Vol. 6, No. 4 Printed in Great Britain
IntamationaJ Journal of EpJdamlology O Oxford University P m 1977
Epidemiology and the Training of Physicians MOHAMMED A FAGHIH1
Epidemiological studies have three basic aims: (1) to describe the distribution and extent of disease, disability and other health problems in communities; 1
Chancellor, University of Azarmbadegan, Tabriz, Iran.
331
(2) to provide the data essential for planning, implementation and evaluation of preventive, protective, promotive and curative services and the establishment of priorities among such services; (3) to identify aetiological factors in the pathogenesis of diseases and disorders. Certainly there are many other areas, in which epidemiology can contribute significantly, for example in historical studies, medical knowledge (including natural history of diseases, completing the clinical picture, identification of syndromes), medical education, development of scientific research and setting up of information, communication, monitoring and feedback systems. It is believed that many diseases and health problems have a multifactorial origin in which social, behavioural, physical, chemical, biological and psychological aspects are involved in an interlinked chain. Full understanding of these problems, cannot be reached using traditional incidental approaches. Carefully designed experiments in which all epidemiological and scientific techniques are used must be applied. The study of the aetiology of cancer, and the search for the causes of cardiovascular diseases or mental disorders are examples in which the proper epidemiological approach is of great value. Taking the above into account, it is appropriate or even necessary for any professional medical staff to have a thorough grounding in epidemiology and health statistics, and perhaps also in social and behavioural sciences, health economics, health planning and administration. Such experience is as important as the knowledge of traditional physical, natural and chemical sciences. The extent of this grounding in epidemiology and statistics for undergraduate medical students depends on the objectives of medical education and the functions the future medical graduate is being taught to fulfil. The generally accepted aim of medical education is to provide medical students with a sound scientific background which will allow them to formulate and evaluate practical and
Downloaded from http://ije.oxfordjournals.org/ at University of Sussex on August 22, 2015
The broad objective of health care is to secure the health of the population. The basic concept and definition of health, as given in the constitution of the World Health Organization, has remained more or less the same for sometime, but its determinants, that is demographic, psychological, social, cultural, political, economic, epidemiological, scientific, technological, administrative and operational factors, are always changing. The rapid changes taking place in societies, particularly those in the process of developing, have created a basic instability in all components of human ecology which at any time and place may require particular activities and services. Massive and uncontrolled use of technology accompanied by extended industrialization and all the often unavoidable physical, social, behavioural and material consequences, such as the population explosion, urbanization, environmental pollution, occupational hazards, accidents, mental disorders and other more neutral elements, have made it necessary for scientists and administrators in particular to face new and broader challenges. Greater awareness and demands by people for proper action of the preventive, protective, promotive and curative type, have provided even greater challenges. Fortunately, the parallel process of growth in biomedical sciences including development of medical technology and of more sophisticated techniques and methods in quantitative sciences, as well as management have given more opportunity to meet the health demands of changing societies. The science of epidemiology has a great part to play in this challenging atmosphere. Epidemiology, with its variety of activities, in conjunction with statistics and other fundamental health-related sciences provides the basis for meeting many health problems.
