Communication About Public Health Should Be A Conversation - Dr. Jan Carney, Associate Dean for Public Health and Health Policy at The Larner College of Medicine at the University of Vermont

Michael Carrese: Hi, everybody, I'm Michael Carrese, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. 

One silver lining of the COVID-19 pandemic is a jump in enrollments in public health degree programs at both the bachelor's and master's levels. In fact, applications to graduate-level public health programs across the country grew about 40% during the pandemic.

According to a study out last year by the Association of Schools and Programs of Public Health, one factor driving that surge is a newfound awareness among young people of the systemic health disparities that impact their communities and that public health is a field focused on structural reasons for health. 

To learn more about the field in general and master's degree programs in public health specifically, we're joined today by Dr. Jan K. Carney, a leading figure in Vermont's medical and academic community with a significant national footprint as well. Dr. Carney is Associate Dean for Public Health and Health Policy and Director of the Master of Public Health Program at the University of Vermont's Larner College of Medicine. She served as the state's Commissioner of Health for fourteen years, during which she highlighted children's health insurance, teen smoking, and cancer screening, among other issues. 

Nationally, Dr. Carney is a member of the Board of Regents of the American College of Physicians, which is the largest medical specialty organization and second largest physician group in the United States. 

Thanks so much for being with us today.

Dr. Jan Carney: Thank you for inviting me.

Michael: So, we always like to start with learning more about our guests and what first got them interested in medicine and then of course, in your case, also public health.

Dr. Carney: Well, all right then. My interest in medicine started when I was in elementary school. I had a teacher whose husband was a medical intern at that time and so she would tell us about all the medical adventures she was hearing about in her life, and I became very interested. I remember specifically learning about and hearing about all aspects of science and so I became extremely interested in science and medicine and decided and told my mother that I was gonna be a doctor when I got older. My father was a dentist and part of his practice that he had for about forty years was making people feel better and relieving their pain and so I think a combination of a love of science and that later grew into understanding more about medicine and healthcare and just basically I wanted to help people like many people starting out going into the profession, but that's where I started and kept going.

Michael: And when did you decide to take the academic route and then further getting into leadership in an academic setting?

Dr. Carney: Well, I didn't discover public health actually until I was all the way through four years of medical school. I did four years of internal medicine residency and I was the chief resident my final year, and so I'm an internal medicine specialist and then I was seeing patients and ended up in a medical conference and there was something about preventive medicine and public health and I, thought hmm, what's all this? 

One thing led to another, and then I ended up going to public health school and getting a master’s in public health, and that was for me, the ah-ha moment of my career. I love medicine and I loved working with patients but what I discovered was there was this whole other science that I really had no clue about that could prevent disease and illness in entire populations and it was a little bit of ‘who knew’ and why haven't I learned about this yet? So I delved right in, got my master's degree, came back to Vermont and was determined to look for any opportunities in public health. 

Pretty soon after that, about a year after, I became the Deputy Health Commissioner then a year following the Commissioner of Health for the state where I worked for three different Vermont governors both Democratic and Republican and just had the amazing experience and opportunity and awesome responsibility for public health in this wonderful state. So, that's how I ended up there. At the end of that time...I think a lot of physicians or nearly all physicians think of themselves as teachers -- we might teach people one at a time, we might teach students in a classroom or in a small group -- but I was always on the faculty teaching even when I was a state health commissioner. Then in 2003, I came back to UVM and to the College of Medicine full-time and then started my work to bring public health education more to our medical students and then graduate public health education as its own discipline here to the university.

Michael: So, at the beginning of your career, was it unusual for an academic medical center and a College of Medicine to have public health programs?

Dr. Carney: It just wasn't a big part of medical education when I was in medical school. I think that's changing rapidly now and has changed in the past ten, twenty years. Part of it is you think about the evolution of our health systems, right? It used to be we'd have people in solo practice or independent practice. My father was a dentist, and he was all by himself in his office for forty years, but that's changed. First we had larger physician groups and now you have more health systems that might have hospitals and lots of physicians and nurses and really healthcare is more of a team sport, I would say, than it used to be. 

