Kerkering, Kathryn Waldrop MD, MPH; Novick, Lloyd F. MD, MPH
Integrating population health content, including both community and clinical perspectives, in the medical school curriculum is challenging. Competition for concentrated time in the medical school curriculum for specific academic activities is intense. Population health has not always been valued as a vital component of medical student education, a reflection of society's view of medicine and public health as separate entities with distinct identities and cultures. Many physicians and medical students regard population health as peripheral or even irrelevant to their pursuit of clinical knowledge and skills.1,2 Incentives, organizational structures, and a strategic approach are essential to foster present and future collaboration and interaction between stakeholders from traditional medical educational and population health perspectives.
In this article, we demonstrate a strategy for the successful integration of population health content and preventive health screening into a medical school curriculum. The term population health encompasses individual- and population-oriented preventive efforts as well as the interactions between them.3 The development and evaluation of the 2006 Regional Medicine–Public Health Education Center (RMPHEC) specific to the Brody School of Medicine at East Carolina University (ECU) are described. We believe that the integration methods we employed may have applicability to other schools of medicine.
The Brody School of Medicine was established as a four-year medical school by the North Carolina legislature in 1977 and was charged to accomplish a threefold mission: to increase the supply of primary care physicians to serve the state, to improve access to health care for citizens in eastern North Carolina, and to enhance the access of minority and disadvantaged students to a medical education. The culture of Brody emphasizes the integral role of understanding the values and rewards of community practice, as it relates to health disparities and chronic disease.
In 2005, the vice chancellor of health sciences and the dean of the Brody School of Medicine recruited one of the authors (L.F.N.) to be director of the division of community health and preventive medicine and director of the new master of public health program. A priority of East Carolina University is to improve the health of residents of eastern North Carolina, a region characterized by poor health indices and marked health disparities. Adding population health instruction to both the medical school curriculum and graduate public health education was recognized as important. With the announcement of a competitive process for RMPHEC grants, the director sought and received approval from the dean, the curriculum committee, and key clerkship directors to proceed with a grant application. The director was able to implement the initiative enabled by the grant funding—the formation of Brody's RMPHEC—by using faculty from the master of public health program as well as the local health department.
There is a compelling need for population health education. Modifiable behaviors including tobacco use, diet and physical activity patterns, microbial agent exposure, firearm use, sexual behaviors, and motor vehicle incidents account for as many as half of all premature deaths in the United States.4,5 World events including bioterrorism, HIV/AIDS, severe acute respiratory syndrome, and the growing problem of obesity confirm the value of population health knowledge, skills, and interventions for future physicians.3,6 National recognition and attention to health care shortcomings such as the high rate of medical errors, emerging and reemerging infectious disease, the obesity epidemic, the anticipated shortage of caregivers for the elderly, the needs of immigrant and refugee populations, and the ever-increasing ranks of the uninsured all call for population health approaches. To improve the health of all individuals, new partnerships are essential to support healthy behaviors, full access to health care, health promotion, and disease prevention. Realizing these objectives requires a fundamental change in the education of health care professionals.1,2
The approach used to integrate population health into the curriculum at Brody included employment of the Clinical Prevention and Population Health Curriculum Framework (hereafter, the Framework). The Framework is a product of the Healthy People Curriculum Task Force convened by the Association of Academic Health Centers and the Association of Teachers of Preventive Medicine. The Task Force included representation from seven health professions educational associations: allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. Its stated mission was to “accomplish the Healthy People 2010 goal of increasing the teaching of health promotion and disease prevention in health professional education.”3 The Framework provides a uniform structure for organizing and monitoring clinical prevention and population health curricula and is applicable to various disciplines. Strengths of the Framework include its broad overview, general recommendations specific to content areas, intention to promote opportunities for interprofessional education and collaboration, and emphasis on incorporation of content longitudinally across the curriculum. In addition to evidence-based medicine, screening, and counseling, there is emphasis on health policy, ethics, and global health.3
A cooperative relationship established in 2000 between the Association of American Medical Colleges (AAMC) and the Centers for Disease Control (CDC) to improve the teaching of public health and prevention at academic medical centers led to one-year funding in 2003 for seven pilot Area Health Education Center grants. In 2006, recognizing the value of these brief pilots, the AAMC and CDC mobilized residual funds from prior cooperative initiatives to offer competitive funding to medical schools to establish or expand existing RMPHECs.1 The Brody School of Medicine was selected as 1 of 11 recipients from an application pool of 47 medical schools. The RMPHEC initiative at Brody was established with the express charge of integrating population health into the medical school curriculum.