332
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
elaboration of the subject and its aims within a well-balanced medical curriculum. Early exposure to the history and development of medicine and public health seems logical in the first year medical curriculum or at the beginning of the pre-clinical period. In this course examples can be given of the application of epidemiology in historical studies. The concept of public health and preventive medicine and the use of epidemiological and statistical methods can be introduced at this early stage within the courses on anatomy and embryology. This should be followed by an introduction to basic fundamentals of epidemiology and statistics in parallel with other subjects (such as demography, medical sociology, population genetics, community psychiatry), in order to expose students to the fundamentals of the ecology of health in a population and to show them how these fundamentals can be studied and measured. This will logically take place in the second year when the subjects related to socio-behavioural and biological sciences are taught Close collaboration between various disciplines, establishment of integrated teaching sessions, presentation of examples from different disciplines in practical and laboratory work, field demonstrations and participation in community studies organized by the teaching institutions or operating agencies (such as the Ministry of Health) are of great value. The next phase will be to encourage students to be 'scientific-minded', and to give them sufficient knowledge and skill for designing experiments by exposing them to methods of studying health and diseases in populations. By this time the students should have enough knowledge and laboratory experience of the subjects required for epidemiological investigation and the study of the natural history of diseases (such as bacteriology, parasitology, immunology and biochemistry). They may also have begun to be exposed to clinical studies. At this stage, collaboration between these various disciplines in the teaching and application of epidemiological methods, through the organization of integrated courses, laboratory experiments, field trials, clinical trials and bedside teaching, is essential. The real application of epidemiological and statistical methods in the study and control of communicable and non-communicable diseases (represented by selected major diseases or disease groups) as well as the relevance of epidemiology in clinical medicine and in planning and administration of health services must be developed in this
Downloaded from http://ije.oxfordjournals.org/ at University of Sussex on August 22, 2015
theoretical problems, and to give sufficient knowledge and experience in different subjects related to medicine to allow competent and satisfactory general practice. Unfortunately, while impressive advances are being made in many aspects of clinical medicine, modern medicine has tended to overlook many community and social problems. One of the major reasons for this can be found in medical education. Most of our medical schools and teaching hospitals have tended to concentrate on the diseases found in hospital wards and have been reluctant to consider diseases, disabilities and health problems found in the community. Our present medical education system is directed towards the training of hospital and specialty oriented graduates; while, within the expectations of a 'health care delivery system' with primary care as the point of entry to the system, we should be training basic 'community physicians' to meet the primary health care needs of the individual, of the family and the whole community. The physician must also understand his role as an agent of social change and make effective contributions to the social and economic development of his community. Therefore, in educating the physician, we must aim to develop the knowledge, skill and attitudes necessary for the comprehensive care including prevention, treatment, after-care and rehabilitation of illness in the community as well as in hospital. This education should enable the physician to recognize the nature of health problems, to understand how factors affecting health care can be examined and measured, to perceive the practical steps to be taken to counteract hazards and to be aware of the necessary economies and priorities for public health programmes and their relationship and impact on the overall socio-economic development of the society. To achieve these aims, as mentioned before, a thorough grounding in basic health sciences is needed; this should include the development of sufficiently profound knowledge, skill and attitudes for application of the scientific method and quantitative sciences, that is epidemiology and statistics in the study and practice of medicine in the community as well as in the hospital. However, it should be remembered that the aim of such a grounding at undergraduate level is not to produce epidemiologists, since this is the responsibility of postgraduate training. However, the introduction of this appropriate grounding needs a proper planned curriculum with suitable content for normal and logical
EPIDEMIOLOGY AND THE TRAINING OF PHYSICIANS
(1) create an atmosphere of understanding and collaboration between the discipline of epidemiology and other disciplines of social and preventive medicine; as well as between basic medical sciences and clinical medicine and different service units of the health service; (2) convey the message of epidemiology to other areas and the message of other disciplines into epidemiology; (3) develop a highly scientific and practical basic groundwork in the science and its teaching which is susceptible to change and modern ideas. Such a unit must also have access to facilities at the field' or community level; ideally these would be in each of the major ecological zones of a county and be administered by the same department, medical school or university.
BIBLIOGRAPHY
(1) Backett, M: Teaching of Epidemiology to Undergraduates, Second Conference of Medical Education, Teheran, Iran, 1970. (2) Butterfield, W J H: Epidemiology in the Planning of the Undergraduate Medical Curriculum. International Journal of Epidemiology 2: 391, 1973. (3) Dixon, C W: New Development in Research and Teaching of Epidemiology: SEA/ME/Meet. Div. Sen. PJL 4/11, New Delhi, 1971. (4) Escande, J P: Les Medians; Bernard Grasset, Paris, 1975. (5) Kostrzewski, J: Epidemiology—Definition and Aims: IEA/IPHA Regional Scientific Meeting, Isfahan, Iran, 1976. (6) McKeown, T: Social Medicine; Teaching and Research; EM/SCD Conference Medical Education/7, Teheran Iran, 1970. (7) McKeown, T: New Development in Epidemiology; SEA/ME Meet. Dir. Sen. P.H. 4/20, New Delhi, 1971. (8) Moxley, J H: Epidemiology in Medical Education. International Journal of Epidemiology 2: 367, 1973. (9) Pemberton, J: Practical Work in Epidemiology and Community Medicine for Medical Undergraduates. International Journal of Epidemiology 2: 399, 1973. (10) Schofield, F D and Muller, A S: Epidemiology in Undergraduate Curriculum of an African Medical School. International Journal of Epidemiology 2: 407, 1973. (11) Sharif, A F: Teaching of Epidemiology for Undergraduates. EM/SCD Conference on Medical Education/8 Teheran, Iran, 1970. (12) Sharma, R: Epidemiological Components of Primary Health Care: DBA/IPHA Regional Scientific Meeting, Isfahan, Iran, 1976. (13) Warren, MD and Acheson,RM: Training in Community Medicine and Epidemiology in Britain. International Journal of Epidemiology 2: 371, 1973. (14) Waters, W E: Epidemiology and Statistics for Medical Students. IEA/IPHA Regional Scientific Meeting, Isfahan, Iran, 1976. (15) White, K L, Williams, T F and Greenberg, B G: The Ecology of Medical Care. New England Journal of Medicine 265:885,1961. (16) White, K L: Contemporary Epidemiology. International Journal of Epidemiology 3: 295, 1974. (17) WHO: Continuing Education for Physicians, Technical Report Series No 534, 1973. (18) WHO: The application of Epidemiology in the Planning and Evaluation of Health Services. Report on a Working Group, EURO 4905 (6), Copenhagen, 1974.
