To the question "Who is the Public Health Practitioner?", Stover and Bassett respond that "the public health practitioner is the person who conducts the daily work of public health on the front lines of federal, state, and local health departments." However, defining the daily work of public health is not an easy task since it consists of the most varied and least defined activities within the health sector and even, the public sector in general. In order to solve this problem, the authors have consulted the A to Z activities directory developed by the New York City Department of Health and Mental Hygiene which lists over 250 activities of the public health practitioner.

Even if, relatively speaking, the public health reality is very different in the United States as compared to Italy, there is no doubt that problems related to a) the plurality of individuals involved and b) the numerous topics relevant to the discipline, are present in our country and condition all debates related to the training of public health practitioners.

I do not intend to develop the subject of how continuing medical education (which according to national regulations comprises both continuous professional development and training) is currently carried out in Italy since it is monopolized by the Continuing Medical Education program (Educazione Continua in Medicina - ECM) which is, in my opinion, a program as highly bureaucratic and formal as anyone could possibly have
devised. Instead, I find it useful to focus on the future prospects of continuing medical education; however, in light of the unavoidable difficulties that need to be overcome, these are to be understood more as a wish or an expectation rather than as a future reality.

I limit to four the future prospects (in my personal opinion) of continuing education for the Public Health Practitioner and place them, to an extent, in order of importance:

1. Creating an environment conducive to continuous education;
2. Updating the content of continuous medical education activities;
3. Modifying the tools and the methods of continuous education;
4. Creating new support systems for continuous education.

1. Creating an environment conducive to continuous education.

It may seem superfluous to mention that the most important stimulus to improving one's competency level and changing one's behaviour is the individual's own desire to see these improvements recognized by a rewarding system (and not necessarily a monetary one). If the social environment in which an individual lives and works does not reward merit to efforts made to improve his level of competence or to change his behaviour, it is unrealistic to hope in "mandatory" continuing education and in the acquisition of training credits resulting from an individual's fruitful participation in training initiatives (which is different from mere physical presence at the training sessions).
Public health practitioners are the ones most aware of this reality as they are promoters of health promotion programs aimed at modifying environmental determinants of health in order to achieve healthy lifestyle changes.

To this thesis, which may not be shared by those who believe that every health professional has high moral standards, follows a corollary : Motivation for continuing education is highest when acquired competencies are more marketable. Professionals, with a university degree or otherwise, who can develop themselves in a free market and extract economic benefits from training are also those who feel the most the obligation (not only moral but also the obligation to stay ahead of the competition) to access proposed training. This has always been the case, so much so that this motivation mechanism is taken for granted amongst all professionals of any kind.

The new 2003-2005 Italian National Health Care Plan mentions this process when it states (in pure "political" style) that "in a wider perspective, continuing education could become one of the tools that will guarantee the quality of professional practice, becoming a way to develop a new culture of professional responsibility and of just recognition of professional excellence".
The prospect that I wish for is that of successfully creating an environment which will facilitate continuing education that is justly "meritocratic" in the way that it values and rewards the training outcomes.

2. Updating the content of continuous medical education activities.

It must be noted that training proposals of managerial culture, typical of corporate knowledge, have seen a strong participation by the very same Public Health university institutions who in this way have left their own field of competence defenceless.

The philosophy of "preventing illness" is really what is being questioned, substituted by a more modern "health promotion" trend. The prospect of becoming a "Health Promotion professional" implies a deep cultural change which requires more specific training with new didactic programs. In reality, it means completely abandoning the teaching of the biomedical model, from the very start of the basic training level, and
replacing it with the socio-biologic model, as well as its accompanying transformation of the healthcare professional into a socio-sanitary provider.

Furthermore, speaking of training, it is impossible to ignore the evidence-based movement which is deeply marking medical sciences in general and public health in particular. The "movement" has the ambition of giving scientific content to decisions that are of interest to individuals as well as to population groups of various sizes. Clinical medicine participated with enthusiasm in the movement (Evidence-based Medicine) while public health has participated to a much lesser extent (Evidence-Based Public Health). One of the reasons for this lack of participation is the low propensity to evaluate public health interventions and to make such studies public.

The prospect that I suggest is to practice public health as extensively as possible on the basis of proven effectiveness.

3. Modifying the tools and the methods of continuous education

Our country certainly does not lack an imposing supply of continuous education activities for a wide range of topics and of different communication and tutorial quality. However, there are still only a few initiatives that use state-of-the-art educational tools (distance training, on-line learning) to overcome the traditional academic training methods.

Even fewer are the initiatives that take into account the most recent educational theories. Malcolm Knowles introduced the term "andragogy" to define "the art and science of helping adults learn" and suggested seven principles suited for obtaining the best possible results.

The prospect that I wish for is that continuous education may be carried out:
a) by participation in courses and accredited events co-involving for this purpose, as stated in the 2003-2005 Italian National Healthcare Plan, "Professional Orders, Colleges, and Associations, not only as actors in the planning of continuous education, but also as standard setting bodies that will guarantee that the education offered meets the European and international standards";
b) through structured learning frameworks delivered by internal teaching staff active within the health departments and verified by external teachers; the learning framework should have strong practical connotations and involve mainly applied, hands-on training experiences rather than didactic teaching;
c) through self-learning modules that must include speeches, lessons, conferences, public readings, both within and outside the health departments;
d) through publication of articles, reports, description of experiences, not necessarily in books or journals but rather and mainly in informal printed means (with a limited and targeted circulation, even in electronic format).

4. Creating new support systems for continuous education

In public health as in other disciplines, dissemination of knowledge is achieved by means of communication, with electronic means gradually overcoming printed ones. The Internet has become an almost infinite source of knowledge that is only waiting to be explored, with the only constraint that one must simply learn how to access the source.

In this case, the prospect is to create a unique website which to refer to for all information specific to public health. The National Knowledge Service (www.nks.nhs.uk) recently created by the British Health Department could be used as the model for this website. Its motto is "Knowledge is the currency of learning. We can only learn what we know. The National Knowledge Service is a pivotal component in the Department of Health's delivery on its promise to ensure a range of knowledge sources to fight disease and improve patient care." The mission of the National Knowledge Service (NKS) is to ensure that all the knowledge sources are brought together to let patients and professionals base their decisions on best current knowledge.

In conclusion, I am not alone to be convinced that continuing education is the ideal tool by which the public health practitioner can accomplish his mission since this "takes the shape of an element for the safeguard of social equity and summarizes the concepts of individual and collective responsibility inherent to the practice of any activity aimed at protecting and maintaining the health of a population" (Italian National Health Care Plan 2003-2005).