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Training Physicians For Public Health Careers 4 Funding The public health training of physicians is funded through a number of mechanisms. For example, federal, state and local, and private entities offer education and training at various stages of a physician’s career or at the time a physician enters into the workforce. This chapter discusses some of the many initiatives that are used to finance public health workforce development for physicians through federal, state, and other traditional funding streams. Supplements to these approaches are also described. Ensuring funding adequate to support public health physician education is a major issue for those practicing and seeking to enter the workforce. Furthermore, it is necessary to develop a funding system that accommodates physicians entering the public health workforce at various stages in their careers. The career structure presented in earlier chapters described the education and training pathways that a physician may undertake in pursuit of a career in public health. Each path presents several options for training, and as a result, various funding approaches and mechanisms are needed. Nevertheless, reliable financial support for physician education and training in public health is lacking because the traditional funding sources are plagued by both uncertain funding cycles and dwindling financial support. In addition, the efforts of current funding mechanisms to sustain training programs and activities often lack coordination, and the funding mechanisms do not articulate in a coherent way to support career development.
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Training Physicians For Public Health Careers CURRENT FUNDING APPROACHES Undergraduate training in medicine is supported by a variety of mechanisms, including tuition, guaranteed federal and state loans, and a variety of scholarships. Medical school education provides some experiences in population health through such classes as statistics and epidemiology. In addition, electives in some of the clinical disciplines of public health practice are available through elective rotations in preventive medicine, community medicine, and occupational health. Although this exposure does provide medical students with some understanding of population-based health, it is not at the level that many believe is necessary for all physicians to achieve a basic competency in public health. Postgraduate Training For more than 30 years, the federal government has provided some degree of funding for postgraduate training of physicians. Acting jointly or as a primary funder, the government has influenced the structure of health professions education and training that is needed by funding several programs through the various departments of the federal government. These programs have often served as the primary means for physicians to acquire training in public health and to prepare them to enter the public health workforce, but few data exist on the number of physicians trained and the amount of funds allocated to their training. The financing of postgraduate education for most physicians is primarily supported through Medicare Graduate Medical Education (GME). GME has two specific payment mechanisms that offer payments for education in the clinical environment: a direct GME payment that partially compensates the teaching institution for the cost of residency training and an indirect GME payment that partially compensates the teaching institution for the higher patient care cost because of the presence of medical residents. As the largest explicit contributor of GME, the Medicare program spent nearly $8 billion in fiscal year (FY) 2004 for residency education and training (GAO, 2006). Preventive medicine residency programs (costing an average of $108,000 per resident/year [ACPM, 2005a]) typically do not receive Medicare GME funds, as most programs do not qualify for direct medical education reimbursement because preventive medicine residency training tends to occur in nonhospital settings, for example, in state and local health departments, leaving such nonclinical programs to scramble for resources. Direct medical education costs usually include salaries and fringe benefits for residents, compensation for the faculty who supervise the residents, program administration costs, and allocated institutional overhead costs associated with graduate medical education (Bruccoleri,
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Training Physicians For Public Health Careers 2005). Typically, the teaching hospital or clinic employing the resident incurs these costs. Traditionally, teaching hospitals have been the site for residency education and training, and patient care revenues support the majority of funding for graduate medical education (COGME, 2000), but in general, because preventive medicine residency training tends to occur in nonhospital settings, such training is not supported through the GME funding mechanism. Because the majority of preventive medicine residency programs receive minimal funding through Medicare GME assistance, the programs are often faced with the issue of how to adequately support their residents. Indeed, insufficient funding has frequently been cited as the chief reason for the decline in preventive medicine residency positions. Funds for preventive medicine residency programs are therefore obtained from a variety of sources, some of which have unpredictable funding cycles, potentially affecting the recruitment and retention of high-quality candidates (ACPM, 2005b) As a result, most preventive medicine residencies rely heavily on funding from programs of the federal Health Resources and Services Administration (HRSA) and other funding sources. TITLE VII: A NATIONAL TRAINING RESOURCE The workforce development programs supported under Title VII of the Public Health Service Act (42 U.S.C.) have been instrumental in the training of physicians and other health care professionals. Administered by HRSA of the U.S. Department of Health and Human Services (DHHS), Title VII was first enacted in 1963 as part of the Health Professions Educational Assistance Act (Public Law 88-129) in response to a shortage of health manpower. The purpose of Title VII was to increase the rate of enrollment in and the financial viability of health professions schools. The act authorized the financing of programs to enhance public health workforce training through (1) institutional grants and contracts and (2) assistance in the form of loans, loan guarantees, and scholarships for students enrolled in these schools. Programs constructed under Title VII supported physicians, general dentists, physician assistants, and allied health personnel by providing institutional grants for training, financial assistance to students, and funding for analyses of the health workforce (GAO, 1994). As the workforce needs changed, amendments to the Public Health Service Act expanded the focus of programs funded under Title VII to enhance minority representation, encourage the distribution of health professionals to rural or medically underserved areas, increase the number of primary care providers, and develop faculty in institutions. In more recent years, Title VII programs have funded efforts for the education of providers, education of the public health workforce, and the analysis of health workforce issues (GAO, 2006).