The challenge of integrating population health into the preexisting medical school curriculum began with establishing a shared agenda with key individuals responsible for teaching courses and supervising clerkships. The authors, who are medical and public health professionals from the division of community health and preventive medicine, acted as “boundary spanners” in developing inroads in the curriculum between medicine and public health.2 The RMPHEC director's decision to term the incorporation of population health a curriculum enhancement, as opposed to expansion or substitution, minimized the reluctance of course directors to relinquish teaching hours and proved the key to integrating population health content in the school of medicine. This opportunistic strategy led to priority being given to incorporation of population health content into courses and clerkships with the most receptive faculty. Within three months, all directors of preclinical and clinical courses had expressed a willingness and interest in potential collaboration. This resulted in a number of successes, which we will describe. Efforts to develop objective structured clinical examinations (OSCE)7 to assess medical students' knowledge and application of population health are ongoing.
The Clinical Prevention and Population Health Curriculum Framework was chosen as the planning template, for the reasons discussed above.3 The Framework consists of four components: Evidence Base of Practice, Clinical Prevention Services–Health Promotion, Health Systems and Health Policy, and Community Aspects of Practice. The components are further subdivided into 19 domains (see List 1), each with specific subitems. Assessing the 2005–2006 curricula for each of the four years of medical school at Brody according to the titles of required instructional activities provided a means for comparing the educational offerings with the Framework, resulting in a comprehensive matrix.
We used gap analysis to determine the relative deficits in the Brody curriculum when compared with the standard set forth in the Framework. A gap was defined by the presence of domain(s) and item(s) from the Framework matrix for which only one or no educational offering could be identified within the medical school curriculum. The Brody curricula included a wide range of topics and clinical experiences specific to prevention and population health; however, the coverage was uneven with respect to selected components of the Framework. Deficiencies were observed in four domains in the Health Systems and Health Policy component and in six domains in the Community Aspects of Practice component. The Evidence Base of Practice component lacked coverage of two domains: health surveillance and outcome measures, and quality and cost.
AAMC student graduation questionnaire comparison
Data from the AAMC's 2005 Graduation Questionnaire (AAMC-GQ) were used to compare medical students' perceptions of their instruction in the four basic competencies of the Framework.1,8 The AAMC-GQ is an individualized, anonymous survey administered yearly to all U.S. medical school graduates. The survey includes questions related to the student's medical school experiences and offers an opportunity for candid evaluation of his or her medical educational program.8 We aligned the 2005 AAMC-GQ responses for Brody to specific domains and items in the Framework. Response ratings reflected individual perceptions of adequacy of instruction and preparation for a variety of educational objectives. The questionnaire, although not intended to specifically match the Framework, did include questions about a number of clinical prevention and population health topics. Pairing specific AAMC-GQ inquiries to the Framework was based on “nearness of fit.” A match could not be identified for all domains and items. Educational objectives rated by 20% or more of graduates as inadequate, or where disagreed was selected to describe completeness of instruction, were tabulated for Brody and compared with the average response for all schools (range: 21.3%–63.1%). Students indicated that Health Systems and Health Policy, the Community Aspects of Practice domain of outcomes measures, and Evidence Base of Practice were lacking in adequacy of instruction, as predicted by the gap analysis. Responses by Brody graduates differed marginally, if at all, from the summary responses of all schools (see Appendix 1).
Meetings with decision makers
With input from the associate dean of the medical school and the curriculum committee, the RMPHEC director identified key course and clerkship directors on the basis of course content specific to prevention and population health topics. These included directors of the first-year Biostatistics and Epidemiology and Doctoring course; the second-year Clinical Skills, Introduction to Medicine, and Medical Microbiology courses; and the third-year core clerkships in family medicine and pediatrics. During individualized meetings, key predetermined strategies for integration of prevention and population health were presented by the RMPHEC director to the clerkship and course directors. Requests were made by the RMPHEC director to enhance the course by adding prevention and population health content. Course directors were not asked to increase course hours or to give substantial personal time to this endeavor. The responsibility for development of instructional materials and student teaching was accepted by the RMPHEC staff. Course directors receptive to these strategies were prioritized as partners. Faculty members transitioned from a position of initial reluctance to one of acceptance, appreciation, and encouragement.
Employment of Educational Enhancements
We selected four published Case-Based Series in Population-Oriented Prevention (C-POP) cases9–13 for integration into the first- and second-year curriculums (List 2). These educational innovations had been previously demonstrated to effectively integrate prevention concepts into medical education and to appeal to students' abilities and learning preferences.