Downloaded from http://ije.oxfordjournals.org/ at University of Sussex on August 22, 2015
period. This requires contributions from clinical disciplines (particularly infectious diseases, paediatrics, obstetrics and gynaecology), by organizing bedside or outpatient teaching of clinical epidemiology, joint lectures and seminars, joint research and study programmes, both clinical and population based, in which the students should participate. Teaching and other activities at community health centres as well as in the programmes and activities by operating agencies (Ministry of Health), and participation in these activities are essential to development of practical skills and to show students the relevance of epidemiology in various health fields. In brief, the teaching of epidemiology, as a scientific discipline with a broad spectrum of application, needs the active participation and utilization of the resources of many disciplines inside the medical school (basic medical and clinical sciences), as well as within health services. In order that this comprehensive and broad curriculum should be carried out, more epidemiological units should be set up within Departments of Social and Preventive Medicine comprising well qualified and competent epidemiologists and statisticians, but it should also have direct collaboration from competent specialists in other fields. Such a unit should:
333
IntamationaJ Journal of EpJdamlology O Oxford University P m 1977
Epidemiology and the Training of Physicians MOHAMMED A FAGHIH1
Epidemiological studies have three basic aims: (1) to describe the distribution and extent of disease, disability and other health problems in communities; 1
Chancellor, University of Azarmbadegan, Tabriz, Iran.
331
(2) to provide the data essential for planning, implementation and evaluation of preventive, protective, promotive and curative services and the establishment of priorities among such services; (3) to identify aetiological factors in the pathogenesis of diseases and disorders. Certainly there are many other areas, in which epidemiology can contribute significantly, for example in historical studies, medical knowledge (including natural history of diseases, completing the clinical picture, identification of syndromes), medical education, development of scientific research and setting up of information, communication, monitoring and feedback systems. It is believed that many diseases and health problems have a multifactorial origin in which social, behavioural, physical, chemical, biological and psychological aspects are involved in an interlinked chain. Full understanding of these problems, cannot be reached using traditional incidental approaches. Carefully designed experiments in which all epidemiological and scientific techniques are used must be applied. The study of the aetiology of cancer, and the search for the causes of cardiovascular diseases or mental disorders are examples in which the proper epidemiological approach is of great value. Taking the above into account, it is appropriate or even necessary for any professional medical staff to have a thorough grounding in epidemiology and health statistics, and perhaps also in social and behavioural sciences, health economics, health planning and administration. Such experience is as important as the knowledge of traditional physical, natural and chemical sciences. The extent of this grounding in epidemiology and statistics for undergraduate medical students depends on the objectives of medical education and the functions the future medical graduate is being taught to fulfil. The generally accepted aim of medical education is to provide medical students with a sound scientific background which will allow them to formulate and evaluate practical and
Downloaded from http://ije.oxfordjournals.org/ at University of Sussex on August 22, 2015
The broad objective of health care is to secure the health of the population. The basic concept and definition of health, as given in the constitution of the World Health Organization, has remained more or less the same for sometime, but its determinants, that is demographic, psychological, social, cultural, political, economic, epidemiological, scientific, technological, administrative and operational factors, are always changing. The rapid changes taking place in societies, particularly those in the process of developing, have created a basic instability in all components of human ecology which at any time and place may require particular activities and services. Massive and uncontrolled use of technology accompanied by extended industrialization and all the often unavoidable physical, social, behavioural and material consequences, such as the population explosion, urbanization, environmental pollution, occupational hazards, accidents, mental disorders and other more neutral elements, have made it necessary for scientists and administrators in particular to face new and broader challenges. Greater awareness and demands by people for proper action of the preventive, protective, promotive and curative type, have provided even greater challenges. Fortunately, the parallel process of growth in biomedical sciences including development of medical technology and of more sophisticated techniques and methods in quantitative sciences, as well as management have given more opportunity to meet the health demands of changing societies. The science of epidemiology has a great part to play in this challenging atmosphere. Epidemiology, with its variety of activities, in conjunction with statistics and other fundamental health-related sciences provides the basis for meeting many health problems.
