When medical student Morgan Clark-Coller first looked at the data she analyzed for her thesis research in Vera Cruz, Mexico, she wondered what had gone wrong. She had been looking at information related to public health interventions such as clean drinking water and latrines in low-income households to see how they related to patterns of dengue fever and diarrheal disease. What she found went against her initial research hypothesis. Instead of preventing illness, the classic interventions seemed to be linked to the spread of mosquito-borne disease.
“So, I did some more background reading, and I found that there is a basis for these results,” she says. She continues to work with the data set, but she has drawn some preliminary conclusions. Among them, she says, is the broader value of paying attention to these results and the history of urban epidemics in developing interventions. This is insight she gained as a direct result of participating in Tulane’s MD/MPH degree program.
Clark-Coller will be doing her residency next year at the University of California Davis in internal medicine and psychiatry, but she credits the MD/MPH program at Tulane with giving her a unique toolset upon which to build her career — a career she hopes will one day benefit people living in disaster-prone areas. For her, these benefits include the opportunity for global health research, the tools to gather and analyze data, even the ability to reconsider traditional public health and medical approaches to individual and community health.
While the 30-year-old pursues her training in California, other recent MD/MPH alumni will be in residencies focusing in a range of fields including obstetrics/gynecology, neurology, internal medicine, radiation oncology, surgery, and emergency medicine. The combined MD/MPH program was founded at Tulane in 1971 and has since graduated over 900 students. Students like
Clark-Coller complete both a medical degree and a public healthdegree during the program. Clark-Coller began her program with a focus on global health systems and development, but soon realized that she wanted to focus on disaster management through the Department of Global Environmental Health Sciences. While she and her colleagues are at the beginning of their careers, the experiences of past alumni serve to illustrate how the unexpected breadth of opportunity multiplies when medicine and public health come together.
MD/MPH DEGREE BROADENS CAREER
With such a long-running and large combined-degree program, Dr. M.A. Krousel-Wood, associate dean for public health and medical education, realized she could draw upon alumni who had MD/MPH degrees and those with MDs alone to learn how the added degree affects career paths. Krousel-Wood and her team surveyed 1,108 Tulane alumni physicians, just over 17 percent of whom also earned an MPH. Her analysis, published in the June 20, 2012, issue of PLoS ONE, showed that those with formal public health training were more likely to have completed a generalist primary care residency, to be working in an academic institution or government agency, or practicing public health or primary care than physicians without such training. The research team also found that medical school graduates with an MPH were more likely to be involved in public health research, to have four or more peer-reviewed publications, and to have five or more scientific presentations than graduates without an MPH.
While it’s true that physicians and other health professionals can complete public health degrees later in their careers, Krousel-Wood says she believes there are significant advantages and cost savings to getting both degrees at the beginning of a career.
“The medical workforce benefits greatly from exposing students to public health and medicine early in their careers,” explains Krousel-Wood. The public health training provides a population-level perspective and research training component that not only enhances individual level practice but positions graduates to make a difference at the broader population and global level, she says.
BUILDING A HEART PROGRAM IN VIRGINIA
One such alumnus is heart surgeon Marc Katz, MD, MPH, chief medical officer of the Bon Secours Heart & Vascular Institute, part of the Bon Secours Health System based in Richmond, Va. Katz graduated from Tulane with his MD/MPH in 1981.
“I got some good advice to do the combined degree program when I was a student, and I am glad I followed it,” he recalls. As an MD/MPH student he wanted to enhance his medical training with the nutrition programs offered in the public health degree program. The benefits of the MPH training, he says, went beyond a broader understanding of nutrition interventions. “For me, it turns out that even though I went into it with one perspective, I’m using that education and training in a different way, but it’s very helpful. When you’re in the student mode it’s easier to do those things than to stop and go back.”
