COMMUNITY MEDICINE
DEFINITION:The
Community Medicine specialist focuses on the health of populations. The
specialist uses current population health knowledge and skills to play
leading and collaborative roles in the maintenance and improvement of
the health and well-being of the community. Through inter-disciplinary
and inter-sectoral partnerships, the Community Medicine specialist
measures the health needs of populations and develops strategies for
improving health and well-being, through health promotion, disease
prevention and health protection. The Community Medicine specialist
applies the theoretical and practical skills to a broad range of
community health issues. The specialist demonstrates skills in
leadership; development of public policy; design, implementation and
evaluation of health programs addressing health protection, disease
prevention and health promotion.
The Community Medicine specialist can
engage in a number of careers, for example:
- the
practice of public health at a local, regional, national or
international level;
- the
planning and administration of health services, whether in
institutions or in government;
- clinical
practice in community-oriented settings;
- the
assessment and control of occupation and environmental health
problems;
- teaching;
and
- research.
The purpose of the training required is
to give the resident a degree of independent responsibility for clinical
decisions; an opportunity for further development of the skills required
in making effective relationships with patients; the consolidation of
competence in primary clinical and technical skills across a broad range
of medical practice.
The other purpose of training required is
to give residents an opportunity to develop the knowledge and skills to
function as a community medicine specialist. The scope of practice is
broad. It requires knowledge of clinical medicine and the basic sciences
of community health; the ability to develop effective relationships with
individuals and communities; and knowledge of the health care system
within its socio-economic and political environment.
GENERAL
OBJECTIVES:Residents
in Community Medicine must develop a comprehensive knowledge of the
sciences of Community Medicine, and the skills to apply this knowledge
to a broad range of community health issues in the socio-political
contexts in which they occur.
In particular, residents who successfully complete the program will
be able to:
- assess
the health needs and concerns of a population;
- investigate
potential or existing health issues occurring in a population;
- assess
sociopolitical realities and be able to take and advocate
appropriate action to improve health; (new item)
- plan,
implement and evaluate health programs and/or other strategies to
deal with these needs, concerns, and issues;
- contribute
to the formulation of public policy and assess its impact on health;
- communicate,
consult, collaborate and build partnerships with the public,
physicians and other health professionals, volunteers, service
provider agencies, elected and appointed officials and the media;
- contribute
to the body of knowledge of community health through scholarly
activity and research;
- demonstrate
ethical attitudes and behaviour and a critical approach in their
work;
- demonstrate
leadership and management skills. (new item)
During training, all residents will be
expected to acquire a substantial knowledge of and necessary skills in:
concepts of health and illness and their determinants, methods in
community health, health services organizations, community health
programs and communication and advocacy. In addition, candidates are
encouraged to develop a higher level of expertise in one of these
fields, and to acquire knowledge in other academic subjects relevant to
their own interests.
SPECIFIC
OBJECTIVES:The
specific objectives outlined in this section are to provide information
to prospective applicants, to guide residents and residency program
directors in planning their programs, to serve as a tool in the
accreditation process and to form a basis for evaluation of residents.
These objectives could be achieved through course work, modular
teaching, self-directed problem-based modules, resident rounds, journal
club and field training placements. Field training is required for the
residents to develop practical skills in the work setting and develop
maturity, confidence, competence, ethical behavior and ability to work
effectively as a member of an interdisciplinary team.
AREAS
OF STUDY,KNOWLEDGE AND SKILL REQUIREMENTS:
- HEALTH
AND ITS DETERMINANTS
- Concepts
of health
KNOWLEDGE
- multiple
dimensions of health and illness
- influence
of social and cultural context on health and illness definition
- perception
of health and illness
- Health's
Determinants
a.
Social, Cultural and Political Determinants
KNOWLEDGE
- sources
of social data
- effects
of social factors on health:
- social
class and education
- poverty
- unemployment
and changing work patterns
- stress
- urbanization
industrialization
- social
attitudes
- individual
and community compliance
- effects
of family functioning, including parenting issues,
dysfunctional families, family violence
- origins
and extent of inequity in health
- ethnicity
- distribution
of power in society
- value
systems of society
SKILLS
- select
and interpret relevant social indicators and health
- identify
stakeholders, their positions, power base and support.
- assess
local political realities and their effects on program
delivery and health, e.g., family planning/abortion services
b.
Biological Determinants
KNOWLEDGE
- risk
markers e.g., age, sex, race, genetic make-up
c.