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Training Physicians For Public Health Careers In the 1992 reauthorization of the title, emphasis was placed on increasing the number of health care professionals practicing in underserved areas, and programs were specifically created for this purpose. In 1998, the U.S. Congress consolidated Title VII programs into six clusters to ensure greater administrative flexibility and simplification of the program structure. The cluster created specifically for the public health workforce sought to strengthen the workforce capacity through support of public health training, preventive medicine residencies, public health dentistry, and health administration programs (GAO, 2006). The following provides an overview of the Title VII programs relevant to physician training in public health. Title VII Public Health Workforce Programs A number of programs were established through the Public Health Service Act to increase the supply of well-trained physicians and health professionals in the public health workforce. The provisos of Title VII included the authorization of grants to institutions of medicine, osteopathic medicine, and public health for the development and maintenance of health professions education and training programs. Of particular interest, the legislation details the funding for preventive medicine residency programs, public health training centers, and public health traineeships. Table 4.1 provides an overview of the programs relevant to physician training. The legislation outlined the following approaches that should be taken to strengthen preventive medicine residency programs: (1) plan and develop new residency training programs, (2) maintain or improve existing residency training programs in preventive medicine, and (3) TABLE 4.1 Title VII Health Professions Programs Relevant to Physician Training Program Name Program Description Recent Funding History Overall Public Health Workforce Development Training The Health Professions programs in this cluster work to strengthen the education and training of health professionals in the areas of public health, preventive medicine, and dental public health. Eligible entities are awarded grants to carry out education and training activities that address workforce needs. 2002: $10.47 million 2006: $7.92 million
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Training Physicians For Public Health Careers Program Name Program Description Recent Funding History Preventive Medicine Residency Training Grants Program This program provides funding for preventive medicine residency programs in accredited public or nonprofit private schools of allopathic medicine, osteopathic medicine, and public health across the United States. In addition to supporting preventive medicine residents, HRSA grants go toward the planning and development of new residency programs and the maintenance of existing programs on a 3-year cycle. 2002: $1.96 million 2006: $1.25 million Public Health Training Center Grant Program Partnerships between accredited schools of public health and related academic institutions and public health agencies and organizations offer training to a number of public health workers, including physicians. The centers provide training through distance learning applications and other educational tools that are tailored to workforce learning needs. Fourteen centers currently service public health workers in 44 states and the District of Columbia with tools to strengthen workforce capacity. 2003: $5.5 million 2006: $4.3 million Public Health Traineeship Program Through the Public Health Traineeship Program, grants are awarded to accredited schools of public health and other public or nonprofit private institutions accredited to provide graduate or specialized training in public health (HRSA, 2006c). The awards support selected students in areas such as epidemiology, environmental health, biostatistics, toxicology, nutrition, and maternal and child health. 2002: $1.82 million 2006: $1.23 million