And also some of the configurations cover geographic areas -- the Accountable Care Organizations, the large academic health networks might encompass a smaller hospital and lots of physician practices across a broader geographic area -- so all that lends itself to population health. When we talk about public health and population health, sometimes it refers to population health management...how do you take advantage of a large number of patients in a geographic area and leverage both higher quality care and also preventive medicine and better preventive care. 

So, if you think about that on a practical level, you can look and see what percentage of your patients has an annual flu shot or has their pneumonia vaccine and certainly check for childhood vaccines and things like that. I would say our systems have changed. That's one factor in terms of thinking about the population. Also, many of the public health we have now just intersect medicine and public health. I feel like many days I have one foot in public health and the other foot in medicine and they're all connected. You can think about many such issues like that that we're dealing with today.

Michael: Yeah, well, right, beyond the pandemic, you've got chronic conditions like diabetes and asthma, all the environmental issues. So yeah, that makes sense. That's a nice big picture look at the whole thing. So, what's your elevator pitch, as they say, when you're talking to young people who might be interested in pursuing a career in public health and also getting an advanced degree?

Dr. Carney: Public health has never been more important and we just are hopefully on the backside of that global pandemic, but that doesn't mean there might not be something else just right around the corner. Some of the negatives and the terrible things that we learned in the pandemic was that our public health systems need a lot more strengthening. People talk about cycles of panic and neglect, and that's human nature. It's really hard to be prepared when nothing's happening so we'll just kind of coast along and then something happens, and you may not be ready. We can't afford to do that. The consequences are just too great. We saw in our own country, in addition to the horrendous impact in terms of illness, death and long COVID -- just horrible situations for patients and families and communities -- that access to healthcare is not universal in our country and remains very uneven, and health remains determined by zip code. I think we also saw that our history of systemic racism and vast health inequities were also greatly magnified during the pandemic in many individuals and communities and populations. 

That was the dark side. Was there anything positive? Well, we learned that we can use telehealth, so let's keep using it. Think about a rural state like Vermont. I work with a lot of colleagues in Northern New England and New Hampshire and Maine, and I did a lot of work during the pandemic with our United Way organizations to try and determine what were the worst priorities and what could we do to help? Access to healthcare, access to mental health services, access to substance abuse treatment, access to healthcare for rural populations that is always challenging, was even more challenging, and telehealth and our medical students did a project on this to talk to both health professionals and patients, and everyone thought very highly of telehealth.

So, think about how can we continue to use this to help make healthcare more accessible to more people. For us, sometimes it's the travel and the winter roads or the mud in the spring, but it's also transportation in rural areas. It's also making it more accessible or easier

for more people in more communities to get counseling or substance use treatment. It gives you another option. So, I'm hopeful that we can remember that and keep expanding that in the areas where that makes sense. 

Another area I just mentioned is that I continue to marvel at how fast they were able to develop vaccines related to COVID and we just saw RSV come out, so vaccine development really was phenomenal. Then on the public health side, getting those out to people. And I understand that not everyone is in total agreement about our need for all these and those sort of political controversies, I'll call them, those remain. It was just an amazing scientific feat that just helped so many people. So, that was a really good thing. 

Another was that in some locations here in Vermont, I think that the teamwork and the collaboration between our department of health and people in healthcare and the university and our community organizations couldn't have been better, and I really attribute how well we actually did despite all the illness that we saw and all the terrible consequences for many people, to the fact that we gave it our best. I was really very proud of how we did that. But in many areas of the state and the country, that was not the case which was unfortunate and made me very sad.

In some places, people who worked in public health were almost vilified and really not appreciated in any way. I think the big picture here is that a report in 2021 that said over the last decade, the number of full-time personnel at local and state health departments and public health agencies across the country had declined by about 15%. Based on their projections, working with some others, it said we really need probably an 80% increase -- 80,000 more people -- working in public health. Maybe two thirds of those in local health departments, and a third of those in state health departments are needed to have the basic essentials of public health. So, we have a huge workforce need and that's why public health has never been more important. The issues are so challenging. And if we can, I’ll talk a little bit about the kinds of education you get in public health that helps you address that.

