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Exit Interview

Dr. Steven Galson speaks about his tenure as acting surgeon general, tomorrow’s role for the Public Health Service and the next steps for health in the United States.

The New Physician January-February 2010

Dr. Steven GalsonDr. Steven Galson served as acting surgeon general for two years, from October 2007 until Dr. Regina Benjamin’s confirmation in October 2009. Prior to his role with the Public Health Service’s Office of the Surgeon General, Galson was director of the Center for Drug Evaluation and Research at the Food and Drug Administration. He completed both an internal medicine residency and a preventive medicine residency, is board-certified in preventive medicine, and holds a master's in public health.

In an exclusive interview for TNP, Galson discusses public health, health care reform and the future of medicine.

How did you first get involved in public health and public service?

I was in medical school at Mount Sinai in New York, and in the summer between my third and fourth year, I did a rotation at a refugee camp in Thailand. It was really an eye-opening experience, coming from a tertiary-care hospital in New York City. And when I went back to New York, I saw the incredible disparities between the health care that U.S. residents were getting compared to the folks in developing countries who were getting absolutely nothing. I realized that I wanted to have an impact on global prevention matters that affected many people, instead of working on a patient-to-patient level. Through my three years of residency, I maintained a really strong interest in public health, joined the Public Health Service and went to work for the Centers for Disease Control and Prevention (CDC) immediately afterward.

Many students are particularly interested in that transition. You went to work for the CDC, but how did you do it?

I applied for this fellowship program called the Epidemic Intelligence Service program, which still exists at the CDC and is an epidemiology field training fellowship. It lasts two years, and that’s how I got my foot in the door. A lot of senior public health officials have taken this route. It’s very, very common.

What initiatives have you worked on as acting surgeon general?

I’ve spent most of my time on childhood obesity. We’ve had a dramatic rise in childhood obesity since 1980, tripling in some age groups, and it is really bad news for public health in the United States. Our kids are not going to be able to do as well in school, be as successful in their lives, and may develop all of the medical problems that are related to obesity and being overweight. In addition to caring about the future health of this group of kids, it’s also going to bust the budget. The health care system is already unsustainable, and with an increase in obesity, it’s become even less sustainable. So we have to do something about it, even purely from an economic standpoint. But the most important drive for me is really the public health side of it.

On what other programs have you worked?

Underage drinking. We have thousands of deaths every year in this country related to underage drinking, such as accidents, homicides and sexual assaults. The most remarkable thing I’ve learned about the issue is that so many parents in the United States consider abuse of alcohol in the younger age group to be a rite of passage, like it’s going to happen anyway, and they sort of take a back seat to the issue. And this is just wrong. It’s sending the wrong message to our young people, resulting in increased deaths. So I’ve been talking about that a lot.

We’ve also released the Surgeon General’s Call to Action on Healthy Homes, which is a report that helps make the link between health and home environment. Hopefully it will result in more programs to address this issue at the federal, state and local levels.

We’ve issued a call to action on deep venous thrombosis and pulmonary embolisms, which also kill thousands of people in the United States. A lot of folks are just not aware of the seriousness. And the fact that you can take steps to prevent developing blood clots if you’re at high risk. I’ve done a lot of other things, too, such as giving speeches on mental health, suicide prevention and preparedness for H1N1.

Let’s talk about the health care system. There has been a massive push for health care reform by the Obama administration and on Capitol Hill. What is your role in this entire process?

Well, my role is really to support and help communicate the administration’s priorities, which is really the typical role of the surgeon general. I have not been involved in the policy negotiations and discussions on the Hill and the White House—there’s a team of people doing that, and I’ve been doing so many other things and haven’t been intrinsically involved in that, but I’ve been talking in each of my speeches since President Obama came into office about the importance of reforming the health care system.

Do you see the role of the surgeon general changing or remaining the same?