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Training Physicians For Public Health Careers provide financial assistance to residency trainees enrolled in the programs (Public Health Service Act, Title VII, §768, 42 U.S.C. 295(c)). Currently, Title VII funds represent a critical source of funding for preventive medicine residency programs, as the annual funding from HRSA represents the largest federal financing source for public health and general preventive medicine (PH/GPM) programs (ACPM, 2005b). In FY 2005, the Preventive Medicine Residency Training Grants Program managed by HRSA (through the Bureau of Health Professions) supported 31 preventive medicine residents in seven academic institutions. The program operates under a 3-year grant cycle, with only 7 of the potential 40 PH/GPM residencies receiving awards for FYs 2004 through 2007. Funding for the residency programs has declined annually from $1.96 million in 2002 to $1.25 million in 2006 (HRSA, 2006b), without adjustment for inflation. In 2005, 31 residents were in training and 36 had either graduated or completed their training (Raggio, 2006). In addition to Title VII, current financial support for PH/GPM programs is provided by institutional funds, state and local agencies, voluntary health agencies, the U.S. Department of Veteran Affairs, foundations, and private corporations (Lane, 2000). Another program supported by Title VII funding is the Public Health Training Center Grant Program. Established under the Health Professions Education Partnerships Act of 1998 (Public Law 105-392), the training centers were created to strengthen the technical, scientific, managerial, and leadership competencies of current and future public health professionals. The centers are partnerships between accredited schools of public health and related academic institutions and public health agencies and organizations that train workers in a range of professions, including physicians and other clinicians. Currently, 14 centers serve the public health workforce in 44 states and the District of Columbia (HRSA, 2006e). Within the last few years, 93,278 public health workers representing more than 17 public health disciplines have been trained through this initiative (HRSA, 2006e). The majority of trainees use the distance-based applications provided by the centers, and more than 86 percent of all training offers competency-based instruction (Raggio, 2006). In FY 2003, the centers received a total of $5,500,000 for program activities (Federal Grants Wire, 2006b). Funding was reduced to $4,302,000 in FY 2006 (Raggio, 2006). The Title VII legislation also authorizes funds to support public health traineeships in graduate health education programs for the provision of graduate or specialized training in public health. Schools of public health and other public or nonprofit private institutions receive grants to provide traineeships that target those public health fields with personnel shortages, such as epidemiology, environmental health, biostatistics, toxicol-
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Training Physicians For Public Health Careers ogy, nutrition, and maternal and child health. The students are selected by the awardee institutions, which are encouraged to increase minority representation and the number of graduates who serve in underserved areas (HRSA, 2006c). In FY 2002, 37 grantees were awarded a total of $1,822,957 appropriated for program activities (Federal Grants Wire, 2006a). By FY 2006, however, the financial assistance awarded to grantees for program activities totaled $1,232,510 (HRSA, 2006d). The traineeships, together with the training centers, seek to increase the number of qualified public health workers by providing the most up-to-date information and tools. Unfortunately, budget cuts continue to threaten these and other Title VII programs. Overall funding levels for HRSA health professions program budgets have steadily declined over the years. More recently, between FYs 2002 and 2006, funding for public health, preventive medicine, and dental public health programs decreased by nearly a quarter, starting at $10,473,000 in 2002 and decreasing to $7,920,000 in 2006 (HRSA, 2006a), as shown in Table 4.2. Although funding for these and other Title VII programs increased after the 1998 reauthorization, the funding for public health workforce development programs received only a slight increase, with the majority of funds flowing to Health Professions Training for Diversity (GAO, 2006). Over the past two decades, both Democratic and Republican administrations have recommended major reductions in funding, only to have the U.S. Congress reinstate critical funds to sustain program activities (Freeman and Kruse, 2006). Lawmakers have argued that Title VII programs support capacity building at the state and local levels and can be sustained through collaborative efforts between and among health departments, educational institutions (schools of public health and residency programs), community-based initiatives, and the private sector. TABLE 4.2 Health Professions Program Funding Levels, FYs 2002 to 2006 FY Funding Level ($) 2002 10,473,000 2003 10,600,000 2004 9,170,000 2005 9,097,000 2006 7,920,000 SOURCE: Adapted from Fiscal Year 2007 Justification of Estimates for Appropriations Committees: Health Professions (HRSA, 2006a).