Michael: Yeah, I did want to get to that issue. You talked about telehealth increasing access to healthcare, but online learning also has increased access to education. You've got an online program there at Larner. So, why don't you tell us about the program and what you think differentiates it?

Dr. Carney: We started in about 2011 developing the program. When I came here from my previous work at the Vermont Department of Health, everyone started asking me, when are we gonna have an MPH program? People who aspire to work in public health are clinicians who want to learn those skills. At the time, you had to actually go to a school someplace. So, we talked to a number of people. I worked in partnership with UVM's Continuing Distance Education -- they were just absolutely fabulous -- and the Graduate College. We talked to students and people who wanted the education and we made a strategic decision to develop an asynchronous online program. This was way before the pandemic, before everybody went, ‘Oh my goodness, we have to do this online.’ 

What came out of that was, in order to do that, you had to have a platform and then you had to start thinking about how you do active learning, because in medical education, certainly, and in most kinds of education, we’ve moved away from the “stand and lecture” to something that's way more active and engaging. So, we had to think about how do we do that in an online environment where everyone could be on at the same time, but you don't have to be. We started to experiment with some innovative discussion platforms, and we use those, and students really like them. Our concept of a lecture is, you should not see one longer than fifteen minutes and there's pre-learning and short video, instructor videos, and quizzes to assess your readiness, and lots of sort of smaller chunks of learning and assessment to keep building your fund of knowledge and your skillset or your competencies in these different domains of public health.

I think that the team that we've assembled here...we have instructional designers who are just amazing. Our faculty are amazing. Our faculty are both full-time faculty, and we have part-time faculty who work in very broad domains of public health, like the Department of Health,

or like in environmental public health or epidemiology. I have two public health veterinarians who help us with zoonotic diseases. There's epidemiology and biostatistics. You have to learn the math. Then there's environmental public health...think about climate change and all about that. We have social and behavioral determinants of health, so think about our habits and behaviors, and how we, in healthcare try to influence those one at a time. 

In public health, we step back and say, what are the practices, policies, programs? What can we do to influence, for example, tobacco use? A good example of that would be if you hike the price of cigarettes, it's like a brick wall in front of young people who are just experimenting with them. So, in all likelihood, they won't, right? Think of a variety of strategies. Alcohol falls into that category, certainly all addictions and opioid addiction. Also think about the habits and behaviors we're trying to promote, like people having enough food and access to healthy food, and also being physically active. These are the predictors of longevity in our population too. So, habits and behaviors. Then of course, we learn about our public health systems and our healthcare systems and how we relate. 

So, there's five broad domains and that’s sort of very traditional, but then if you think about today's practice, one of the ones that just cuts across that is communication. Think about how people get information, but think about all the misinformation that we just have been experiencing. In public health, it’s about learning to be excellent communicators -- whether that's in writing or to a group or to individuals -- and then on a population level, what are some of those strategies we can use to try and counter some of that misinformation that unfortunately is out there? I'll stop there, but those are kind of the broad areas of public health.

Michael: Yeah, it's a lot and that's what makes it an appealing career choice because you can go in all of those different directions and each one of them is incredibly important. You know, Vermont is a very rural state. You touched on that before. What do you do to help prepare folks to operate in that environment with all of its challenges?

Dr. Carney: As you asked that question, I thought about some of our medical students who did a project last spring and worked with a community organization in Windham County on healthcare access. It’s a huge issue in the rural areas, so they asked medical students and nursing students, you know, what is it that might attract you to a rural location? And the answer that we got was having experience in a rural location. So, we have to give -- whether in healthcare or public health -- people that experience, because I think that you can't just read about it or study about it or learn about it in the abstract. You have to be able to experience and problem solve. How do you know about that, the health of that community, and what are the different factors from those different domains that we just talked about? How can I make a difference here? 