332
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
elaboration of the subject and its aims within a well-balanced medical curriculum. Early exposure to the history and development of medicine and public health seems logical in the first year medical curriculum or at the beginning of the pre-clinical period. In this course examples can be given of the application of epidemiology in historical studies. The concept of public health and preventive medicine and the use of epidemiological and statistical methods can be introduced at this early stage within the courses on anatomy and embryology. This should be followed by an introduction to basic fundamentals of epidemiology and statistics in parallel with other subjects (such as demography, medical sociology, population genetics, community psychiatry), in order to expose students to the fundamentals of the ecology of health in a population and to show them how these fundamentals can be studied and measured. This will logically take place in the second year when the subjects related to socio-behavioural and biological sciences are taught Close collaboration between various disciplines, establishment of integrated teaching sessions, presentation of examples from different disciplines in practical and laboratory work, field demonstrations and participation in community studies organized by the teaching institutions or operating agencies (such as the Ministry of Health) are of great value. The next phase will be to encourage students to be 'scientific-minded', and to give them sufficient knowledge and skill for designing experiments by exposing them to methods of studying health and diseases in populations. By this time the students should have enough knowledge and laboratory experience of the subjects required for epidemiological investigation and the study of the natural history of diseases (such as bacteriology, parasitology, immunology and biochemistry). They may also have begun to be exposed to clinical studies. At this stage, collaboration between these various disciplines in the teaching and application of epidemiological methods, through the organization of integrated courses, laboratory experiments, field trials, clinical trials and bedside teaching, is essential. The real application of epidemiological and statistical methods in the study and control of communicable and non-communicable diseases (represented by selected major diseases or disease groups) as well as the relevance of epidemiology in clinical medicine and in planning and administration of health services must be developed in this
Downloaded from http://ije.oxfordjournals.org/ at University of Sussex on August 22, 2015
theoretical problems, and to give sufficient knowledge and experience in different subjects related to medicine to allow competent and satisfactory general practice. Unfortunately, while impressive advances are being made in many aspects of clinical medicine, modern medicine has tended to overlook many community and social problems. One of the major reasons for this can be found in medical education. Most of our medical schools and teaching hospitals have tended to concentrate on the diseases found in hospital wards and have been reluctant to consider diseases, disabilities and health problems found in the community. Our present medical education system is directed towards the training of hospital and specialty oriented graduates; while, within the expectations of a 'health care delivery system' with primary care as the point of entry to the system, we should be training basic 'community physicians' to meet the primary health care needs of the individual, of the family and the whole community. The physician must also understand his role as an agent of social change and make effective contributions to the social and economic development of his community. Therefore, in educating the physician, we must aim to develop the knowledge, skill and attitudes necessary for the comprehensive care including prevention, treatment, after-care and rehabilitation of illness in the community as well as in hospital. This education should enable the physician to recognize the nature of health problems, to understand how factors affecting health care can be examined and measured, to perceive the practical steps to be taken to counteract hazards and to be aware of the necessary economies and priorities for public health programmes and their relationship and impact on the overall socio-economic development of the society. To achieve these aims, as mentioned before, a thorough grounding in basic health sciences is needed; this should include the development of sufficiently profound knowledge, skill and attitudes for application of the scientific method and quantitative sciences, that is epidemiology and statistics in the study and practice of medicine in the community as well as in the hospital. However, it should be remembered that the aim of such a grounding at undergraduate level is not to produce epidemiologists, since this is the responsibility of postgraduate training. However, the introduction of this appropriate grounding needs a proper planned curriculum with suitable content for normal and logical
EPIDEMIOLOGY AND THE TRAINING OF PHYSICIANS
(1) create an atmosphere of understanding and collaboration between the discipline of epidemiology and other disciplines of social and preventive medicine; as well as between basic medical sciences and clinical medicine and different service units of the health service; (2) convey the message of epidemiology to other areas and the message of other disciplines into epidemiology; (3) develop a highly scientific and practical basic groundwork in the science and its teaching which is susceptible to change and modern ideas. Such a unit must also have access to facilities at the field' or community level; ideally these would be in each of the major ecological zones of a county and be administered by the same department, medical school or university.