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Training Physicians For Public Health Careers Nevertheless, existing funding from other federal sources, such as that from the U.S. Departments of Defense, Labor, and Veteran Affairs, has been cited as a key factor in the decision of various administrations to eliminate Title VII funding for health professions (HRSA, 2006a). For FY 2007, the U.S. Senate Appropriations Committee approved $154.4 million for Title VII health professions education programs, including $8 million for public health, preventive medicine, and dental public health programs, restoring the funding to FY 2006 levels (AAMC, 2007). In its report, the Senate Committee commented on the continued need for public health training and the contributions of HRSA-administered public health workforce development programs in sustaining the nation’s public health infrastructure (U.S. Senate Appropriations Committee, 2006). Despite this recognition by the U.S. Senate, the future of Title VII remains unclear. The decreases in funds for Title VII programs have meant the reduction or elimination of vital public health training opportunities. Even though Title VII provides funds for essential training and educational services, Title VII alone cannot sustain public health training for physicians. Other funding mechanisms and approaches must be developed and strengthened to prepare public health physicians for their roles in the workforce. OTHER FEDERAL FUNDING While Title VII supports a large portion of public health training for physicians, several other agencies and groups have actively supported training efforts at various stages of physician engagement in public health. Among these, federal agencies such as the U.S. Departments of Defense and Veterans Affairs provide financial support for preventive medicine residency programs as well as health professions training. The following sections describe these mechanisms in greater detail and their implications for public health training of physicians. U.S. Department of Veterans Affairs The U.S. Department of Veterans Affairs (VA) serves as a major funder of graduate medical education, financing about 9 percent of all U.S. residency positions (VA, 2006). In 2004, VA spent $493 million on education and training programs for health professions students and residents (GAO, 2006). Approximately 28,000 medical residents along with 16,000 medical students receive a portion of their training through the VA each year (VA, 2006). Through its affiliations with schools of medicine and institutional medical centers, VA currently supports about 27 percent of all
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Training Physicians For Public Health Careers preventive medicine residents and approximately 11 percent of occupational medicine residents at 18 Veterans Affairs Medical Centers (Veterans Health Administration, 2007). However, a VA primary care initiative has converted about 1,000 GME specialty residency positions to generalist positions within VA, with the result that preventive medicine residency programs must now compete with other primary care programs for funds from a common source (Lane, 2000). U.S. Department of Defense Preventive medicine residency training is the primary means of public health training in the military, and these positions are fairly well funded. The National Capital Consortium of the Uniformed Services University of the Health Sciences is “currently capitated at about $12,000 per resident per year”1 for its general preventive medicine residency program. The U.S. Department of Defense also supports medical education and other health professions through the Defense Health Program (DHP) for active-duty personnel, civilian medical personnel, and students. In 2004, DHP funding for health professions education totaled $318 million (GAO, 2006). Within DHP, the Armed Forces Health Professions Scholarship Program (HPSP) provides financial assistance and training to health professions students and serves as the primary source of trained health care professionals entering the armed forces. Created under the authority of the Uniformed Services Health Professions Revitalization Act of 1972, HPSP was designed to ensure that adequate numbers of commissioned officers with health profession qualifications are on active duty. The program is supported by the U.S. Army, Navy, and Air Force and subsidizes the costs associated with training for the majority of candidates entering health professions programs. HPSP provides financial assistance to students in accredited graduate programs, including medicine, osteopathy, veterinary medicine, optometry, psychology, and other accepted disciplines (Naval Education and Training Command, 2005; U.S. Army, 2006). Epidemic Intelligence Service The Epidemic Intelligence Service (EIS) program of the Centers for Disease Control and Prevention (CDC), like many federal programs, operates with funds appropriated by the U.S. Congress. Currently, the EIS program supports 160 EIS officers, with the funding for each of FY 2006 1 Personal communication, R. D. Bradshaw, National Capital Consortium (NCC)/ Uniformed Services University (USUHS), March 9, 2007.
