Training to Improve Wellness

The Preventive Medicine Residency — with the full name of the specialty being public health and general preventive medicine — is a small but mighty program that has racked up numerous successes and graduated 16 residents. January 2023 brought a passing of the directorship torch from Patrick Remington, MD ’81, MPH, professor emeritus, Department of Population Health Sciences, to Elizabeth Salisbury-Afshar, MD, MPH, associate professor, Departments of Family Medicine and Community Health, and Population Health Sciences. She had served as the Preventive Medicine Residency’s associate program director since July 2022.

With an overarching goal to improve the public health physician workforce in the state, the residency program received initial accreditation in 2014 and full accreditation in 2016 with zero citations, a rare score to achieve.

Salisbury-Afshar frames preventive medicine as training physicians in population health. She says the field aims to develop policies, systems, and resources to improve health and wellness, rather than prescribe medications.

“In clinical medicine, we are trained to think about the person sitting in front of us and advocate for them,” she says. “In preventive medicine, we are trained to think about the entire population. I may have $10 million and need to serve a population of 100,000. It is a different kind of thinking when you take what you have and make it go as far as possible for the population being served.”

Well-rounded Leader

While earning her medical degree at Rush University Medical College in Chicago, Salisbury-Afshar completed rotations at the public Cook County Hospital. There, she realized early on that many patients needed something she could not prescribe.

“Individuals were in need of housing, living-wage jobs, safe communities, and healthy foods,” she says. “I was involved in national advocacy work in medical school, and I had some mentors in Washington, DC, who helped me explore my passion for how these systems interact and how to influence policy. That led me to preventive medicine.”

Salisbury-Afshar then completed residencies in family medicine at Illinois Masonic Medical Center in Chicago, and in preventive medicine at Johns Hopkins in Baltimore, Maryland. During the latter, she worked with the city and state health departments; her work in those departments focused on addiction, which piqued her interest in pursuing board certification in addiction medicine, in addition to family medicine and preventive medicine/public health. Even while working in public health, she has always maintained a clinical practice. She previously worked as the medical director and director of addiction services at a Chicago-based, federally qualified health center (FQHC) dedicated to providing care for individuals experiencing homelessness.

In addition to her work in public health departments in Baltimore and Chicago, Salisbury-Afshar has gained more than 13 years of experience working at FQHCs. These community health care providers are funded by the federal government to provide care in medically underserved areas. In particular, the centers receive funding from the Health Resources and Services Administration (HRSA) Health Center Program.

When Salisbury-Afshar joined SMPH faculty in summer 2020, she immediately set to work providing clinical care and performing research, but she was interested in getting involved in preventive medicine training and, broadly, in public health.

“As soon as I arrived at UW–Madison, I learned about the Preventive Medicine Residency and looked for a way to get involved,” she says.

And her involvement began at the perfect time. Remington recalls how Salisbury-Afshar initially presented a seminar to the preventive medicine residents, and this cemented her interest in the residency program.

Today at the UW School of Medicine and Public Health, Salisbury-Afshar wears many hats. In addition to serving as the Preventive Medicine Residency Program director, she practices at Madison’s Access Community Health Centers, consults on addiction medicine at UW Health, and serves as a core faculty member in the UW Addiction Medicine Fellowship Program. She conducts research on the implementation and evaluation of addiction-related programs. And she serves as medical director of harm reduction services for the Wisconsin Department of Health Services Division of Public Health.

“This combination of public health, clinical work, and research is my happy place,” Salisbury-Afshar says.

Remington comments, “She has served in leadership roles in public health and is a practicing clinician, which is a rare combination of talents. Dr. Salisbury-Afshar shares her experience as a clinician with our residents, who continue seeing patients during our program. She has all the elements to lead this program, and I know the future is bright.”

Program’s Big Picture

Learners in the Preventive Medicine Residency focus on clinical approaches to prevention and public health, and to community health, says Salisbury-Afshar, who embodies SMPH’s integration of medicine and public health. Residents are challenged to approach a problem; understand the data behind it; plan a practice or service; and consider how it can be built, implemented, and scaled.

Applicants to the program must have completed one or more years of a clinical residency before applying. Some join while they are in the middle of another residency, while others complete another residency first. The two-year program admits two residents per year, so there are four residents at any given time.

“Some physicians decide early that purely clinical medicine isn’t for them,” Salisbury-Afshar says. “Others do a full residency and then decide to extend their training. Still others complete a clinical internship knowing they want to apply to the Preventive Medicine Residency as soon as possible. We welcome all of them.”

