Dharam J Kumbhani explains how studying epidemiology has influenced his clinical practice

What does a formal training in epidemiology entail? I came to the Harvard School of Public Health to do my masters degree in clinical epidemiology right after medical school. Many people found this appalling, mainly because I was expected to follow the general trend of completing medical school and getting a good house job--like most medical students. A disbelieving aunt thought that it meant that I was going to become a skin specialist.

Epidemiology programmes, at least in the United States, are mainly offered by schools of public health. Most schools require students to have taken the graduate record examination and the test of English as a foreign language, if applicable. The courses are usually a blend of epidemiology and biostatistics (box 1). You gradually begin to understand how all the numbers and ubiquitous P values in the BMJ find their way there. As part of a clinical research team, you may never be called upon to do these analyses yourself. But it helps to have a working knowledge of things.

Box 1: Core courses

* Epidemiology:Introduction and basics of epidemiology
* Design and analysis of case-control and cohort studies
* Basics and methods of clinical research
* Biostatistics:Introduction and principles of biostatistics
* Applying biostatistical principles to clinical research (eg, regression methods, survival analysis, meta-analysis)
* Applications and use of biostatistical software packages (SAS, STATA, SPSS, EpiInfo)

Substantive courses (area of interest)
* Cardiovascular epidemiology
* Cancer epidemiology
* Molecular or genetic epidemiology
* Nutritional epidemiology
* Infectious disease epidemiology
* Environmental or occupational epidemiology
* Pharmacoepidemiology
* Reproductive epidemiology
* Psychiatric epidemiology
* Others (dental epidemiology, etc)

Other public health related courses (optional, if interested)
* Health policy and management
* Health finance and economics
* International health
* Environmental health
* Health ethics and human rights
* Maternal and child health
* Law in public health
* Social medicine

Box 2 shows the directions you can take after completing a masters degree programme. My own driving force for doing the programme was to be able to understand medical literature in greater detail, to do my own clinical research, and to evolve my medical reasoning in line with the ideology of evidence based medicine. I also find that there is a different appeal in interacting with patients after studying epidemiology; it broadens your understanding of health issues at a population level. You also develop a slightly preventive based approach to medicine compared with the aggressive diagnosis and treatment based approach that exists in the current era of specialised care.

Box 2: Options after a masters degree in clinical epidemiology

* Academic medicine (clinical work along with clinical research)
* Full time clinical research
* Doctoral degree
* International agencies
* Government agencies
* State and regional public health agencies
* Pharmaceutical industry
* Consultancy
* Teaching

How can you practise evidence based medicine using epidemiological methods? You could generate hypotheses in topics of your interest and collect data from patients, either prospectively or retrospectively. Say you are an obstetrician--are hypertensive Asian mothers who smoke more likely to have low birth weight babies than normotensive white mothers who don't smoke? You could compare your results with that of published studies and perhaps tailor your approach accordingly. You may thus want to treat hypertension more aggressively in pregnant Asian mothers and try harder to convince them to quit smoking, at least for the duration of pregnancy. We are obviously not talking about drastic overhauls in clinical practice here, just subtle variations and customised treatments. This may not seem like much, but this simple step makes you a clinician practising evidence based medicine.¹ Your approach to patients is now more scientific, more specific, and less mechanical.

If you take the opinion of senior clinicians about a confusing case or management protocol, they often say, "From my experience, this is probably XYZ," or "I have seen ABC work in most patients with this disease." This actually means that the evidence that they have accrued over many years of practice slants their choice of diagnosis and treatment in a particular direction--a primitive form of evidence based medicine. So, it would help if you could scientifically inculcate these skills right at the beginning. You learn not only from your own experiences but from those of others around the world.

Some more thoughts about clinical research: as a clinical researcher involved in clinical trials you may have the exciting experience of being involved in a product that is a breakthrough in treating specific diseases. When this happens you will feel that you have contributed to medicine and to the community. Value can also be derived from testing "me too" products. On getting involved in a trial, you are likely to be educated and ultimately know much more about the disease. This can be good for you--in the opinion of many senior doctors who have got involved in clinical research, this helps build your practice.³ Moreover, the work that you end up presenting or publishing will add to the information pool on that particular topic.