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Training Physicians For Public Health Careers and FY 2007 being $18.9 million (CDC, 2007b). Training costs for the EIS program are dependent on two separate personnel systems that are used to hire EIS officers: the Title 42 Civil Service Fellows program and the Commissioned Corps program. The costs for the first year of this 2-year on-the-job training program range from $105,000 for Civil Service Fellows to nearly $139,000 for members of the Commissioned Corps; in the second year the costs are $98,000 for fellows and nearly $129,000 for the members of the corps. These figures include the costs associated with on-site training, travel to assignments, salary, and benefits, in addition to other expenses.2 OTHER FUNDING MECHANISMS Governments at all levels have always made some contributions to the initial public health education, as well as continuing education and on-the-job training, of public health personnel, although governmental contributions have dwindled in the past few decades. Nevertheless, special issues are related to attracting physicians with appropriate training to careers in public health: the initial training period is long and arduous; undergraduate medical education often leads to the accumulation of substantial personal and family debt; tuition for master of public health or equivalent degrees, as for other graduate programs, has been increasing rapidly; and salaries in public health jobs are generally lower than those for other physician practice options, including academic positions. To mitigate this problem and to continue to attract physicians into public health jobs, financial as well as other incentives need to be in place. It should be noted that all agencies at all governmental levels bear some responsibility for maintaining the quality of their workforces and should contribute to this responsibility, as should the private sector. State Funding Other sources of funding for public health training activities and programs are the states, which have long supported public health training and medical education. By offering loan subsidies and scholarships to medical students and physicians in training, the states have worked to increase the number of physicians in underserved areas. Since the 1940s, individual states have provided this support to students and have also provided some level of institutional support (HRSA, 2000). Health departments serve as the primary source of funding for public health training in states. Partnerships with academic institutions, federal 2 Personal communication, D. Koo, Centers for Disease Control and Prevention, March 13, 2007.
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Training Physicians For Public Health Careers agencies, public health training centers and institutes, community-based organizations, and other parties enable the states to provide the necessary skills-building training and continuing education activities. However, many states fall short of providing adequate training for their public health workforces, as other activities and needs compete for limited resources. Greater collaboration among new and existing funders is thus essential to increasing the number of competent physicians in the public health workforce. Certificate Courses and Continuing Education Certificate courses and continuing education are designed to give physicians specific training in public health. These mechanisms offer brief training over periods ranging from weeks to months and are generally offered by a variety of schools of public health, federal public health agencies, and private nonprofit organizations. The cost for this training is usually borne by the individual or the individual’s employer. On occasion, the CDC may provide some support for participation in programs, such as programs on leadership development, epidemiology, and bioterrorism. This form of training is an important resource for ensuring that people interested in public health careers maintain and learn new skills. Additionally, it is critical as a learning mechanism for physicians who move into the public health workforce from other specialties. However, the funding for these programs is eroding. In FY 2007, CDC Public Health Improvement and Leadership activities received approximately $189.2 million for leadership and management and public health workforce development, a $74 million decrease from the previous fiscal year (DHHS, 2007). Funding for public health workforce development activities in particular has remained relatively constant over the past few fiscal years, with programs receiving approximately $19.7 million (CDC, 2007a). RECOMMENDATIONS Although training programs are a necessary component for ensuring an adequate supply of well-trained public health professionals, these programs cannot do it alone because serious challenges to attracting the necessary numbers of qualified physicians remain. The money-saving decisions made by many local governments have severely restricted the employment of physicians in health departments, confining them to clinical roles or those required by law and restricting them to working for the minimum number of hours legally possible. The importance of physician contributions to all public health policies has been diminished as the qualifications for agency leadership have expanded to include other
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Training Physicians For Public Health Careers public health practitioners. Furthermore, once a public health physician position has become less than full time, attention to public health preparation for the incumbent may be minimal. The distribution and size of governmental public health agencies also mean that many public health physicians work in relative isolation from their peers. All of these forces in combination mean that there are insufficient numbers of funded positions for part-time and full-time public health physicians. Furthermore, the salaries of public health physicians are significantly lower than those of their counterparts in private practice. Reliable financial support for physician education and training in public health is also lacking at the agency level, as traditional funding sources are plagued by limits on educational investment, uncertain funding cycles, and dwindling support. All of these challenges are more noticeable at the state level than at the federal level and are particularly acute at the local level, especially outside of urban areas. Finally, other practical barriers to entering public health professions exist for physicians. For many students studying to be physicians, their first introduction to public health may be after