The program’s first year focuses on classroom learning, and residents complete full-time coursework to earn a master of public health (MPH) degree from SMPH — thus, every residency graduate holds an MD and an MPH or equivalent degree. Students who already have an MPH have time to complete additional practicum rotations.

Trainees spend the second year completing a variety of rotations. After required rotations at the Wisconsin Department of Health Services and Wingra Family Medical Center, the sky’s the limit. Residents who want to focus on community work can partner with a local community organization, while those who are interested in data and research may explore a more traditional research project.

An upcoming project will be a collaboration with a local fire department to answer questions related to cancer screenings. A resident will work to understand why firefighters have higher rates of cancer compared to the general population and determine whether additional cancer screenings and surveillance may be needed.

“The projects our residents take on are meaningful to the partner,” Salisbury-Afshar says. “The residents don’t approach the projects as dropping in for three months, but instead they ask partners what questions and problems they have, so they can try to develop and implement a lasting solution or process.”

Receiving Support

The individual attention and diverse training experiences residents receive in their rotations are almost unparalleled. However, the funds to pay residents are constantly in short supply.

Because preventive medicine residency graduates’ careers are not typically focused on clinical care, the program does not receive federal funding the way clinical residencies are funded. While the program got off the ground thanks to funding from the Wisconsin Partnership Program, it is constantly having to be creative and seek additional support. Often, funding is pieced together through generous philanthropy or partnerships with other organizations, such as the William S. Middleton Memorial Veterans Hospital, where residents complete clinical rotations. Remington and Salisbury-Afshar say they have profound appreciation for the Wisconsin Partnership Program and other supporters.

As the residency approaches the end of its first decade, its program leaders are thrilled to have received a highly competitive grant from the HRSA, part of the U.S. Department of Health and Human Services. The grant is targeted for preventive medicine residencies, and less than 20 programs receive a grant each cycle. With more than 50 preventive medicine residencies in the country vying for limited funding, receiving the grant — or not — can mean the difference between continuing or closing.

Salisbury-Afshar says a residency alum, Collin Pitts, MD, MPH ’20 (PG ’21), helped with the enormous effort of putting together the grant application. Remington recalls applying for the grant in previous years and getting approved — but ultimately being told there were insufficient funds. But in the most recent cycle, there was a new requirement that applicants must do some training at an FQHC, and Remington and Salisbury-Afshar felt the stars aligning.

“For me, personally, it was the perfect fit because I’ve worked in federally qualified health centers for the past 13 years,” says Salisbury-Afshar. “And we were lucky that SMPH already had a partnership with Wingra Family Medical Center, which is an FQHC that is part of Madison’s Access Community Health Centers.”

The residency program’s goal in partnering with Wingra Family Medical Center is to support the clinic’s quality-improvement work in the residency’s areas of focus. For example, residents are trained in epidemiology and biostatistics, and they can help the clinic with data analysis and interpretation to support quality-improvement efforts.

Having started in May 2023, the four-year HRSA grant provides $400,000 each year to help pay resident and faculty salaries, MPH tuition, and other training expenses.

Additionally, through the HRSA grant, the Preventive Medicine Residency has been able to add a preventive medicine fellow each year — a position to which a graduating resident can apply, with the goal of further training and ideally a future role in the state. Another benefit of the HRSA grant is the ability to retain Remington as an advisor so he can continue sharing expertise from his four-decade career in this field.

Alumni Success

Although the Preventive Medicine Residency Program is small, its alumni know how to punch above their weight. Several alumni work in governmental public health and administrative leadership roles in hospitals and health systems. Others enter industry roles at pharmaceutical and technology companies. And some stay in Wisconsin and keep their connections to SMPH, serving in leadership roles of all kinds.

For instance, alumni Karina Atwell, MD, MPH ’15 (PG ’14, ’16), an assistant professor in the Department of Family Medicine and Community Health, is a leader in medical student and resident education; and Maria Mora Pinzon, MD, MS (PG ’17, ’22), an assistant professor in the Department of Medicine, performs health services research in dementia care.

Another alumna, Jasmine Zapata, MD ’13, MPH ’17 (PG ’16, ’18), is an assistant professor in the Department of Pediatrics who also serves as chief medical officer and state epidemiologist for community health for the Wisconsin Department of Health Services. She says the Preventive Medicine Residency was “an incredible launching pad” for her career, and she learned skills that helped pave the way for her community-based research and state public health role.

“I am so grateful I found a program that was supportive of my long-term dreams and passion for public health and social determinants of health,” Zapata says. “The program was amazing and a great addition to my pediatrics training. I am excited about the future of preventive medicine and all the possibilities it has opened for my own future, as well.”