You know, in public health, I think about connectors. As an example, community health workers -- who are not necessarily doctors and nurses or formally trained in healthcare to that intensity -- can connect people in communities to things like cancer screening, health education, preventive services, all kinds of things. That might be a public health kind of approach to doing that.

Another thing I might mention, and which is a focus of my research right now, is around health communication and health literacy. Here's the idea: think about how we all got information or tried to get information during the pandemic. It was coming at us. It came from government agencies and health departments. It might've come from the news media or social media. It might come from the hospital or academic health center. It might come from university faculty, on and on and on. But when I think about that, I think it's all one way. It's one direction. It's from us to you. So, my question was, how do we know that that's the right way to communicate or that people want to receive that important and potentially life-saving health information in that way? 

One of the things we did when we worked with the United Way about six months into the pandemic was an electronic survey. We asked people, first of all, was there enough health information reaching them? Of course there wasn't, particularly in rural areas. But also, were there differences if you were in a rural area of Vermont or if you were in our -- I use the term loosely -- urban center in Burlington? And the answer was yes. People in Burlington and Chittenden County wanted to receive health information through the internet and Front Porch forum, a local networking platform, and people in the rural parts of our state still like word of mouth, but really like their town papers and Facebook. 

These were all yes, and they reached statistical significance. So, we were like, “Hmm, maybe we should think about this a little bit differently.” If you think about getting that important evidence-based scientific medical health information out to the public, maybe we should start to make sure that we're sending it in a way they want it and that we can start to think about it more like two-way communication, more of how you think about a conversation as opposed to a one-way information flow. 

We're actually trying to do that now with one of the grants that I'm working on. We're working with some older Vermonters in the Support And Services At Home (SASH) program specifically around COVID vaccines and the booster shots and just asking, what do you want to know more about this area? And how would you like us to present that or offer that to you? What they've been telling us is, basically, we want a one pager. We want it to be fun and have cartoons. We want it to be from reputable sources like our health department or the CDC and we want the font to be big enough. I'm like, okay.

Michael: Yeah, this is great.

Dr. Carney: Well, so here it is. So, we've been pilot-testing that idea and we're about ready to offer that same information to some more people to further refine that. But that's the concept anyway. It might look different for different places and rural versus not, versus depending on where you live and maybe what your age is. But the idea is that maybe we could cut through some of this misinformation if we started to think about presenting our science and health information in a way that people want.

Michael: Yeah. Know your audience, right? 

Dr. Carney: Right.

Michael: So, it just seems like communication science is really becoming integral to the science of medicine and public health.

Dr. Carney: Yeah.

Michael: It's kind of unavoidable. We just have a couple of minutes left. We always like to end with having our guests provide their go-to advice for an audience of learners, particularly how to meet some of these huge challenges at this moment. What's your advice for folks navigating through all of that?

Dr. Carney: If you're a student and any of this that we've been talking about interests you, find out more. You can go to our website https://www.uvm.edu/publichealth and you can learn about the kind of content and where that leads you. The good news is that now everyone knows what an epidemiologist is, and there's lots of opportunities. The science and practice of public health is extremely important. It's also very practical. So, learn more about it if you might be interested. What we have here and what is available is students or anybody can take a course, not as a degree student, and try it out. We are in the process of developing -- and we hope we'll have them offered by the first of the year -- these three course packages of areas of public health that are called ‘micro certificates of graduate study’ so that you can learn a chunk of public health and see if that's something that is right for you or might compliment your knowledge. For example, if you're a nurse or if you're in medical school, if these are the kinds of things that might help you broaden your view of the world to include populations and might resonate with you.

Michael: Yeah, that's interesting. Stackable credentials have become a trend as well. 

Dr. Carney: That's right. 

Michael: So, a lot of options, a lot of flexibility. And if folks wanted to learn more, they can go to https://www.uvm.edu/publichealth/

With that, Dr. Carney, I want to thank you very much for taking the time to join us today and also for all the work you have done throughout your career and you're doing now to support public health. We really appreciate your time.

Dr. Carney: Thank you very much for inviting me.

Michael: I'm Michael Carrese. Thanks for checking out today's show and as always, remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.