they are well into their medical school training, making it difficult to redirect their professional paths. Alternatively, when a physician who is already trained in medicine encounters the challenges and the potential of public health at mid- or late career, the lack of flexible training opportunities makes the development of the needed competency extremely difficulty. Several actions are necessary to facilitate physician training in public health and to maintain an adequate public health physician workforce. First, the committee endorses the recommendation in the report The Future of the Public’s Health (IOM, 2003) that the U.S. Congress increase funding for HRSA programs that provide financial support for students enrolled in public health degree programs and that the funding for Public Health Training Centers be increased. The committee recommends that the U.S. Congress fund a comprehensive educational strategy sufficient to produce the additional number of public health physicians required through the following mechanisms: Funding for residency training in public health should be equivalent to and parallel the funding streams for graduate medical education in other medical disciplines. Funding to support the recommended expansion of the EIS and AHD programs. Reinstatement and growth of funding for health professions training through the Title VII programs. Congress fund Health Resources and Services Administration and the Centers for Disease Control and Prevention to work
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Training Physicians For Public Health Careers collaboratively to develop model demonstrations and evaluation programs that explore other models than direct physician hiring by health agencies. Such models might include regional physician health agency groups, development of public health expertise in larger health systems, or creation of a national network of consultants in specific public health domains. agencies, particularly state and local public health departments, create and adequately fund additional public health physician positions (full- and part-time) to accommodate the 10,000 additional public health physicians required. the American College of Preventive Medicine, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the U.S. Department of Health and Human Services, and the federal Office of Personnel Management regularly conduct a salary assessment of governmental public health and comparable private sector physicians. The agencies should use these results to align the salaries of their public health physicians to parity with private sector physicians performing comparable work. federal, state, and local public health agencies develop loan forgiveness programs for physicians who enter and continue to work in the public health sector. federal, state, and local public health agencies develop (or expand existing) programs that support public health training for physician employees in exchange for continued employment in that agency. employers of physicians in the public health workforce develop incentives to recruit and retain public health physicians that include discretionary benefits (e.g., leave, continuing education and conference support, portable retirement, etc.); career development support, based upon statewide or regional analysis of long-term public health physician needs across agencies, with support for further graduate training to physicians who agree to remain in public health, potentially moving to more responsible or more technically demanding positions over time; and opportunities for increased professional interaction for public health physicians practicing in remote or isolated circumstances. federal and state governments develop tax incentives for individuals who train and enter governmental public health.
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Training Physicians For Public Health Careers CONCLUSION Physicians play key roles in ensuring the public’s health and helping sustain the public health system. However, the availability of adequate funding for education, training, and related resources is crucial to building and maintaining sufficient numbers of public health physicians. Maintaining important key academic and job-related training programs and resources is a tremendous challenge, given frequent budgetary cuts in current funding mechanisms at the federal, state, and local levels. Similarly, a lack of funding and support continues to compromise the recruitment and retention of high-quality physicians in training for preventive medicine residency programs. The funding for these and other mechanisms is overstretched, and supplemental funding is needed to maintain an adequate number of well-trained public health physicians. The committee strongly believes that these challenges must be met through a collaborative effort among stakeholders to maintain and expand existing programs and key leadership and programmatic positions in public health agencies, assess the salaries of public health physicians so that they are congruent with the salaries of individuals in similar positions in the private sector, and create incentives for physicians to enter the public health sector. Without adequate funding, sufficient numbers of public health physicians will not be engaged in keeping the public healthy. REFERENCES AAMC (Association of American Medical Colleges). 2007. Health professions programs, FY 2007. http://www.aamc.org/advocacy/library/laborhhs/tables/2007/hped.htm (accessed March 22, 2007). ACPM (American College of Preventive Medicine). 2005a. ACPM Board of Regents meeting/ communication. Preventive medicine residency costs. Washington, DC: American College of Preventive Medicine. ———. 2005b. Statement of the American College of Preventive Medicine: Submitted to the Labor, Health and Human Services, Education, and related agencies Subcommittee Committee on Appropriations United States House of Representatives for the record on fiscal year 2006 appropriations. Washington, DC: American College of Preventive Medicine. Bruccoleri, R. E. 2005. Graduate medical education funding. Reston, VA: American Medical Student Association. CDC (Centers for Disease Control and Prevention). 2007a. Budget request summary fiscal year 2008. Atlanta, GA: Centers for Disease Control and Prevention. ———. 2007b. Centers for Disease Control and Prevention: Fiscal year 2007 A-Z fact sheet: Epidemic Intelligence Service. Atlanta, GA: Centers for Disease Control and Prevention. COGME (Council on Graduate Medical Education). 2000. Fifteenth report: Financing graduate medical education in a changing health care environment. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration.
