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Choosing Your Path: Internal Medicine, Public Health
Mark A. Levine, MD, MACP
Specialty or subspecialty: IM but current position Commissioner of Health, State of Vermont.
Residency training: Medical Center Hospital of Vermont (now UVM Medical Center), Burlington, VT.
Fellowship training: Fellowship in general internal medicine and pediatrics, University of North Carolina at Chapel Hill.
Practice setting: Academic general internal medicine practice until assuming current position in March, 2017 (see below).
Years in practice: 34.
In a given week, what nonclinical duties do you have outside of patient care? In March 2017, it was my privilege to accept the position of Commissioner of Health for the state of Vermont when asked by Governor Phil Scott. This created the need to transition my practice to my partners and give up my administrative duties at the medical center and College of Medicine. However, I have continued to teach regularly, facilitating Morning Report several times per month and conducting student Professor Rounds weekly (where we would often see patients as well before the pandemic). My current position allows me to be at the nexus of where health care, health, public health, population health, and health policy all meet. With health care (which only determines about 10% of health) being the least of those components but where my insights from my career allow me to forge important partnerships and collaborations, I hope to advance both health and clinical medicine. What I once practiced on a one-on-one basis, often waiting years or decades for patients to make lifestyle changes, I now have the opportunity to see occur on a population-wide basis, made possible by the incredible dedication and passion of my public health workforce and the impact of policy changes that we have influenced all branches of government to enact. Examples include: preserving the brains of our youth through tobacco and vaping legislation and reducing exposure to lead in school drinking water; impacting the health of mothers and their newborns through home visiting programs; reducing population and childhood obesity and chronic disease development through programs that make the default choice the healthy choice in nutrition and physical activity; policies and programs that impact substance misuse; and developing strategies that facilitate healthy aging. Finally, we have all been taught that doctor comes from the Latin docere, to teach. I am now frequently speaking in press conferences or on the news or asked to give talks at medical events or courses, allowing me to teach more broadly.
The most challenging and rewarding aspects of caring for patients in your specialty or subspecialty: During my years of practice, the rewards were clearly the development and cultivation of long-term relationships with my patient population, developing a holistic style of practice (Engel’s “biopsychosocial framework”), solving complex diagnostic dilemmas, participating in the breadth of IM, engaging in problem solving with my colleagues in the practice, and practicing prevention and assisting my patients in lifestyle behavior change. Challenges included time management while trying to be comprehensive, dealing with system and governmental accountability demands in the context of each visit, trying to still communicate effectively while meeting the expectations of the EMR, being available to my patients in the midst of a complex schedule, having to demonstrate my competence in specialty care and balancing caring for all of my patient’s needs to some of my subspecialty colleagues.
What is the most important clinical skill in your daily practice? I believe the skill set that sets internists apart from others and defines us is our clinical reasoning/critical thinking/data synthesis abilities delivered in a framework of empathy, compassion, integrity, and professionalism.
What characteristics, or personal qualities, help you most in your specialty/subspecialty (e.g., being unafraid to ask probing questions)? All of the above.
How do you feel about the balance of your professional and personal lives? During my academic career, the challenges of practice, teaching, and administration of educational programs (IM Residency Director, then in later years Associate Dean for GME) provided challenges to this balance, but the professional and personal rewards were immense. In my current position, similar challenges occurred but less frequently—until 2020, when all sense of balance has been lost. (But who could have predicted I would help lead our state’s effort in facing a once-in-a-century pandemic? And it has truly been an honor to do so.)
Advice for diverse medical trainees in your specialty/subspecialty: 1) General IM: Do not let loan repayment and “stature” interfere with your career decision. You want career gratification over the long term, and this field can provide it. Always go with your passion, whether that be as a generalist or in a specialty. Also, “lifelong learning” is more than a catchphrase and on its own keeps such a career full of opportunities and freshness. And prevention will really become of paramount importance as our profession embraces the dual goals of the Triple Aim and health care reform. 2) Public health: The critical need to better integrate health, public health, and medical care is increasingly being understood by diverse audiences (and hopefully your medical school instructors and leaders). I urge you to find ways to best accomplish such integration as your career unfolds, first slowly but later with increasing intention.
What resources do you suggest for trainees interested in your specialty/subspecialty (books, podcasts, articles, websites)? Resources that point out health inequities or where medicine has either been part of the problem or lack of integration has been the problem. Examples include When the Spirit Catches You and You Fall Down, Dreamland, and Hillbilly Elegy.
What is your motto, or favorite saying, to describe your life in this specialty? A question I often ask students and residents when confronting them with a challenging health care scenario or differential diagnosis: Do you have a systematic approach to this problem? That way, it removes the photographic memory component to problem solving (which most of us don’t have) and reinforces the need for critical thinking skills.