It’s never a good idea in jobs like this to talk about hypotheticals and look into a crystal ball. Looking at the health care reform bills that are currently in the House and Senate, a number of bills give a much more prominent role to the surgeon general and the Office of the Surgeon General in establishing minimal standards for health insurance. Whether these components remain in there, I really don’t know. But if they do, it’s going to fundamentally change the role of the surgeon general, and I think it will be very positive.

Many policymakers cite that prevention needs to be a key part of health care reform, that people need to take better care of themselves to help us fix our broken system. How do we implement prevention?

I think that that’s a big part of my role, and it has been for my predecessors as well. The only real way to implement a complicated change like this is to continue to fight for it on many different fronts at the same time. There isn’t one solution. It’s got to get into the health care reimbursement system. It has to get into family life, into how parents educate their kids. It’s got to get into the schools, into the way we design our transportation systems, into our food subsidies, into our crop subsidies and the way we decide what people eat in restaurants. There’s almost no part of our society that doesn’t need to be touched. But across the board we have to continue to talk about prevention at every single opportunity, and that’s the only way to get change.

It’s similar to 30 years ago with tobacco. It was everywhere: school, home and work. People wondered how we were going to get rid of it, and it was through a concerted, multifront effort over decades that we’ve made such amazing progress in tobacco control. So that’s the sort of thing that’s needed.

What are some other public health challenges we’ll be facing in the next decade?

I think the major challenge, and I think maybe the one that should have been addressed first, even before obesity, is the access problem. We’ve got terrible disparities with access to health care in the United States, and as a result, terrible health disparities in outcomes from cancer, heart disease and stroke are much higher in minority groups, and it should be embarrassing to every health care practitioner in the United States. I would put that as a No. 1 issue. We have got to flat out achieve better access to health care in this country, and that, I think, is the single greatest challenge.

For these preventive programs, do you see an expansion in a health care team-based approach?

I think a lot of the solutions lie in interdisciplinary teams. We tend to be very siloed in the health care professions: Doctors talk to doctors, nurses talk to nurses, pharmacists talk to pharmacists. The best examples of health care, such as the Mayo Clinic, that the president cites all the time as being successful, work much more in interdisciplinary teams. I saw that in my medical training as well. It’s also the case in public health, and one of the reasons I love the Commissioned Corps so much is that we are an interdisciplinary team. It can be very difficult for people, that they go to graduate school and learn a specialized language that they want to use with their colleagues or cohorts, but that sort of thinking doesn’t get us toward solutions.

Do you see the role of physicians changing when working with a team?

I do. Physicians have to get a lot more used to working in a collaborative environment with others. So many physicians are already there, but in many cases we haven’t figured out how to use nurses, physician assistants and pharmacists most efficiently, who can really do a lot of primary care work to follow patients on anticoagulant therapy or antihypertensive therapy, analyze their tests, and figure out how to adjust the dose at a much, much lower cost than seeing a highly trained physician. And do just as good a job. So there are a lot of steps like that the medical profession traditionally has fought against. I think they’re changing, but we need to go even farther than that.

How do we deal with the aging population? When current medical students go into the workforce, many of our patients are going to be older.

The first thing is we need a lot more specialized help. We need more geriatricians, and we need geriatrics and specialized training in the aging population to be folded into all of the medical specialties. We have to make sure that the ophthalmologist and the dermatologist and all the subspecialties are getting adequate training in geriatric issues.

Do you think that it should also be integrated into the medical school curriculum?

It has to start there, just like convincing people to go into primary care. It has to start in medical school.

What advice do you have for students who want to be involved in the health care reform process? How can they go about doing this?

In your rotation time, there are opportunities to get involved in policy development. You have to become an expert about something; you have to learn about it. Even in the first two years, ask questions about what the school is doing to help health care reform. Sometimes that’s a great way to get questions going.

With your time in office coming to a close, what’s next for you? What does one do after being surgeon general?

It’s been an enormous privilege to be in this position and see the great work that is taking place all over the country, but I don’t know yet. There are a lot of options and different possibilities.

Preyanka Makadia is a first-year at the Philadalphia College of Osteopathic Medicine.