Riegelman, Richard K. MD, PhD; Garr, David R. MD
The Institute of Medicine (IOM) has recommended that “all undergraduates have access to education in public health.”1 In November 2006, a Consensus Conference on Undergraduate Public Health Education made specific recommendations to operationalize this recommendation. The participants recommended that “Public Health 101” and “Epidemiology 101” be offered by all of the approximately 2,000 colleges and universities in the United States. In doing so, the participants saw these curricula as part of general education designed to produce an educated citizen. They also recognized that inclusion of undergraduate public health content could be excellent preparation for health professions education, including medicine.2
The Consensus Conference on Undergraduate Public Health Education was convened in 2006 to implement the specific recommendations for undergraduate public health education. The conference was supported by a grant from the Josiah Macy, Jr. Foundation and was sponsored by the Association for Prevention Teaching and Research (APTR), the Association of Schools of Public Health (ASPH), and the Council of Colleges of Arts and Sciences. The Association of American Colleges and Universities (AAC&U) and the Centers for Disease Control and Prevention (CDC) participated in the Consensus Conference, as did representatives of the seven health professions that constitute the Healthy People Curriculum Task Force, including allopathic and osteopathic medicine.
These participants developed a set of recommended learning outcomes or competencies for undergraduate public health education. These learning outcomes may serve as the intellectual link for articulating the connection between undergraduate public health education and medical education. The learning outcomes include an emphasis on gaining a big-picture or population perspective on health and health care.3
The recommendations of the Consensus Conference are consistent with the 1998 recommendations of the Association of American Medical Colleges' (AAMC's) Medical School Objectives Project report on medical informatics and population health. In that report, a population health perspective was recommended for all medical students and was defined as such: “a population health perspective encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for individual patients in the context of the culture, health status, and health needs of the populations of which that patient is a member.”4
The first portion of this definition, that is, the ability to assess the health needs of a specific population and implement and evaluate interventions to improve the health of a specific population, is grounded in what is increasingly being called evidence-based public health.5 Evidence-based public health encourages broad-based systems thinking examining the evidence for a range of options from prevention, to cure, to rehabilitation. Evidence-based public health frames questions such as what are the options for addressing the AIDS epidemic, rather than jumping to traditional approaches such as how can we develop a vaccine or drug treatment.
Data from the ASPH and the APTR obtained as part of their ongoing data-collection process indicate that more than half of the approximately 40 accredited schools of public health and over 60 accredited programs in public health, located mainly in medical schools in the United States, offer introductory undergraduate public health course work, usually including an introduction to public health and epidemiology. An increasing number of these institutions are offering academic minors, and a small number are offering majors either through public health directly or through arts and sciences.6
An informal survey conducted in 2006 through the ASPH's Task Force on Undergraduate Public Health Education suggests that a majority of students who enroll in existing undergraduate public health and epidemiology courses plan careers in medicine, and a substantial minority of graduates of these courses do go on to medical school. Most institutions offering introductory public health and epidemiology courses to undergraduates have found that these courses are very popular, often resulting in students being turned away or the institutions having to open the classes to more students. Institutions are increasingly offering multiple sections of introductory courses to accommodate the students' interest (personal communication). Despite the growing popularity of undergraduate public health education in institutions with graduate public health education, courses in public health are still unusual in other undergraduate institutions.
To facilitate the introduction of undergraduate public health and epidemiology courses based on these learning outcomes into the approximately 1,900 colleges and universities without graduate public health education, a series of recommendations for implementation were made by Consensus Conference participants. These included a recommendation that clinical health professions, including medicine, encourage applicants to enroll in undergraduate public health and epidemiology curricula. The recommendations also encouraged faculty- and curriculum-development efforts. Activities designed to implement the faculty- and curriculum-development recommendations are underway through the APTR in collaboration with the AAC&U.7 These efforts include faculty development workshops and the development of a Curriculum Guide for Undergraduate Public Health Education, available at (www.teachpublichealth.org).