He spent over 20 years directing his own heart surgery practice before joining Bon Secours Health System to serve in the chief medical officer role, while also continuing to practice as a surgeon. The variety of practice situations contemporary physicians face, along with the changing landscape of health insurance, requires more skills and training beyond the clinical, argues the 59-year-old Katz.
“You have to run a business, interface with hospital and insurance, and even if you hire somebody to do it, the bottom line is, it’s your business. I probably use my public health training even more now, because of having helped Bon Secours start this heart and vascular institute, and helping them to administer it,” he says. Katz has overseen the growth of a heart program that includes programs ranging from cutting-edge surgical tools and techniques to community-based screenings and interventions geared towards prevention and early heart disease treatment.
“The face of medicine is changing on an annual basis. Does that affect how you put sutures in? No, but it affects the hoops you have to jump through, the new programs that we start on a routine basis, and the multiple layers in the system. That’s where I’ve used my training the most.”
LEARNING FROM MOTHERS IN NEW ORLEANS
Ultimately, public health research could help inform clinical practice, argue public health researchers. For instance, a collaboration between epidemiologists and the obstetrics and gynecology department in the Tulane School of Medicine has yielded greater understanding of how stress affects pregnancy. Drawing on the experiences and birth outcomes of 146 women who were pregnant during Hurricane Katrina, epidemiologists and associate professors Dr. Xu Xiong and Dr. Emily Harville were part of a team of researchers who determined that the stress of a disaster can complicate pregnancy. Individual coping styles, they found, can mitigate those complications, results they reported in the March/April 2015 issue of the Journal of Obstetric, Gynecologic, & Neonatal Nursing.
Xiong has also collaborated with Tulane ob-gyn physicians to better understand oral health during pregnancy as well as the impact of other health risk factors, such as weight and in vitro fertilization pregnancies.
“We not only look at the individual patient, we need to compare to healthy people to see the difference,” explains Xiong. The knowledge drawn from population-level research could inform individual practice and, over the longer term, policy and practice recommendations for the field.
MEDICINE AND PUBLIC HEALTH TRAINING AROUND THE WORLD
Collaborations between public health training and medicine reach from the lush historic streets of Richmond and New Orleans to the rural communities of China and Peru. While many students like Clark-Coller have the opportunity to conduct research internationally during their training at Tulane, others become part of the global health training focus through the annual Fogarty Global Health Fellows Program. Administered through the National Institutes of Health, the program builds on collaborative global health research infrastructure at Tulane and peer institutions. Tulane is one of four universities that are part of a consortium administered through the University of North Carolina. Dean Pierre Buekens is director of the Tulane arm of the program.
Fellows in this program spend 11 months working and being mentored at a research site in a low- or middle-income country. Tulane has identified 20 sites around the world where global public health and medical research can be conducted by students through this program. The Fellows also receive training throughout the year in developing and writing grant proposals and manuscripts for publication, all based on their research.
“The kind of training that they get is public health, but it is also related to the patients,” says program co-director Dr. Geetha Bansal, who is also associate professor in the Department of Tropical Medicine and director of the Interdisciplinary Innovative Programs Hub (I2PH). “Some of the research questions could be ‘How could I improve health care in terms of mental health?’ Or ‘How can I improve hospital outcomes?’ People do research on surgical procedures, such as preventing complications. People working in the HIV field look at different cohorts facing different issues. There are lots of other ailments that are global in nature, because you could take that instance of that cohort facing a set of conditions that affect their treatment, and that could apply in other low-income settings, even in some parts of New Orleans,” she explains. Ultimately, the fellows are expected to use their 11 months in the fellowship to create a foundation for a career in global health research at the nexus of medicine and public health.
Bansal adds that about 25 percent of the program funding is dedicated to supporting students from the countries hosting the research sites.
“It is about capacity building,” she says. Bansal, who has experience managing programs for the NIH, also teaches a research skills course for public health students, preparing them to craft competitive grant applications. In the course, she actively encourages cross-disciplinary research.