Physical Environment
KNOWLEDGE
- ecological
approach to health: effect of interactions between environment
and human populations, including their effect on health,
- sustainable
development,
- global
effects of pollution and hazardous industrial processes
d.
Health Behaviours
KNOWLEDGE
- nutrition
- tobacco
habits
- alcohol
and other substance use/abuse
- physical
activity
- sexuality
- risk
taking behaviors
- harm
reduction
- cultural
patterns
e.
Health Service Organizations
KNOWLEDGE
- characteristics
of health services organizations
- payment
mechanisms
- health
manpower
- health
institutions
- Indicators
and Measures
KNOWLEDGE
- major
health indicators and data sources
- demographics
- mortality,
incidence, prevalence, quality of life
- risk
factor indicators of physical and mental morbidity:
institutional & non-institutional
- impairment,
disability and handicap
- indicators
of occupational health
- taxonomies
of disease, e.g., ICDA, ICHPPC
SKILLS
- calculate
major health indicators
- assess
and interpret these data for public health programming
- assess
the health of populations including special groups
- Demography
KNOWLEDGE
- indicators
of birth trends
- indicators
of fecundity and fertility
- mortality
data
- population
migrations, demographic trends and projections
- aging
of population
SKILLS
- find
and interpret population health data
- and
registration forms
- collect
and validate the data
- Health
Status
KNOWLEDGE
- descriptive
data of health status and data on determinants
- health
of special groups: elderly, natives, immigrants,
socio-economically disadvantaged, workers etc.
- international
comparisons
SKILLS
- describe
the distribution and determinants of health status of a specific
population
- METHODS
IN COMMUNITY HEALTH
- Epidemiology
KNOWLEDGE
- models
of epidemiology: person, place and time; agent, host,
environment
- concept
of denominator
- measures
of disease frequency: rates, ratios, frequencies and their
calculation
- techniques
of standardization
- nature,
strengths and weaknesses of major study designs: ecological,
cross sectional, case control, cohort, randomized trials
- ecological
fallacy
- risk
indicators: RR, AR (exposed & population), odds ratio,
etiologic fraction, preventive fraction
- guidelines
for determining causation (Koch, Hill)
- models
of disease causation: additive, multiplicative; interactions
(synergy, antagonism)
- definitions
of screening and case finding
- theory
of screening; criteria for carrying out a screening program
- principles
and uses of meta-analysis
SKILLS
- critically
appraise research and literature
- interpret
epidemiologic studies, assessing their validity and
applicability to a particular situation
- use
microcomputers in epidemiologic investigations
- use
microcomputers in data analyses
- calculate
and interpret screening test characteristics
- Statistics
KNOWLEDGE
- techniques
for assessing the relationship between variables: t-test,
analysis of variance, chi-square, correlation kappa
- basic
multivariate techniques: multiple regression, discriminant
analysis
- adjustment
for bias: standardization, analysis of covariance
- interpretation
of tests of significance: Type I and II errors, statistical
power
- life
tables, survival analyses
SKILLS
- select
appropriate descriptive and analytic methods
- present
data clearly in tables, graphs
- carry
out simple tests of statistical significance (e.g. chi-square,
t-test, use computers in data analysis
- determine
sample size
- analyze
the significance of clusters of disease
- Social
Sciences
KNOWLEDGE
- be
aware of quantitative and qualitative methods used by social
scientists explaining the differences in health and health
related behaviors, including utilization e.g., participation,
observation, key informant survey, case-2 studies, nominal group
processes, Delphi process
SKILLS
- working
with social scientists, use these concepts and methods for needs
assessment and intervention in community health
- Research
Methods
KNOWLEDGE
- principles
of quantitative and qualitative research:
- design
- principles
of sampling
- methods
of sample selection
- random
(chance) and systematic errors (bias): their origins and
avoidance
- decision
analysis
- ethical
issues
SKILLS
- critically
appraise research proposals and reports
- develop
research protocols
- design
a questionnaire
- carry
out fieldwork for an investigation or survey
- design
and implement a participatory research design, identify key
informants, set up focus groups and use consultants and
collaborators appropriately
- grant
preparation
- Leadership
Development
KNOWLEDGE
- approaches
to leadership development
- best
leadership practices
- collaboration
- partnerships
- negotiation
- feedback
on leadership skills
- stages
of group development
SKILLS
- clarify
organizational values
- develop
an organizational vision
- demonstrate
team building abilities
- model
appropriate behaviours and values
- facilitation
- Communication
KNOWLEDGE
- interpretation
and communication of health data in various formats
- risk
communication theory
- communication
with a variety of individuals, groups, and situations
- media
channels
- principles
of lobbying
- communication
styles
SKILLS
- interpret
epidemiological data and risk information for the public, other
professionals and the media
- develop
and implement a communication plan about a public health issue,
including a media component
- elicit
and provide effective feedback
- media
relations:
- interview
and be interviewed
- public
speaking
- group
facilitation
- HEALTH
SERVICES ORGANIZATION
- Policy
Formulation and Analysis
KNOWLEDGE
- mechanisms
of policy development
- methods
of policy implementation: legislation, regulation and incentives
- health
law and common law relevant to community health practice
- health
impact of public policy
- integration
of medical knowledge into social change
- analytical
approach to decision making
- policy
analysis and evaluation
SKILLS
- carry
out a policy analysis on a health issue
- demonstrate
development of healthy public policy
- Ethics
KNOWLEDGE
- ethics
of resource allocation and public policy
- public
health ethics: ethical issues arising from community health
problems and programs
- informed
consent: clinical setting, research setting
- responsibilities
to: employers, public, individual
- privacy
rights in epidemiologic data management
- conflicts
of interest
SKILLS
- identify
ethical issues arising from specific community (or public)
health problem and programs and address their resolution
- Canadian
Health Care Systems
KNOWLEDGE
- evolution
- relevant
political structures: federal, provincial, municipal and their
jurisdictional responsibilities
- organization
and regulation of hospitals and professions
- health
manpower alternate health care workers
- economics
of health care:
- expenditures
- systems
of professional remuneration
- alternate
methods of financing care
- major
national documents and Acts
- future
trends and issues
- international
comparisons of health care structures
SKILLS
- use
knowledge of health services for analysis of health problems and
planning
- identify
issues which have an impact on the current structures
- Community
Health Systems in
KNOWLEDGE
- organization
of community health services
- public
health legislation in at least one province
- structure,
function and effectiveness of public health programs
(maternal and child health, daycare and school health,
family planning, STD programs, programs for the elderly,
dental health, mental health nutrition, home care, etc)
- health
law relevant to community health practice
- social
service programs e.g., child abuse, family violence, income
maintenance
- mental
health services: institutional and community
- role
of voluntary agencies
- role
of informal care-givers
SKILLS
- use
and coordinate community health services
- COMMUNITY
HEALTH PROGRAMS
- Intervention
strategies
- Health
protection
KNOWLEDGE
- monitoring
of health status
- statutory
responsibilities for public protection: regulations, standards
- public
policy approaches to health protection, e.g., limitations on
legal, physical and economic approaches
- global
perspective on environmental health, e.g., contamination in
food chain
- effectiveness
and risks of health protection approaches
SKILLS
- assess
health risks from environmental exposures
- develop
health protection approaches to community health issue/problem
- Prevention
of Disease
KNOWLEDGE
- principles
of disease prevention
- levels
of prevention
- role
of screening, case finding
- organization
of clinical and public health preventive services
- methods
and recommendations of Task Force on the Periodic Health
Examination
- effectiveness
and risks to preventive approaches
SKILLS
- advise
on preventive strategies for clinical and public health
settings
- evaluate
preventive programs, e.g., trials
- Health
Promotion
KNOWLEDGE
- concept
and definition
- health
promotion strategies
- models
of influencing, health behaviour
- health
education techniques, health advocacy; approaches to
influencing public policy
- community
development theories and practice
- principles
of social marketing
- nature
and effectiveness of health promotion programs for major
behavioral health problems and population groups
- international
developments in health promotion: WHO activities, targets
- risks
and benefits of health promotion approaches to specific groups
SKILLS
- develop
a health promotion approach to a community health
issue/problem
- health
advocacy: define a position and argue for it persuasively
- Program
Areas
- Communicable
Diseases (CD)
KNOWLEDGE
- principles
of CD control
- characteristics
of and policy governing vaccines and chemoprophylactic agents
- reporting
requirements
- case
definition
- uses
of isolation, quarantine, surveillance, contact tracing and
legal dispositions
- role
of various individuals and agencies in management of CD (e.g.
laboratory net-work, LCDC, CDC, etc.)
- for
each of the major CD:
- natural
history
- descriptive
epidemiology
- risk
factors
- impact
- prevention
and treatment
- principles
of nosocomial infection control
- recommendations
for international travel
SKILLS
- investigate
and manage a CD outbreak
- develop,
implement and evaluate a CD surveillance and control program
- use
legal dispositions
- assess
ethical issues in surveillance and control
- use
of prophylaxis and treatment modalities as appropriate
Community Medicine context practice
- Non-communicable
Disease (NCD) and Injury
KNOWLEDGE
- principles
of NCD prevention, control, methods of surveillance of risk
factors for each major NCD, condition, or injury(high impact
or high preventability):
- natural
history
- epidemiology
- risk
factors
- health
impact
SKILLS
- select
an appropriate approach for prevention and control of an NCD/injury
- develop,
implement and evaluate NCD/injury surveillance and control
program
- Programs
for Special Populations or Problems
KNOWLEDGE
- structure
of community health programs: perinatal health, child and
family health, day care and school health, family planning,
elderly health, dental health, nutrition, home care,
immigrants, refugees, workers, women, and socio-economically
disadvantaged, etc.
- international
health, e.g., primary health care
SKILLS
- work
with a community group to develop and/or evaluate a health
program
- Environmental
Health Programs:
i.
Methods
KNOWLEDGE
- principles
of toxicology
- mutagenesis,
carcinogenesis teratogenesis
- methods
of monitoring water, air, soil, food
- risk
assessment techniques
- methods
of setting and expressing standards for exposure to hazards
(TLV)
SKILLS
- carry
out simple risk assessment of an environmental hazard
ii.
Environmental health
KNOWLEDGE
- major
environmental health hazards and diseases
- water,
air and soil characteristics
- health
effects, epidemiological aspects of major environmental
agents: e.g., physical, chemical, biological including
sanitation, water purification, sewage treatment, milk
hygiene, quality control: water, air soil, food
- management
of environmental exposure
SKILLS
- assess
and manage an environmental health problem/issue
- contribute
to the development of a disaster plan, from a community
health perspective
- make
public health recommendations for toxic environmental
hazards
- organize
the strategies to protect exposed population
iii.
Occupational health
KNOWLEDGE
- organization
of occupational health services, including:
- employee
assistance programs
- health
promotion in the workplace
SKILLS
- investigate
an occupational health problem
- Program
Management
- Program
Planning, Implementation and Evaluation
KNOWLEDGE
- models
of program planning
- needs
assessment techniques
- health
status measures
- utilization
data
- service
inventory
- health
care provider and consumer perceptions
- methods
of setting priorities
- local
and regional planning and coordination
- methods
of implementation
- management
information systems
- resource
allocation
- program
evaluation:
- evaluability
of assessment; design of structure, process, outcome
evaluation
- use
of experimental and quasi-experimental design
- economic
evaluation
- cost
benefit
- cost
effectiveness
- cost
utility
- principles
of technology assessment
- quality
assurance programs
SKILLS
- conduct
a needs assessment
- prioritize
program alternatives
- design
an implementation plan
- assess
the evaluability of a program
- design
and carry out a program evaluation
- Program
Administration
KNOWLEDGE
- principles
of strategic planning, mission statement, specific objectives,
management philosophy and program styles
- management
of change
- conflict
management
- principles
of organizational design and behavior
- operational
planning
- financial
budgeting and monitoring
- labour
relations information systems
- role
of Chief Executive Officer, and other senior management
positions
- policy
and procedure development
- accreditation
and procedures record keeping
SKILLS
- develop,
maintain and implement strategic plan
- assess
the structure of an organization
- assess
the impact of a significant change in an organization and
develop a strategy for addressing it
- assess
a personnel policy
- develop
a budget
- set
an agenda and chair a meeting, act as secretary
- participate
in the following personnel activities: supervision, hiring,
discipline, staff development, performance
- appraisal
- develop
organizational policies and procedures keep appropriate
records
CONTENT
AND ORGANIZATION OF THE RESIDENCY PROGRAM:
There must be an
organized program of rotations and other educational experiences, both
mandatory and elective, designed to provide each resident with the
opportunity to fulfill the educational requirements and achieve
competence in the specialty.
The content and organization of each
accredited program in community medicine must be consistent with the
specialty training requirements.
The program should ensure that each
candidate is assigned graded and increasing personal responsibility
throughout the residency program to the fullest extent compatible with
the legal regulations governing the health agencies in which training
occurs.