The original C-POP cases were developed by SUNY–Upstate Medical University, in collaboration with the local health department, and they use actual scenarios and data adapted for student oriented case-based instruction.9 The Brody School of Medicine Master of Public Health program was a useful resource to the RMPEC program. Some of the MPH program population health teaching cases were adapted for teaching medical students. Faculty from the MPH program were available as preceptors for case sessions. At Brody, three of the four cases were adapted to reflect local data exemplary of eastern North Carolina, thereby increasing the relevance to medical students in North Carolina. The cases were
* Community Health Assessment: Pitt County, North Carolina10
* Racial and Ethnic Disparity in Low Birth Weight: Wayne County, North Carolina11
* A Community Outbreak of Influenza-Like Illness (Bioterrorism Preparedness)12
* No Fair Warning: An Outbreak Following the 1999 Washington County Fair13
All C-POP cases were taught to groups of 15 to 20 students by course instructors and a cofacilitator from the division of community health and preventive medicine and/or the Pitt County Department of Health. The community assessment and racial disparities cases were integrated into the first-year Biostatistics and Epidemiology course, and both outbreak cases were integrated into the second-year Medical Microbiology course. Students were required to apply epidemiological skills, consider limitations of sources of data, calculate relative risks, consider causes for health disparities, and propose potential interventions. After the case discussion, the preceptor's version of the case was posted on the school's Web-based curricular management system for more in-depth student review and preparation for the course examination.
Students' third-year family medicine clerkship was enhanced by the addition of a public health postpartum home visit and a community assessment specific to a chronic disease encountered in their community rotation with a local provider (List 2). The goal of these assignments was to foster students' awareness of the impact of community resources or deficiencies on chronic disease risk, access to care, and quality of life. Short essays were required for both assignments. These essays included an assessment of the determinants of health that had affected their patient, an estimate of the burden of this disease in the community, relevance to three to five Healthy People 2010 indicators, existing community-based interventions, and obstacles and opportunities for behavioral change. The chronic disease choices for more than 60% of the students were diabetes, heart disease, and obesity, a reflection of the prevalence of these chronic health issues in eastern North Carolina. For the home health visits, the students were instructed to identify family strengths; identify support systems including financial, emotional, and spiritual ones; determine the health history of the mother and infant; determine where “health” fits in the family's priorities; and evaluate how they view the role of health care providers. The range of experiences and encounters is enumerated in Table 1.
With few exceptions, the family medicine students gave the home visiting experience very high marks. Traveling into the community was welcomed as a refreshing opportunity to experience the world in which their patients would grow and learn. Observing firsthand the home and community of patients was deemed to be invaluable as a source of information and understanding. One student even rated this experience as the favorite part of his family medicine clerkship.
Some students compared this experience to that of physicians of years past who, through home visits, established trust and created a special bond with their patients. Another student recognized the young mother of a preterm infant as a prior classmate whose course in life had taken a very different turn from her own. On a separate home visit, an empty refrigerator alerted one student to the dire poverty of the family and the mother's reluctance to share this information. This realization led the student to question whether these circumstances would have been shared in the office setting. Continuity of care was evidenced by the experience of a student who, after participating in a prenatal home visit to a mother with borderline hypertension, made rounds on her healthy boy four days later, after delivery for maternal preeclampsia. Home health visits were valued both for the role they played in physician education and understanding as well as for their positive contributions to the future health of the mother and infant.
Third-year pediatric clerkship students were instructed to consult with their pediatric community physician preceptor and choose a topic of public health concern from a list of 11 potential topics. Their choices were asthma, child abuse and neglect, dental care, early developmental intervention for infants and children, teen pregnancy, sexually transmitted diseases, infant mortality, lead poisoning, mental health, obesity, and tobacco use. Instructional materials were developed to facilitate ready access to data specific to the state and locality for each issue. Students prepared oral briefings on the topic of their choice during which they were expected to define the community, demonstrate knowledge regarding the impact of their topic on the community, and identify local stakeholders, social and environmental risk factors, and evidence of health disparities. Debriefing sessions were led by division of community health and preventive medicine faculty and/or the Pitt County public health director. One particularly poignant community experience was that of a young girl whose morbid obesity prohibited her ability to pass through the school bus door.
Preventive health history-taking
A major objective of this RMPHEC was to make the integration of preventive health history-taking an integral and required part of medical student education at Brody. “Put Prevention into Practice” (PPIP), an Agency for Health Care Research and Quality initiative, provided the following resources: “A Step-by-Step Guide to Delivering Clinical Prevention Services: A Systems Approach,” “Health Risk Profiles,” and “Preventive Care Flow Sheets” for clinical patient management. PPIP Health Risk Profiles were selected as the template for preventive health screening instruction.14 RMPHEC staff taught an instructional session for first-year students and their preceptors, after which students practiced interviewing standardized patients using PPIP. Students were required as part of their third-year family medicine and pediatric clerkships to complete at least one family or patient interview with PPIP. This preventive health strategy was also reinforced in the second-year Clinical Skills course.
We believe that through implementing the RMPHEC at Brody, population health topics were successfully integrated into existing curricula. Specifically, topics determined to be deficient by gap analysis in the domains of Evidence Base of Practice and Community Aspects of Practice were augmented. From the Evidence Base of Practice domain, curricular content on passive surveillance/reportable diseases and active surveillance for epidemics and bioterrorism was included. From the Community Aspects of Practice domain, curricular content on evaluation of health information and public health preparedness was included.
Standard measures of students' knowledge acquisition included examination questions specific to C-POP cases in the second-year Medical Microbiology course, and grading of home and community assignments in the third-year family medicine clerkship. These evaluation tools provided insights into students' application of knowledge in both academic and community environments. Active individual student participation was realized in both orientation and debriefing sessions for pediatric and family medicine clerkships. Numeric grades were assigned to written assignments and factored into the final grade for each clerkship.
The primary evaluation goal was the integration of preventive health screening and population health skills into simulated patient encounters, as measured by clinical performance examination procedures (OSCEs) and/or clinical performance examinations (CPXs).7 The clinical skills assessment team and RMPHEC staff reviewed all standardized cases and performance checklists to identify current and potential opportunities for preventive screening questions specific to age, health, and behavioral risk factors specific to PPIP. At the midpoint of their third year, students participated in two CPXs, which provided an opportunity to introduce measures of preventive health into two simulated cases. For end-of- year testing, a CPX was adapted for assessment of preventive health knowledge, and an adolescent case was developed that specifically addressed the preventive health needs and concerns of this age group. The results of this assessment strategy will be presented in a separate publication.
At Brody, there is a commitment to sustain the initiatives and enhancements established for the preclinical and clinical years. In addition to family medicine and pediatrics, other clerkship directors have expressed interest in participation, including obstetrics–gynecology, psychiatry, and internal medicine. Not all gaps in coverage of population health topics have been addressed. Improvement in the areas of Health Systems and Health Policy and Community Aspects of Practice continue to be sought. In the year that it has existed, the RMPHEC has provided the resources and support for the development of a collaborative community of educators who have expressed interest in continuing to strengthen the medical school curriculum as it pertains to population health. Most importantly, the division of community health and preventive medicine will have the capacity to sustain this integrated curriculum when RMPHEC grant funding is no longer available.
The literature is replete with articles extolling the merits of integrating preventive and population health content into medical school education.1–3,15–17 The question is no longer why or when but how. World conditions including emerging infectious diseases, bioterrorism, the aging population, and the preponderance of chronic diseases reaffirm the essential value of population health knowledge, skills, and interventions for future physicians.3,6 The experience of the Brody School of Medicine RMPHEC demonstrates the successful integration of preventive and population health throughout the medical school curriculum using an enhancement strategy that is potentially generalizable to other medical schools.
The primary factors contributing to the successful integration of population health at Brody included a receptive primary care medical school committed to addressing the health issues of the surrounding region, use of the Framework and gap analysis, building on strengths and providing enhancements to existing curriculum, employment of nondidactic case-based instruction, and integrating population health into a variety of classroom and community medical learning experiences.
Employing the Framework developed by the Healthy People Curriculum Task Force provided a foundation for present and future curricular analysis, planning, and development in clinical prevention and population health.3 The gap analysis and responses by Brody graduates to the 2005 AAMC-GQ established a baseline from which to monitor and compare present and future content and student perceptions of adequacy of preparation.
Opportunism and enhancement were key strategies for the integration of population health initiatives. A first step was the establishment of trust and a shared agenda with basic science and clinical course directors. The authors, exercising the role of “boundary spanners,” were able to bridge the gulf between medicine and public health and assist in identifying common educational objectives.2 Recognizing and building on the existing strengths of the curriculum facilitated the introduction of population health initiatives. Resistance of course directors was minimized by using the term curriculum enhancement, as opposed to expansion or substitution.
Nondidactic case-based and community-oriented interventions were well received by students and faculty. The four C-POP cases9–13 were successfully cotaught in the preclinical years, and community assessments, home visits, and public health assignments were interwoven into the family medicine and pediatrics clinical clerkships to good effect.
Developing an evaluation strategy for population health is another one of the major objectives of the RMPHEC. The OSCE is viewed as the optimal evaluation method for determining the degree to which medical students have internalized and integrated preventive health screening and population health skills into clinical medicine.7 The third-year students' OSCEs presented an opportunity to introduce measures of preventive health into two standardized patient cases.
Prevention and population health instruction has now been integrated within and throughout the Brody medical school experience. This approach, as opposed to creating a separate and distinct course, seeks to reinforce the realities of the interconnectedness of communities, families, and individuals. Public health and medicine can no longer afford to be seen as distinct medical fields. Partnerships built on mutual respect and acceptance of respective strengths and aptitudes hold the potential to markedly influence the next generation of medical and public health professionals for the betterment of all persons, individually and collectively.