Investing a year or two in getting a degree in epidemiology before embarking on a career in clinical practice is a great idea. Many other authors feel the same way.^{3 4 5} I strongly encourage students who want to set themselves apart from the multitudes of internists, surgeons, and obstetricians to think about this seriously. Let this be your first evidence based decision, and see for yourself how your outlook and approach to clinical medicine changes once you acquire these skills.

Further reading

1. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practise and Teach EBM. Churchill Livingstone: Edinburgh, 2nd edition, 2000.
2. Greenhalgh T. How to read a paper: the basics of evidence based medicine. London: BMJ Publications; 1997.
3. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology. A basic science for clinical medicine. Little, Brown: Boston, 1991.
4. Bassand JP, Martin J, Rydén L, Simoons M: The need for resources for clinical research: the European Society of Cardiology calls for European, international collaboration. Eur Heart J. 2003;24:1171-3.
5. Academy of Medical Sciences. Resuscitating clinical research in the United Kingdom. BMJ 2003;327:1041- 3.

Dharam J Kumbhani, research fellow, Harvard Medical School, USA
Email: dharam@post.harvard.edu

studentBMJ 2004;12:393-436 November ISSN 0966-6494

References:

1. Okasha M. Epidemiology – who cares? studentBMJ 2001;9:226-7.( July)
2. Okasha M. Epidemiological research. studentBMJ 2001;9:277-8.( August.)
3. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Scott Richardson W. Evidence based medicine: What it is and what it isn't. BMJ 1996;312:71-2.
4. Sharon E Straus, The Editors. Evidence-based medicine in practice. Evid Based Med May 01, 2002;7:68-69.
5. Ginsberg D. Should you become a clinical investigator: The investigator’s guide to clinical research. Center Watch, Inc, Boston, 2nd edition, 1999:3-16.
6. Nguyen-Van-Tam JS, Logan RFA, Logan SAE, Mindell JS. What happens to medical students who complete an honours year in public health and epidemiology? Med Educ 2001;35:134-6.
7. Evered DC, Anderson J, Griggs P, Wakeford R. The correlates of research success. BMJ 1987;295:241-6.
8. Stewart PM. Improving clinical research. BMJ 2003;327:999-1000.

I totally agree with the author in the sense of the importance of epidemiology and more general public health. As a fresh graduate from medical school who is doing research, I must say that unfortunately public health is not emphasized and taught enough in the medical school curricula. I can at least talk about my home country Turkey. Instead of trying to combine public health as a class and a department within the medical school, here in United Stated they are seperate graduate schoolsn where people can get degrees like MSc and MPH.

I strongly believe that public health approach is extremely important for clinicians in the fields of Internal Medicine, Ob/Gyn and Pediatrics as epidemiology on its own is essential for all health care professionals.

Hope in the near future, this field is going to be more "popular" among medical students.

Below I give you the web address for the Association of Schools of Public Health in US, where you can get info on different programs and public health itself.

http://www.asph.org/ (new window)

I was so happy to see this article as i am going through the same difficulty of explaining to my parents why am i suddenly interested in epidemiology and public health.

I am a M.B.B.S doctor from Mumbai India,who never liked Public health as a student but after my internship i took up a job of surveillance medical officer with WHO/ National Polio Surveillance Project in Uttar Pradesh and that changed my career interests totally. Being a university ranker and Gynaecology goldmedalist , everyone in my family and freinds thought i would be a gynaecologist, so they just can not understand why am i searching for a course in public health. Generalised idea is , public health is nothing but going to villages and treating the poor, thank god they did not think that i am going to be a skin specialist. But this is a generalised apathy towards the subject and i have been pressurised to change my career choice.

But,I am clear and i know i need to understand basics of epidemiology in any branch of medicine.

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