In addition, the Web-based Prevention Education Resource Center (www.teachprevention.org) is being developed under the auspices of the APTR to provide a range of curriculum materials for public health and clinical education, and it includes education materials designed for undergraduate public health education. Materials are available to develop an “epidemiology laboratory” to enable epidemiology to fulfill a science distribution requirement, providing hands-on experience using evidence. An undergraduate public health “interest group” is organizing a growing network of public health, arts and sciences, and clinical health professionals interested in teaching undergraduate public health. Information about these efforts is available at (www.teachpublichealth.org).
Why Connect Undergraduate Public Health with Medical Education?
Almost a decade ago, the AAMC encouraged the inclusion of a population health curricula as part of the four years of medical school.4 The Healthy People Curriculum Task Force, consisting of representatives from seven clinical health professions educational organizations, including allopathic and osteopathic medicine, has since produced the Clinical Prevention and Population Health Curriculum Framework.8 This framework includes specific recommendations for teaching the evidence base for medical practice, clinical preventive services and health promotion, health systems, and health policy and community aspect of practice as part of the basic degree programs of clinical health professions including medicine.
Data from the AAMC9 and an article by Garr and colleagues10 suggest that medical schools are doing an increasingly good job of teaching clinical prevention and health promotion. The larger issues of instructing students about health systems, health policy, and other aspects of population health fare less well.
In addition, a recent study of residents from Yale indicates that their knowledge of study design and statistical analysis is inadequate for reading the medical literature. The authors attribute this to inadequate, elementary, and one-shot introductions of study design and data analysis to medical students. They recommend that a more sophisticated and integrated approach be incorporated into expanded teaching of evidence-based medicine.11 Teaching evidence-based public health to undergraduates should make it far easier to teach evidence-based medicine to medical students and residents.
Under the assumption that there is and will be only be a limited amount of time in medical school to achieve these goals, an alternative is to bolster these efforts with adequate preparation as part of undergraduate or college education. One approach is to rely on a growing list of prerequisite courses for medical school. Given unlimited time for medical school preparation, a comprehensive list of prerequisite courses might be desirable. However, given the competing demands of undergraduate education, we believe that the alternative of defining competencies in evidence-based public health as well as other key areas of preparation for medical school seems desirable and more acceptable from the perspective of medical educators, college educators, and students.
The success of this competency-based alternative requires
* defining competencies or learning outcomes that candidates for medical school need to achieve and providing a testing mechanism to ensure fulfillment; and
* articulating these competencies with curricula in medical school that build on basic understandings, reinforcing the curricula throughout the four years of medical school, and viewing these competencies as an inherent part of the education of physicians.
How Can Competencies Serve as the Basis for Connecting Evidence-Based Public Health and Medicine?
Evidence-based public health needs to be solidly grounded in epidemiology. Although epidemiology may be taught merely as a technical skill, it can and should be used to develop in students a population or big-picture perspective on health issues. These are foundations for teaching evidence-based medicine as well as evidence-based public health.
The recommendations of the Consensus Conference include a series of competencies that may serve as the basis for connecting undergraduate public health education with medical education. These are stated here as understandings. The specific measurable learning outcomes or competencies defined by the Consensus Conference participants are included in Tables 1 and 2.3
* Understanding basic epidemiological principles and their applications to study designs and to reading research literature.
* Understanding the determinants of health and disease, including, but not limited to, behavior, physical environment, and genetics.
* Understanding the basic structure of the U.S. health care and public health systems and the synergy possible through collaboration between medicine and public health.
* Understanding the range of roles and career routes in health care and public health.
Together, these frameworks are recommended as the foundation for undergraduate public health and epidemiology curricula, and they constitute the basis for evidence-based public health.
In addition to outlining competencies or learning outcomes, the Consensus Conference encouraged the development of a Curriculum Guide to Undergraduate Public Health Education. The Curriculum Guide also provides recommendations on structuring curriculum to achieve a coherent approach to evidence-based thinking, including fostering “enduring understandings” or concepts designed to be carried away from the curricula and incorporated into future education and practice. The Web-based Curriculum Guide is being developed as an ongoing joint project of APTR and AAC&U, and it is available at (www.teachpublichealth.org).