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Training Physicians For Public Health Careers DHHS (U. S. Department of Health and Human Services). 2007. Fiscal year 2008 congressional justification for the Centers for Disease Control and Prevention. Washington, DC: U.S. Department of Health and Human Services. Federal Grants Wire. 2006a. Public health traineeships. http://www.federalgrantswire.com/public_health_traineeships.html (accessed May 11, 2006). ———. 2006b. Public health training centers grant program (93.249). http://www.federal-grantswire.com/public_health_training_centers_grant_program.html (accessed May 12, 2006). Freeman, J., and J. Kruse. 2006. Title VII: Our loss, their pain. Annals of Family Medicine 4(5):465-466. GAO (U.S. Government Accountability Office). 1994. Health professions education, role of title VII/VIII programs in improving access to care in unclear. GAO/HEHS-94-164 ed. Washington, DC: U.S. Government Accountability Office. ———. 2006. Health professions education programs, action still needed to measure impact. GAO-06-55 ed. Washington, DC: U.S. Government Accountability Office. HRSA (Health Resources and Services Administration). 2000. Graduate medical education and public policy: A primer. Washington, DC: National Conference of State Legislatures (NCSL). ———. 2006a. Fiscal year 2007 justification of estimates for appropriations committees: Health professions. http://www.hrsa.gov/about/budgetjustification07/publichealthworkfor-cedevelopment.htm (accessed May 11, 2006). ———. 2006b. Preventive medicine residency training grants program. http://bhpr.hrsa.gov/publichealth/preventive/index.htm (accessed February 10, 2006). ———. 2006c. Public health traineeship. http://bhpr.hrsa.gov/publichealth/phtrainee.htm (accessed May 11, 2006). ———. 2006d. Public health traineeship—fiscal year 2006. HRSA. http://granteefind.hrsa.gov/searchbyprogram.aspx?select=A03&index=149 (accessed March 25, 2007). ———. 2006e. Public health training centers. http://bhpr.hrsa.gov/publichealth/phtc.htm (accessed May 4, 2006). IOM (Institute of Medicine). 2003. The future of the public’s health in the 21st century. Washington, DC: The National Academies Press. Lane, D. S. 2000. A threat to the public health workforce: Evidence from trends in preventive medicine certification and training. American Journal of Preventive Medicine 18(1):87-96. Naval Education and Training Command. 2006. Health professional scholarship programs. http://www.nomi.med.nacy.mil/pages.nmetc/hpsp/index.htm (accessed October 30, 2006). Raggio, T. P. 2006. Training physicians for public health careers. Paper presented at First Meeting of the Committee on Training Physicians for Public Health Careers, Washington, DC. U.S. Army. 2006. Health professions scholarship program factsheet. http:www.goarmy.com/amedd/docs/hpsp.pdf (accessed October 31, 2006). U.S. Senate Appropriations Committee. 2006. Departments of Labor, Health and Human Services, and Education, and related Agencies Appropriation Bill, 2007: Senate Report 109-287: U.S. Senate. VA (Department of Veterans Affairs). 2006. Graduate medical education. http://www.va.gov/oaa/GME_default.asp (accessed June 3, 2006). Veterans Health Administration. 2007. VA preventive medicine residency programs and sponsors. Washington, DC: Office of Academic Affiliations, Veterans Health Administration, Department of Veterans Affairs.
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Representative terms from entire chapter: