mazes. And I want to thank them particularly for restoring me as a healer so that I was willing to go back into a clinical practice and treat patients with chronic pain. Thank you very much. Thank you, Dr. Christian. Keep working out with that. Congratulations to all our 2022 award recipients. This concludes our award ceremony. Let's hear a round of applause for all of our honored colleagues. Thank you. I now have the honor of introducing our speaker for the 69th annual Sappington Memorial Lecture. This lecture, named for Clarence Olds Sappington, the first American to hold a degree of public health, a doctor of public health degree, serves as a forum from which to address major issues in the field of occupational medicine. This year our speaker is Dr. Paul Jung, a preventive medicine physician who has been front and center in the fight against COVID-19. Dr. Jung will share his insights on the future of preventive medicine. Dr. Jung has served in various posts throughout many administrations, including Health Resources and Services Administration, Indian Health Service, Peace Corps, Office of the Surgeon General, CDC, NIH, and the FDA. In addition, Dr. Jung was a two-term chair of the Physicians Professional Advisory Committee of the U.S. Public Health Service and is one of the most widely published authors on the health of Peace Corps volunteers and the specialty of preventive medicine. Ladies and gentlemen, please join me in welcoming Dr. Paul Jung to the stage. Good afternoon, everybody. Okay, thank you. Thank you so much for inviting me to give you this year's Sappington lecture. It's quite an honor for me to be here and deliver this presentation. The first order of business is for me to thank Dr. Bob Bourgeois for the invitation and to his gracious wife Terry for being such a generous host over the past couple of days, and also to Dr. Alia Khan for giving me the opportunity to meet with the residency program directors yesterday. That was an excellent discussion that we had. I know there were a lot of people behind the scenes who made this happen, so I'd like to thank them as well, specifically Susan Philz and Heather Hodge at the ACOM head office for waiting patiently with me while I navigated the federal clearance process for this speech. And speaking of the federal clearance process, before we go any further, I'm required to indicate that I'm here in my own personal capacity as a private citizen. I'm not here as a government official, and nothing that I say here this evening is to be construed as that of the federal government specifically, and I quote, the opinions expressed here are mine and mine only and should not be construed as the policy of the Bureau of Health Workforce, the Health Resources and Services Administration, the Department of Health and Human Services, or the federal government, nor does mention of any products or organizations constitute an endorsement, unquote. In other words, the thoughts presented here are mine and mine alone. As I mentioned, it's an honor for me to give this lecture. In Dr. Sappington's obituary from 1949, he's described as having facility in lucid expression, and I hope that I can do justice to Dr. Sappington and his legacy through my presentation. The topic tonight is the future of preventive medicine, and since I am a preventive medicine physician speaking to a room full of preventive medicine physicians, let me be clear, I am not here to tell you what I think the future of preventive medicine is. Instead, I plan to present some information for you to consider and then discuss how collectively we might be able to forge that future for ourselves and for our specialty, but most importantly for the young doctors and residents in the audience, or even the younger future doctors who might be in the audience, and so let's start with that. Let's start with the future doctors of America. Imagine, if you will, the young Jane Doe, recent high school graduate, headed to college, and her pathway to becoming a physician, hopefully a preventive medicine physician. What an amazing hypothetical this is. We get to imagine a world that we knew 10, 20, 30 years ago, but updated for today, and we get to see how vastly different it is now. I purposely chose Jane Doe and not John Doe because the majority of medical students today are women. That change happened in 2019. It's not going to change anytime soon, so the first thing we know is that Jane Doe is more likely to be a physician than John Doe. That's a fact. A few things that haven't changed is that Jane is still expected to go through some sort of college pre-medical experience before medical school, and then she'll have to do a residency to be a practicing physician. The other thing that hasn't changed is probably at this point in her career, Jane has no idea what preventive medicine is. The more things change, the more they stay the same. So what then are we to do to get Jane Doe to experience those things that will make her say, I want to be a preventive medicine physician? That's where we need to go for the future of this specialty. So let's start that process. What happens to Jane pre-med when she's in college? As I said, she'll have to go through some sort of pre-med track, some pre-med courses, but here's some interesting statistics. If we look at the early part of the pipeline, undergraduate studies, we find that in 2010, about 20% of students graduated with double majors. That does not mean a major and a minor. It means two full majors on their transcript. That number has increased. Today, it's about 40% at some schools. Approximately a third of all medical students today graduated with a double major in their undergraduate studies, and they weren't always both science majors. They quite often double majored in the science combined with a non-science major, for example, biology along with philosophy. It could also be two humanities majors as well. This is a huge increase over the past couple of decades, and interestingly, the number of health humanities majors and interdisciplinary major that combines the humanities with science has quadrupled since 2000. So there's a good chance that Jane Doe, the pre-med, is not just a biology or a chemistry major. Instead, there's a good chance that Jane is a philosophy and biology double major or that she majored in an interdisciplinary field like the literature of chemistry or the chemistry of literature. Compare this to our own majors, the majors of our classmates in medical school. This has huge implications because Jane, the doctor, who probably double majored in college, this tells you what her frame of mind is and what she expects to get out of medical school and out of practice. And so Jane successfully completes college and goes to medical school. We have Jane, the medical student, with her short white coat. In medical school, many of us had the standard curriculum, two years of sitting in a classroom being lectured at by faculty, occasional breaks for anatomy lab, peering through a microscope to find gram-stained bacteria, and then two years of rotations in a hospital. There were a few MD-PhD students in my class. We had to figure out how to account for them in our yearbook. Are they part of the class that they graduated with or are they part of the class that they started with? That's as difficult as it got for us. And those MD-PhD students were all getting their PhDs in hard sciences, physiology or biochemistry. And in my class, there was one single medical student who had an MPH prior to medical school. She was a rare unicorn, but you know what we all thought when we met her? You didn't get into medical school the first time around, didn't you? Today, 58% of medical schools offer formal dual degree programs along with their MD. Over the past 10 years, there's been a 67% increase in schools offering formal MD-MPH programs, a 50% increase in MD-MBA, Masters in Business Administration programs, and a 400% increase in MD-PhD programs where the PhD is specifically in the social sciences or the humanities. When I say formal, I don't mean a med student leaves school for a year to find themselves and they pick up a degree on the way back. I mean this is a formal, sanctioned, integrated part of their curriculum. To give you a flavor of the changes over the past few decades, 20% of students at Tufts earned both a medical degree and a second graduate degree. 30% of students at Duke earned an MD along with a PhD or a JD or an MS or an MBA. I'm only calling these two schools out because there's no systematic data. They happen to mention it on their websites. I would venture to say that they might have been bragging about this. When I went to medical school, there was no bragging in our brochures about dual degrees. Note that I said the word brochure. That's what we had when I went to medical school. There were no websites. There was no internets. Maybe that's the best indication of how much things have changed. In fact, as an aside, when I was a fourth-year medical student, I went to do a fourth-year medical rotation in a new field called medical informatics and my final paper was on the use of this new tool called the internets and how it might be used for students to look at apply for residency programs. And the faculty member at that time looked at my paper and said, this idea is far-fetched. Yes, I'm an old man. So going back to Jane Doe, the medical student, whereas in my generation, the Joe medical student was stuck in a standardized curriculum, there's a good chance that today, Jane Doe will be enrolled in a dual degree program along with her MD. She was probably a double major in college. Why wouldn't she be a double degree seeker in medical school? Today's anatomy labs look nothing like the formaldehyde-soaked labs when I went to medical school. Today's curriculum looks nothing like the one that I had in medical school. Just imagine what Jane Doe's clinical rotations look like, especially given her interest in double majoring in college and double degreeing in medical school. Imagine what her attitude would be to a standard six-week inpatient medicine rotation at the VA. And when it comes time for Jane to fill out her residency applications, how will Jane Doe's skills and interests manifest themselves in her specialty choice? What specialty will Jane choose and why? Well, here's some facts about today's residency landscape. Prior to 2001, no program in the United States offered a formal degree as part of their residency except those in the specialty of preventive medicine. So maybe we were visionaries ahead of our time. Now, however, 10% of residency programs offer an MPH, an MBA, or a PhD during residency as a formal part of their training. In addition to those degrees, residencies are increasingly offering training in management, leadership, even global health. And if they're not offering degrees, they're offering certificates. When I was a resident, I had the great fortune of being able to attend a conference and I ran into an old professor who looked me up and down and said, huh, when I was a resident, we saw patients, we worked, we didn't have time to go to conferences. Imagine what he would say if today his residency program was offering an MBA to Jane Doe, the resident. But more important than additional degrees is the increase in combined residency programs. There was a 16% increase in single categorical residency programs since 1996. There was almost a 50% increase in combined residencies in that same time period. Just like double majors, these are residency programs that train physicians in two distinct specialties. For example, we all know med-peds, but now there are other combined residencies like internal medicine plus emergency medicine, family medicine plus anesthesia, internal medicine plus neurology plus dermatology, et cetera, et cetera. And these are increasing at triple the rate of standard single residency programs. This table shows on the top line the number of categorical or single internal medicine residencies in 1996 and 20 years later in 2016. They increased from 374 to 446. There were only two other combined internal medicine residency programs in 1996, med-peds and med-psych. But in 2016, 20 years later, an explosion in the type and number of combined residencies with internal medicine as shown in this table. Internal medicine, emergency medicine, internal medicine, family medicine, et cetera, et cetera. This next table shows the combined pediatrics residency in that same time frame. Back in 1996, it was plain old categorical pediatrics. We covered med-peds on the last slide, and there was pediatrics combined with psychiatry. By 2016, in addition to those three, we had pediatrics and emergency medicine. Thank you, George Clooney and ER. Pediatrics and physical medicine and rehabilitation, pediatrics and anesthesia, and pediatrics and medical genetics. And finally, this table shows the variety of all the other combined residency programs in 2016 that didn't exist 20 years earlier in 1996. We now have family medicine, psychiatry, psychiatry and neurology, emergency medicine, and family medicine, et cetera. Remember, this is not additional training for one specialty to focus on a given area. This is two separate full training programs combined together like a double major. When a resident completes their full combined program, they will be eligible to sit for two separate medical boards. So over 20 years, 17 new specialty combinations have been created. It's not just med-peds anymore. And like the dual degrees in college, like the dual degrees in medical school, these were probably initiated by the students themselves. I have a hard time thinking that family medicine faculty and the emergency medicine faculty got together and decided, you know what, we need to combine our forces, create a dual residency for the betterment of our patients. I just don't think that happened. But it happened because people like Jane Doe, who's now a resident with the longer white coat and the stethoscope. Jane Doe probably wanted it to happen. So what will happen to Jane Doe now, who double majored in college, had a good chance of getting double degrees in medical school, and has a much higher chance of getting into a combined residency with two different specialties? Chances are Jane Doe's pipeline into practice looked very different than the pipeline that brought us here today. When Jane is done with residency, what kind of a job will Jane be looking for? Let's look at the marketplace where physicians look for jobs. A colleague of mine, Dr. Colin Smith, and I did just that. We searched the New England Journal of Medicine, probably the most widely read medical journal in the U.S. We searched their online database of jobs and found a total of 7,235 jobs. Only 54 of them, less than 1%, required combined training. Of those 54, half of them required med-peds. Of the remaining jobs, only five of the 19 possible combinations that I just mentioned in the past three slides were mentioned in any of the job advertisements. In addition, only 10 out of the 7,235 jobs required additional training with a degree in public health, business administration, or even a Ph.D. When we looked at the USAJOBS website, which is the employment website for the U.S. federal government, there were 1,500 medical positions available, and only four of the 1,500 required combined training, and all four of them were in med-peds. No other combined specialties were advertised, and separately, only three of the 1,500 jobs required an additional degree, either an MPH, an MBA, or a Ph.D. So there are two ways of looking at this. Two ways of looking at this data. First, is Jane Doe and her colleagues doing it all wrong? The marketplace does not appear to be seeking candidates with all these double majors and dual degrees and double specialty boards. Could it be that they are playing the fool's game, peppering their wall with all these extra diplomas for no good reason? Does the world really need a family emergency medicine doc with an MBA? The marketplace isn't advertising for one, so why are they doing this? It's a legitimate question to ask. But let's turn the question around. Maybe Jane's doing it right, and the rest of us are doing it wrong. Maybe the marketplace has it wrong. Maybe the reason that Jane Doe and her generation aren't going into single specialties and entering typical clinical jobs is because they've already figured out that stovepiping themselves into traditional specialty roles isn't going to use all of their talents to make their patients healthy. Is Jane simply trying to figure out the best combination of specialties and degrees to use her talents to make her patients healthy? And that's what it's all about, isn't it? Making people healthy. And so here we are, Jane Doe the physician. Now she has one of those head reflector thingies in addition to her stethoscope. Clearly her journey to being a doctor differed from the same journey that many of us took 10, 20, 30 years ago. What I've shown you so far outlines the obvious differences between Jane's course toward being a doctor and ours. And given these differences, what are the chances that she will make the same specialty and career choices as us? But more specifically, what are the chances that she's a preventive medicine physician? And if she is, what made her choose that specialty? And if she isn't, and I admit that unfortunately this is probably more likely the case, what is keeping her from choosing our specialty? These facts about millennials are maybe eye-opening, but they shouldn't be surprising to any of us. Majority of millennial physicians that are currently in the workforce are unhappy with medicine. And this was based on a poll taken way before the pandemic. 55% of millennials are unengaged at work. 21% leave their jobs faster than other generations. And millennials would rather take a $60,000 pay cut than to do work that they find boring. So if all we can offer Jane Doe the physician is a standardized clinical job grinding away in a burnout medical center as a family practitioner or an emergency doc, but not both because we haven't figured out how to incorporate those skills into a single job, maybe it's our fault. And if Jane Doe really wants to be a family emergency doc with an MBA, but we tell her that we could only use one or the other but not both, it's no wonder that Jane and her classmates are dissatisfied and looking to do other things. So who's at fault here? Is anybody at fault at all? Am I at the point in my career now where I can play the crotchety old doctor and tell Jane and her classmates, nice try, but you're doing it all wrong when I was a medical student, blah, blah, blah, right? What would her attitude be if I were to tell her that? Or if we go back a little further to the early 1900s and I could play the really old crotchety doctor wagging my arthritic finger and saying family medicine, emergency medicine, MBA, yeah, we all did that. It was called general practice and we did it because we had to, right? How would she respond to that? Or can we go back even farther and can I say, hi Jane, my name is John Snow, I'm an anesthesiologist, I've just geo-mapped all the cases of cholera around London, why don't you come with me and help me dismantle the handle from the Broad Street water pump? What would her reaction be to that? She would probably say, sure, that sounds awesome. And by the way, you were great in Game of Thrones. And so I would like to make the case that preventive medicine is exactly the perfect specialty for Jane Doe. For someone like Jane Doe and all of her classmates who want to be doctors to make people healthy. I think this generation of physicians have figured out that in today's world we need people to be healthy. That's why she became a doctor in the first place, to create and maintain health. What I mean by that is she didn't do it to expend relative value units, she didn't do it for the financial windfall, and if she did, that financial windfall would all be going to pay back her student loans for all the additional degrees and majors that she had. I would say that Jane and her generation have figured out that health is not only obtained through clinical interactions with a physician in a clinic, there's more to health than even the best clinical medicine. We all know the studies. At best, 20% of our health is a result of direct medical care. The other 80% is a function of our lifestyle and the environment that we live in. And so if Jane Doe is really doing all of this to make people healthier, then preventive medicine should be the first specialty that should be on her mind. It has a focus on population health. It brings an additional free degree with it. The skill sets are broad enough that she doesn't have to be pigeonholed into a narrow clinical silo. What's not to love? And yet here we are. Preventive medicine has suffered a 17% decline in the number of US residency programs since 2000. Current residency programs are, on average, half full, and that includes those that receive federal funding. There does not appear to be a common understanding of what the specialty of preventive medicine is. There's no obvious or expected career path for preventive medicine specialists after residency. If somebody wanted to be the head of a state health department, or the chief medical officer for one of the new space exploration companies that's out there, or the chief health officer for any new company in this digital economy, I doubt that anyone would tell them, hey, Jane, you need to specialize in preventive medicine in order to do one of those jobs. And I don't think the advertisements would require a doc boarded in preventive medicine to fill that job either. And does it need to be said out loud, we are in the third year of a deadly global pandemic. Shouldn't preventive medicine be the number one specialty on everyone's mind? It should be on the tip of everyone's tongue. And yet, here we are. As an example, I gave a presentation once to make the case that the core specialty of public health in general preventive medicine should entirely focus and align itself with the field of public health. And we should try to reframe the specialty as the medical specialty for public health to make the case that we should be the most qualified to lead state and local health departments. And one audience member raised her hand and shouted, I do not do public health. She was clear and emphatic. She also appeared offended that I would even propose that kind of a connection. She was boarded in public health and general preventive medicine, but she worked for a private health system. And I think that what she meant was, I don't do governmental public health. And she didn't want to be pitted and hauled as a, God forbid, government employee. But that's what we're dealing with. Perhaps the biggest problem we have is a problem of vocabulary. But our problems here are not new. I looked up previous Sappington lectures and found similar existential questions going as far back as 1971. Dr. Irving Tabershaw said, we are still not a satisfactorily identifiable group. Or rather, a group not identified satisfactorily. Yet, in the midst of change, we seem to have little public acceptance as specialists capable of making a major contribution. Unless we change and meet the challenge, I am pessimistic for the future. Let me repeat that. In the midst of change, we seem to have little public acceptance as specialists capable of making a major contribution. Was Dr. Tabershaw predicting the current COVID pandemic? His words are so true today, and yet he said them 50 years ago. And in 1987, Diana Chapman Walsh said, how can a career in occupational medicine appear to an ambitious medical student as an exciting option when there seems to be so little science, so little standing in the academic community from which he's taking his cues? Think about that. Dr. Chapman Walsh says ambitious medical student. She was clearly thinking of Jane Doe, double degrees and all. But other than replacing he with she, I think the sentiment remains the same. And so if we go back to the pipeline and Jane Doe's place in it, how are we to assist Jane Doe, the medical student, in her choice of specialty? Let's make sure that we first understand how the medical specialty selection process happens. I know some of us would like to think that there's an ultimate day during the fourth year of medical school when we all assess our interests, map out all the available specialties. Find the best fit using logic and a formula and so forth. We all know that that's not how it happens. It's never a rationalized, systematic assessment. It's actually more like buying your next car or picking a candidate to vote for in an election. It's a function of exposure, history, culture. In other words, it's a gut decision. And Jane will be no different when she makes her choice. So given this messy yet consequential decision that she has to make, how should our specialty make our appeal to Jane Doe, the medical student? What might we tell her that will make her give our specialty a second look? Just like buying a car or picking a candidate, marketing is probably the biggest factor. So I'm not proposing that we change our specialty and what we do at all. But I am proposing that we think critically about how we view our specialty and how we communicate about it. In other words, how we market our specialty, because I think there may be a few simple ways to do this. Now, I know that some of us, when I say marketing, you probably automatically thought of brochures, pamphlets, flyers, websites, things that we can give to medical students to explain to them what preventive medicine is. After all, that's what we got when we were in medical school. The two things, first, remember what I said before about brochures. When I say marketing, if the first thing that comes to your mind is a brochure and not TikTok, please join me, step into a time machine, and we'll go to where Jane Doe and her classmates are in 2022. That's where they are. They are not where brochures are. Second, even if we were to make a brochure for Jane and her classmates, God help us, what would it actually say? The first problem may be our name, preventive medicine. What the heck is that? What is preventive medicine? Is it a clinical service like maternal child health? Or is it a way of life like gemstones and herbal healing? Or is it a medical specialty like cardiology? What does it mean if somebody says, I want preventive medicine, or I believe in preventive medicine, or I want to specialize in preventive medicine? Preventive medicine can mean different things to different people. It's just like the phrase primary care that I hear a lot about. It reminds me of a conversation I had with a medical student who said they were going into ophthalmology. You know, it's primary care for the eye. As well-meaning as that medical student may have been, I'm still shaking my head at that one, you got to wonder how we got to a place where an eye surgeon wants to promote themselves as a primary care doc of one sort or another. Preventive medicine, and the phrase preventive medicine, is no different. The biggest problem with our specialty is that it can mean so many different things. We all know that I've been talking about the specialty of preventive medicine and its three core subspecialties. But if we went outside this ballroom and talked with anyone on the staff at this hotel, they'd think we're talking about a clinical service. So the words preventive medicine can be the biggest hurdle that we have as a specialty because it allows others to co-opt the phrase for themselves. And at some point, it therefore becomes meaningless. And our specialty suffers because of that. For better or for worse, the average layperson may have some idea of what occupational medicine is or what aerospace medicine is. Those two core specialties are the lucky ones. If anything, the biggest name change should be for my unfortunately named core specialty, public health and general preventive medicine. What a mouthful, public health and general preventive medicine, the longest, wordiest specialty name on the books today. At the very least, we could change that name to public health and clinical preventive medicine, if not just public health medicine alone. But that still doesn't fix the overarching specialty problem, preventive medicine. The fact remains that preventive medicine is still the name of our board, the American Board of Preventive Medicine. And as I said, no one automatically knows what that means. One solution would be to get everyone to really understand what we mean when we say preventive medicine, a huge undertaking in my opinion. The other solution would be to change what we call ourselves, easier but still very difficult. And I know what you're thinking. If we change our name, what would we change it to? To which I would only say, don't let the perfect be the enemy of the good. We could call it population medicine, that way ABPM wouldn't have to change their initials at all. And we could ride the population health gravy train that's left the station. Why not? Please resist the urge to list all the reasons why we can't do this. Instead, try to think of all the reasons that we should do this. The main point is, if we don't change the overarching name to something other than preventive medicine, I'm not sure we're going to get anywhere and definitely not with Jane Doe and her classmates. To me, this is the fundamental function of a preventive medicine physician. And that is the ability to both care for the patient in the clinic in front of us, as well as making changes in the community where they live and work and do their thing. The key is that whereas standard clinical specialties go counterclockwise in treating the patient and then expecting the health of the population to follow as the sum of all the parts of the healthy people that they've created from their clinic, preventive medicine is the only specialty that goes clockwise. We can affect change in the population, because we know that that's the major source of the health of the individual. And the only difference between our three core specialties is the definition of that community in the right hand corner. In public health, we're generally talking about some political or geographical boundary. In occupational medicine, we're looking at the work and labor environment. In aerospace medicine, we're generally looking at the flight environment. And we can spend all of our time parsing out the differences between these three. But we can also spend that time pointing out the similarities. In my opinion, there are more similarities among us than differences. The tools that we have to assess and improve the health in the populations that we're looking after are nearly identical. And our ability to go clockwise in this diagram spans all three of our core specialties. So I would like to make the case that there's strength in numbers and that we have more to gain by unifying ourselves than by splitting us apart. There are only about 6,000 of us to begin with. Our specialty is small enough as it is, no need to dilute us any further. Then we can go back and look at the way we train for our specialty. Training is the bedrock for us as physicians. And that's where we may be able to make some tiny adjustments that have huge, significant effects. This slide shows the basic components of our training. We need some clinical time, some academic coursework, and practicum training. And although these three components aren't separated into distinct years anymore by the ACGME, it's still a good reference for our discussion. So taking these three things in turn, first, our clinical training. We are all physicians, first and foremost. Because of our clinical training, we all have licenses. We have the ability, legal and otherwise, to examine, assess, diagnose, and treat patients. But on the other hand, the required clinical year, for us, is not unique to preventive medicine. Any accredited clinical training, whether it's neurosurgery, pediatrics, pathology, qualifies any physician to claim a third of our specialty. I understand that an intern year is an intern year, but this leaves preventive medicine with no distinct clinical training. And that allows other specialties to claim not only the skills that we have, but our identity. A potential solution may be the development of a preventive medicine specific clinical year. Rotations in occupational health clinics, public health clinics, aerospace clinics, they're all available. Would it benefit us to make any of these required rotations in the first year of training? Can we do it? Should we do it? I know there's accreditation issues and so forth, but don't forget the main idea. Is it valuable for us to create our own very unique clinical training that no one else has? And I know I'll get into a lot of trouble for saying this. Are we being recorded? Should we possibly increase our clinical training time to make it more preventive medicine specific? To make it more unique? To distinguish ourselves from neurologists and emergency docs? Just remember that in Canada, it takes five years of residency to become a preventive medicine physician. So regardless of your opinion about Canadians, I just bring this up to say, it's not unheard of to spend more than three years to make a preventive medicine physician. Next, our academic training, our Master of Public Health. This poses, to me, the biggest problem, not with other medical specialties, but with the field of public health. As I mentioned earlier, about two-thirds of medical schools already offer combined MPH programs along with their medical degree. More than 17,000 MPH degrees are conferred each year in the United States. A basic, undifferentiated MPH does not distinguish a preventive medicine physician from the much larger cohort of any physician with an MPH. Who, by that fact alone, can claim two-thirds of our training, two-thirds of our identity. So why not ask our degree-granting institutions to confer instead a Master of Preventive Medicine degree? It could be based on the standard MPH requirements, but require specific coursework only available to preventive medicine residents, like practicum rotations in public health clinics, occupational medicine clinics, aerospace clinics. That MPM would be comparable to an MPH, but would distinguish its holder as a preventive medicine physician, and not just a physician with an MPH. We can call it an MPH-PM, we can call it an MPH-PM, it doesn't matter. The main thing is that it's different and unique for the preventive medicine physician. It could retain the cachet of an MPH, but give us the distinction that we need, because this is the biggest problem that I believe that we're facing. This is what I think people see when they see a preventive medicine physician applying for a job. They see a doctor with an MPH. And since there are many doctors with an MPH out there, it's easy for them to mistakenly hire a doctor with an MPH to do a preventive medicine job. This is the danger that's out there. And if we go back to our training framework, the preventive medicine practicum year, that's what truly gives us our legs. But our practicum year requirements are quite broad. Other than two to four months in specific settings related to our core specialty, everything else is up to the interest of the resident. Similar to our clinical year, do we want to be more standardized? Do we want to be more liberalized? I think back to Hippocrates and his goal of professionalizing physicians. He said, we're all gonna follow certain standards. If you don't follow those standards, you're not a real doctor. And that's what has led us today to the idea of evidence-based medicine. This is what separates us from the herbal healers and the gemstones and the metapressurists. So I'd like to think that a rigorous, standardized curriculum during the practicum year is one way to ensure that we all know what preventive medicine is. But then again, the flexibility of the practicum year is what gives our specialty breadth. And thinking about Jane Doe and her interests, this is our opportunity to create that small batch, artisanal, bespoke, handcrafted, personally curated farm to table residency that she's probably looking for. I think back to the preventive medicine physician who was adamant that she did not practice public health, and that makes me think twice about standardizing the practicum year for everybody. And so here we are. I've presented some basic fundamental changes for consideration, not to our specialty and what we do, but to the marketing of our specialty that may reap positive dividends for us. We can change the name, we can change the degree, we can change the training by standardizing the practicum year or liberalizing it. This is the push and pull of what we're trying to accomplish. This is where I would reemphasize, I do not have the answers, but I pose the possibilities simply because I really believe that our specialty needs to come up with the answers or else we will lose Jane Doe, the physician, to other specialties. And as I've shown you, I think Jane Doe and her classmates are primed and ready to be preventive medicine physicians. Again, please resist the urge to list all the reasons why we can't do this. Instead, think of all the reasons that we should do this. There are many things that we can do for the collective good of our entire specialty. We can't assume that just doing one thing is going to get everyone like Jane Doe to look closely at our ranks and to join us. And that, ladies and gentlemen, is what it will all come down to. Because if we can't attract Jane Doe to be one of us, our specialty will die a quick, painless, and unfortunately, anonymous death. Medicine in 2022 is vastly different than medicine in 1949 when Dr. Sappington passed away. Heck, it's even vastly different in some ways than medicine in 2019. We need to embrace the future and think critically about where we want to go. Will we try to cling to old ideas, old notions of how we ought to be doing things, or can we shape a future that fully utilizes our capabilities and brings our specialty forward to take its rightful place front and center in the medical hierarchy? As I said before, please resist the urge to come up with all the reasons why we can't. Instead, let's think of all the reasons why we should. We ignore these issues at our own peril. For the sake of the specialty, for the populations that we serve, and for the sake of Jane Doe, future preventive medicine physician, I pray that we don't. If there's one thing that I want you to take away from this year's Sappington Lecture, it's that we need to act. We need to act now, we need to act decisively, and we need to act with purpose for the specialty, for our patients, and for Jane Doe. Thank you very much. Thank you, Dr. Jung, for this exciting and challenging look into the future. At this time, Dr. Jung will take questions from the audience. Please approach the aisle microphone and wait to be recognized. I knew you would hit this out of the park. Bunch of these ideas and things we've talked about to resident directors and other folks, and I think this is spot on, so ask while you can ask. The only people getting up are the people leaving. I loved your talk. Thank you very much. Very thought-provoking. I did notice that you didn't mention money, and the data that I've seen is that people tend to be aiming at the highest-priced specialties, so isn't preventive medicine one of the lowest-priced specialties? I'm assuming you're talking about income of a preventive medicine physician. If people—I get what you're saying, I don't think we disagree with that, but if money was all that it is, then everybody would be running for the highest-paid specialties, and only those people who couldn't make it into those highest-paid specialties would trickle down into the primary care specialties at preventive medicine. I don't think that's the case. I think that there are a lot of people who are going into medicine, especially now after the pandemic, because they want to do what they want to do. I'm not going to be Pollyannish and say money doesn't matter, especially when the average medical student comes out of school with hundreds and hundreds and hundreds and hundreds of thousands of debt, but we've looked, we've done the studies. Just as an example, we know that debt burden, for example, is not a determinant of whether people go into primary care or specialties. We have discovered that debt burden is not the reason that people choose radiology over family medicine. And so I would like to think that those people going into preventive medicine are doing it because they want to. What we need to do is make sure that we make preventive medicine an attractive option for Jane, not so Jane can make a lot of money, but because it stirs the heartstrings of Jane and her colleagues to do what she wants to do. Dr. Zhang, good to see you also. Thank you for a very thought-provoking talk. Since we're talking about money and your early disclosure slide notwithstanding, did I hear you tonight committing that HRSA will be fully funding the PGY one years of training and fully funding all of the currently unfunded occupational medicine and preventive medicine residency slots? Because that's awesome. Jim, if that's what you want to take away from this lecture. But I will remind, well first, I believe we're being recorded so I have to watch what I say, but I will remind everyone of the disclaimer slide at the beginning of the presentation. The only thing I can say to that is HRSA receives appropriations from Congress and HRSA's spends every dollar that it gets from Congress for preventive medicine on preventive medicine residencies. If Congress wants to give us more money to spend on preventive medicine, we will spend that money gladly on preventive medicine. Thank you, Dr. Zhang, for a very thought-provoking lecture. So I was struck by what you said about the job postings. And I was wondering if you had any thoughts on how to market the specialty to the people that are creating jobs in medicine and not just to Jane Doe and various stages of her career choice. Thank you. Right. That's an excellent question. We not only have to work on the Jane Doe's, we need to work on the employers of Jane Doe. I am not the expert on how to do that, other than to say that we need to do that and somehow we need to get the word out about what a preventive medicine doctor is and what they can do. I know that there was a recent study that was done where they asked high-level officials in health systems about what they're looking for. And when they were presented with preventive medicine as especially the trained physicians in what they're looking for, they got the typical response. I didn't know that existed. I didn't know anything about this specialty. These are the leaders of health systems in the United States, not knowing that preventive medicine exists and not knowing what it does. So definitely there has to be a way to change that and get them to understand that there are physicians out there today trained specifically to do what they want to do or want to have done in their health systems. It just hasn't happened yet. Thank you for your wonderful lecture, and I agree with a lot of what you had to say. Seventy percent of the incoming Dartmouth College undergraduates in admissions essay, the thesis was climate change. After a 40-year career of trying to convince medical students and residents how wonderful our field is, this is the first year that many, many medical students, even before they got to medical school, have reached out to me because of a burning interest in doing something about our degrading ecosystem and the climate change that's coming with it. And I would say that as a specialty, one of the things we need to do to attract Jane and colleagues is to pay close attention to that burning interest. Yes, thank you. Absolutely. There is no question that climate change is the issue of the day, and there are specific areas in medicine where climate change as an issue can be addressed, can take its place in the curriculum. There are papers on the teaching of climate change to medical students and residents, the role of climate change in people's practices, physicians' practices. If preventive medicine, number one, there's no reason that preventive medicine shouldn't incorporate climate change into its curriculum. You go back to the diagram I had with the doctor, the patient, and the community, that's climate change in the community. There's no reason that we should be thinking that climate change will have no effect on our individual patient's health. I think the bigger question is we have to be careful that preventive medicine doesn't get pigeonholed as the climate change specialty, which is not where I think you're going with this. I don't think anybody wants to do that, but it's a fine balance, right? But as a part of the cohesive body of education within preventive medicine, we ought to be the first ones who incorporate climate change and its effects on patient's health as a required part of our curriculum. There's no reason that shouldn't happen. Great talk. Interesting questions you've thrown up, but I don't know general preventive medicine well, but in occupational medicine, Phil Harbour years ago wrote about how there are really three different clinical specialties, and you don't really have the knowledge to pursue any one of those for five, six, seven years after you've completed your training, and you acquire that knowledge working with others. The general preventive medicine tracks that exist going to state health departments leave people pretty lonesome, and I don't know whether, you know, where else they get the wisdom, the experience to be plausible practitioners and not burn out when you talk to county health officials, certainly after COVID. So have you thought about whether there are ways of restructuring collaboration or extending training in a way that gives people other kinds of resources? That's an excellent point, and one of the things that I didn't say when I said here are some things that will get me into trouble is that preventive medicine could, if you wanted to, require all of its residents to spend their practicum year doing all three of our core specialties, four months in public health, four months in occupational medicine, and four months in aerospace medicine. That way, every preventive medicine graduate will have the core knowledge or as much of the core knowledge as possible when they complete the residency, and from there, they can choose the career that interests them the most, right? And that's specifically why I was asking this question. Four months of clinical medicine will not make you able to take care of patients. Well, it would be a year plus the four months in the practicum time, right? But we can talk all we want about the relationship between residency training and your skills as a physician, right? Presumably, that's one of the reasons why we take boards and so on. There are probably internists out there who believe that three years of internal medicine training is not adequate at all for what we see in the real world, especially if those three years are spent in a hospital, and then you get a job in a clinic, right? So the bigger question that I see here is, what should our residency training look like to prepare us for whatever our practice might be? And one of the problems, as I mentioned, is that we don't know what preventive medicine practice is. For better or for worse, we have people doing so many different things. Is three years enough? Does it need to be five years? Could it still remain three years with a few adjustments to make our graduates more prepared for the world out there? I don't have the answers. I wish I did. I imagine if there was an answer out there, we would find it, and we would plan our residencies accordingly. But it's a good point, and it's well taken. Fantastic talk. Thank you so much. One of the reasons I got into occupational medicine is I had a mentor, someone who was in internal medicine who actually migrated over to be a corporate medical director, and I saw what a cool job he had. And to your point about emergency physicians with George Clooney on TV, we just don't have that cachet. And even during the pandemic, during a time where many of us were leaders in preparing for how the response went, there were many talking heads, and none of them were occupational physicians, maybe a few were preventive medicine, but we certainly didn't hear about it. So any thoughts on how we could get our specialty more up front and center, so people would actually know about it? That's an excellent point. We need to create a show with George Clooney, the preventive medicine physician, although let's, hold on, we, the Dr. Pam show, yes. We're all clapping, but Jane might be saying, George who, right? One of the Jonas brothers, maybe? And we would, what would we call it? We could call it cruise ship, right? What do preventive medicine docs do? Is it possible that our job is not sexy enough to make it on television, right? But I will say there was a show called Marcus Welby, and he was just a plain old regular community doctor, and that made it to television. So maybe I should say if I knew what it took to make a good television show, I would not be here. I would be working for a television production company making that show. But it is an important point. People apply to colleges that won the NCAA tournament the last year because they saw that name on television. People will probably go into preventive medicine if they see an exciting television show with a star who does great things in that show. I'm not the person to get us there, but we should find the person who can. Okay. We're going to wrap it up because we have to get back to the exhibit opening in just a second. Dr. Young will be up here for a few more minutes if y'all want to visit with him. We want to give you a token of appreciation for doing this. Okay. Thank you again, PJ. Before we adjourn, I'd like to note a few housekeeping notes. I want to encourage everyone to take advantage of Swapcard, our AOHC app, while you're here. If you participated in AOHC Virtual 2021, it's the same platform as last year, and also where the sessions will be live streamed and viewed later for AOHC Encore. It's a great way to stay organized during a meeting, connect with colleagues, and access last-minute program changes. Just scan the QR code on the front of the program to open the mobile app. I think you can scan that if you have a Zoom enough on your phone. Log on with the email address you used to register to view the agenda and build your schedule. Speakers' bios, session handouts, and CME information are available in Swapcard. If you have any questions, visit the ACOM member booth, the registration desk, or find any ACOM staff member. Be part of the conversation. All AOHC attendees are encouraged to post their social media channels using hashtag AOHC2022. See your Twitter and Instagram posts on our social media wall outside the exhibit hall. And don't miss our big AOHC photo op letters. Lastly, please plan to attend our membership breakfast meeting on Wednesday morning. This is a very important meeting as we will be asking you to vote on an amendment to our bylaws. In addition to the bylaws vote, the outcoming and incoming board of directors will be recognized. I look forward to seeing everyone there. One more thing, Senator Cassidy's video is going to be posted on LinkedIn and other social media, so don't just like it, like it and share it. We want to get that out there and give us some more press. That brings us to the end of our opening session, so please join us for food and drinks at our opening reception in the exhibit hall next door in the Grand Ballroom starting at 5.30 p.m. Have a great conference and let the fun begin.

preventive medicine

medical education

training

specialty

dual degrees

combined residency programs

future doctors

relevance

impact

physicians

Jane Doe

population health

challenges