RESOURCES:There
must be sufficient resources including teaching faculty, the number and
variety of patients, physical and technical resources, as well as the
supporting facilities and services necessary to provide the opportunity
for all residents in the program to achieve the educational objectives
and receive full training as defined by the specialty training
requirements in community medicine.
The unit of practice for a community
medicine specialist is primarily population based. This standard is
interpreted to mean that there must be a variety of population
reflecting urban, rural, gender, multicultural and other diversity.
In those cases where a university has
sufficient resources to provide most of the training in community
medicine but lacks one or more essential elements, the program may still
be accredited provided that formal arrangements have been made to send
residents to another accredited residency program for periods of
appropriate prescribed training.
The resources required for the basic
clinical training year shall be based in a sponsoring faculty of
medicine and its affiliated hospitals.
It is essential that a broad range of
community health activities be involved, covering all the major
applications of community medicine. Normally this will require the
participation of several different agencies, but in some cases a single
broadly-based agency may suffice.
Each participating agency or institution
must be willing to provide a sufficient number of qualified teaching
staff to supervise the resident at a level acceptable to both the
program director. Usually, the field supervisor should be a physician
qualified in community medicine in some cases another qualification may
be appropriate.
ACADEMIC
AND SCHOLARLY ASPECTS OF THE PROGRAM:
The academic and scholarly aspects of the program
must be commensurate with the concept of a university postgraduate
education. The quality of scholarship in the program will, in part, be
demonstrated by a spirit of enquiry during clinical discussions,
seminars, rounds, and conferences. Scholarship implies an in-depth
understanding of basic mechanisms of normal and abnormal states and the
application of current knowledge to practice.
- Organized
Scholarly Activities
The program will
involve a combination of academic, clinical, and field experiences, to
ensure that residents will develop a broad range of competence in
community medicine. The academic component may entail the granting of an
academic degree, such as an M.Sc., M.H.Sc., M.P.H. The program should be
flexible enough within the guidelines to suit the career plans of the
candidates. In particular, it is desirable that the program provide
candidates the opportunity to develop special expertise in a specific
area of community medicine.
- Collaborative
and Leadership Skills
It is essential that
the program provide the resident with an opportunity to work as a member
of an integrated team with other professionals in health and
health-related fields and, where appropriate, with members of the
community. The assumption of progressive responsibility under close
supervision is an important aspect of resident training and must be
adhered to. Residents must be given opportunities to acquire leadership
skills.
- Biomedical
Ethics
The academic program
must ensure that residents gain an understanding of the principles and
practice of biomedical ethics and their applications to the field of
community medicine.
- Communication
Skills
The program must
ensure that residents learn effective communication skills for
interacting with agencies, communities, individuals and their families,
media, colleagues, co-workers from other disciplines, and students.
Residents should participate in conference presentations, clinical and
scientific reports and patient, public or community education. Clearly
defined educational objectives for teaching these skills and mechanisms
of formal assessment should be in place.
- Teaching
Skills
Residents must be
given opportunities to develop effective teaching skills by teaching
junior colleagues and students.
- Quality
Assurance/Improvement
The program must
provide residents with opportunities to gain an understanding of the
principles and practice of quality assurance/improvement and program
evaluation.
- Research
Opportunities for Residents
The university centre
must be engaged in a program of research in community medicine or its
basic sciences and be capable of supervising candidates in research at a
level appropriate for a graduate degree.
- Faculty
Research
A satisfactory level
of research and scholarly activity must be maintained among the faculty
identified with the program.
- Outside
Conferences
The program should
provide opportunities for residents to attend conferences outside their
own university.
SPECIALTY REQUIREMENTS:
1.
Basic clinical training.
2.
Approved
training, university sponsored program which may include:
- This
will include the equivalent of course work in Community Medicine;
- Field
placements. Appropriate settings will include public health
departments, health planning authorities, government departments
of health, environment health settings, occupational health
departments in government and industry, and clinical departments
with a commitment to practice and research in preventive medicine.
It is essential that candidates gain experience in a broad range
of such placements, although it is recognized that a single
placement will often provide experience in more than one subject
area;
PROGRAMS (WITH TRAINING REQUIREMENTS):
Diplomas(Dip):
Six
months of approved training.
Doctor of
Medicine(M.D):
Eighteen
months of approved training.
Master of
Public Health(M.P.H):
Thirty
six months of approved training.
Doctor of
Philosophy(Ph.D):
Forty
eight months(four years)of approved training.
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