BIBLIOGRAPHY
(1) Backett, M: Teaching of Epidemiology to Undergraduates, Second Conference of Medical Education, Teheran, Iran, 1970. (2) Butterfield, W J H: Epidemiology in the Planning of the Undergraduate Medical Curriculum. International Journal of Epidemiology 2: 391, 1973. (3) Dixon, C W: New Development in Research and Teaching of Epidemiology: SEA/ME/Meet. Div. Sen. PJL 4/11, New Delhi, 1971. (4) Escande, J P: Les Medians; Bernard Grasset, Paris, 1975. (5) Kostrzewski, J: Epidemiology—Definition and Aims: IEA/IPHA Regional Scientific Meeting, Isfahan, Iran, 1976. (6) McKeown, T: Social Medicine; Teaching and Research; EM/SCD Conference Medical Education/7, Teheran Iran, 1970. (7) McKeown, T: New Development in Epidemiology; SEA/ME Meet. Dir. Sen. P.H. 4/20, New Delhi, 1971. (8) Moxley, J H: Epidemiology in Medical Education. International Journal of Epidemiology 2: 367, 1973. (9) Pemberton, J: Practical Work in Epidemiology and Community Medicine for Medical Undergraduates. International Journal of Epidemiology 2: 399, 1973. (10) Schofield, F D and Muller, A S: Epidemiology in Undergraduate Curriculum of an African Medical School. International Journal of Epidemiology 2: 407, 1973. (11) Sharif, A F: Teaching of Epidemiology for Undergraduates. EM/SCD Conference on Medical Education/8 Teheran, Iran, 1970. (12) Sharma, R: Epidemiological Components of Primary Health Care: DBA/IPHA Regional Scientific Meeting, Isfahan, Iran, 1976. (13) Warren, MD and Acheson,RM: Training in Community Medicine and Epidemiology in Britain. International Journal of Epidemiology 2: 371, 1973. (14) Waters, W E: Epidemiology and Statistics for Medical Students. IEA/IPHA Regional Scientific Meeting, Isfahan, Iran, 1976. (15) White, K L, Williams, T F and Greenberg, B G: The Ecology of Medical Care. New England Journal of Medicine 265:885,1961. (16) White, K L: Contemporary Epidemiology. International Journal of Epidemiology 3: 295, 1974. (17) WHO: Continuing Education for Physicians, Technical Report Series No 534, 1973. (18) WHO: The application of Epidemiology in the Planning and Evaluation of Health Services. Report on a Working Group, EURO 4905 (6), Copenhagen, 1974.
Downloaded from http://ije.oxfordjournals.org/ at University of Sussex on August 22, 2015
period. This requires contributions from clinical disciplines (particularly infectious diseases, paediatrics, obstetrics and gynaecology), by organizing bedside or outpatient teaching of clinical epidemiology, joint lectures and seminars, joint research and study programmes, both clinical and population based, in which the students should participate. Teaching and other activities at community health centres as well as in the programmes and activities by operating agencies (Ministry of Health), and participation in these activities are essential to development of practical skills and to show students the relevance of epidemiology in various health fields. In brief, the teaching of epidemiology, as a scientific discipline with a broad spectrum of application, needs the active participation and utilization of the resources of many disciplines inside the medical school (basic medical and clinical sciences), as well as within health services. In order that this comprehensive and broad curriculum should be carried out, more epidemiological units should be set up within Departments of Social and Preventive Medicine comprising well qualified and competent epidemiologists and statisticians, but it should also have direct collaboration from competent specialists in other fields. Such a unit should:
333