Thus, with the rapid growth in undergraduate courses in public health and epidemiology, it is will soon be possible to use this educational content as solid grounding for medical education.
What Can Teaching Evidence-Based Public Health Accomplish?
Evidence-based public health is built on what the CDC describes as the following four components12:
* Problem. Describe the problem using concepts from descriptive epidemiology.
* Cause. Examine the evidence for risk factors, causation, and efficacy, using research studies.
* Interventions. Evaluate a range of options from prevention to cure to rehabilitation, relying on evidence-based recommendations.
* Implementation. Consider a range of strategies, including patient- and population-oriented approaches for implementation, asking when to intervene, what methods to use, and at whom to target the intervention.
An evidence-based public health curriculum aims to encourage students at an early stage in their education to broadly frame options, critically analyze data, and understand the uncertainties that remain. Such critical thinking skills can and should be part of the general education for a wide range of students. For students preparing for medical school, these skills can be taught in a health context through courses in public health and epidemiology. This approach can serve as the basis for specific competencies that can be set forth as expected preparation for medical school and, if deemed appropriate, tested as part of the Medical College Admission Test.
Students who come to medical school ready to read the health research literature and discuss the determinants of health and disease should be better prepared for the self-directed learning inherent in problem-based learning. Students who understand the basic elements of the U.S. health care system should be better prepared to integrate their clinical experience into a large context. Students who understand the roles of a range of health care and public health professionals will hopefully make career decisions consistent with their interests and abilities and be prepared to learn to work with other health professionals.
The movement toward undergraduate public health education has been a student-driven movement. According to Nancy Alfred Persily, an early implementer of undergraduate public health education, “Students appear to be the driving force behind undergraduate public health education. Public health helps them understand people and populations and delivery of care. Students want to learn more about the health of the community and society.”9 It is time that public health, arts and sciences, and medical educators join this movement as well.
Teaching of evidence-based public health as preparation for medical school will greatly enhance a coherent approach to teaching evidence-based medicine in the four years of medical school. Students who come to medical school with skills for reading the research literature, an appreciation of the determinants of disease, and an understanding the structure of the U.S. health care system will be better prepared to incorporate evidence-based thinking and a population perspective into their education. Medical education built on this foundation should provide invaluable service to students, the medical profession, and society at large.
A population perspective on health issues and an evidence-based approach to practice should be part of the education of all future physicians, starting at the college level and continuing throughout the four years of medical school and beyond. An undergraduate public health curriculum grounded in epidemiology provides a natural way to introduce premedical students to key concepts that they can use throughout their education and practice of medicine. Early experience strongly suggests that students are voting for undergraduate courses in public health and epidemiology with their course registrations. It is time for medical and undergraduate public health educators to work together to strengthen the connections between college and medical school.
1 Gebbie K, Rosenstock L, Hernandez LM. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academy Press; 2003.
2 CDC. Notice to readers: Recommendations for public health curriculum-consensus conference on undergraduate public health education, November 2006. Morb Mortal Wkly Rep. 2007;56:1085–1086.
4 Association of American Medical Colleges. Medical School Objectives Project Report II: Contemporary Issues in Medicine: Medical Informatics and Population Health. Washington, DC:Association of American Medical Colleges; June 1998.
5 Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health. New York, NY: Oxford University Press; 2003.
8 Allan J, Barwick TA, Cashman S, et al. Clinical prevention and population health: Curriculum framework for health professions. Am J Prev Med. 2004;27:473–476.
9 Holmes DE, Riegelman RK, eds. Integrating Clinical Prevention and Population Health into Education, Practice, and Research: Proceedings of the 12th Congress of Health Professions Educators. Washington, DC: Association of Academic Health Centers; 2005:4.
10 Garr DR, Lackland DT, Wilson DB. Prevention education and evaluation in U.S. medical schools: A status report. Acad Med. 2000;75(7 suppl):S14–S21.
11 Windish DM, Huot SJ, Green ML. Medical residents' understanding of the biostatistics and results in the medical literature. JAMA. 2007;298:1010–1022.