Chamberlain, Lisa J. MD, MPH; Wang, N Ewen MD; Ho, Evelyn T. MPH; Banchoff, Ann W. MPH, MSW; Braddock, Clarence H. III MD, MPH; Gesundheit, Neil MD, MPH
Starting in the 2003–2004 academic year, the Stanford University School of Medicine required that first-year medical students complete “hands-on” small-group projects to address population health issues. The project structure has evolved since that time to incorporate more community input and increased infrastructure support at the medical school. With the establishment of Stanford's Regional Medicine Public Health Educational Center (RMPHEC) in 2006 and the development of a required population health curriculum for all medical students, a new academic foundation for these projects was created. In this report we describe the early stages of the school of medicine's effort to integrate experiential population health projects into a required medical curriculum.
To practice medicine effectively in a multicultural society, physicians need to understand population health determinants and disparities and expand their concept of professionalism to include prevention, health promotion, advocacy, and community engagement.1–5 The biomedical model traditionally employed in medical education does not emphasize population-based approaches to our current health challenges but focuses instead on care of the individual patient. This is a shortcoming of medical school curricula because it addresses improving health at the individual level while overlooking the factors influencing the larger context of health.
The causes of disparate health outcomes extend beyond health coverage and access to care. In the United Kingdom, where health coverage and access to medical care are more evenly distributed than in the United States, disparities continue to exist. Poverty is a root cause for many health disparities, and it is well established that poor health outcomes are associated with declining income gradients.6–8 In addition, when minority status is examined independently of income status, these disparities persist. Health outcomes in the United States for minority groups compared with the outcomes for their nonminority counterparts are worse for conditions such as low birth weight, obesity, cardiovascular disease, asthma, and injury.9,10 Additional factors that lead to disparities include low education level, negative environmental factors, low social capital, low health literacy, and unsafe neighborhoods.6,11–13
Physician training should build both knowledge about health disparities and skills to address the root causes of poor health. The physicians of the future will ideally be able to move seamlessly between the perspective of the individual patient and that of the population.14 Future physicians will be most effective if they have the skills to collaborate effectively with the public health sector to address population-level health challenges.
Although there are published accounts of medical school programs that incorporate population health concepts,15–19 there are few examples of required population health curricula. The recent establishment of RMPHECs across the country, funded by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention, has initiated a wave of required population health curricula in U.S. medical schools. An important mandate of some of these new curricula is to incorporate an experiential learning component through which students work actively with community partners on projects that address population health issues.
Experiential, or “hands-on,” learning has been shown to increase retention, comprehension, and application of new knowledge.20–22 Public health education has long relied on experiential models, requiring students to complete field placements and/or internships to extend knowledge into skill building. During the last decade, U.S. medical education has similarly increased its emphasis on experiential learning, as evidenced by the proliferation of problem-based learning methodologies in preclinical instruction23; the use of standardized patients to teach and assess clinical and communication skills24,25; the introduction of early clinical practica to engage students in patient contact throughout medical school26; and the use of simulation modalities to enhance clerkship education.27 This type of early experience-based learning helps medical students develop professionally and develop their unique civic role as physicians.
The Population Health Curriculum
The medical curriculum at Stanford has long included individual lectures on population health topics (e.g., epidemiology, biostatistics, and health policy). When a reorganized medical curriculum was introduced in the fall of 2003, these lectures were placed into a curricular block entitled The Practice of Medicine (POM) that integrated the topics of ethics, health policy, behavioral health, epidemiology, patient–physician communication, and physical examination skills. In 2006, with funding support from the AAMC's RMPHEC initiative, a population health curriculum was designed for inclusion in the POM course. This curriculum sought to fill critical population health gaps in the existing coursework and to unify the population health content into a coherent set of related lectures. The new lectures covered social and economic determinants of health, health disparities, Healthy People 2010 objectives, physician advocacy, and environmental health. Population health concepts and approaches were also integrated into case studies and discussion sessions within the broader POM curriculum.
The introduction of the population health curriculum in 2006 also offered an educational home for what had previously been a stand-alone community project requirement. Beginning in 2003, first-year medical students had been required to carry out small-group projects in partnership with a variety of community-based organizations and governmental partners. In the early years (2003–2004 and 2004–2005), student groups selected the project topics, and course instructors supported students by linking them with community partners and other stakeholders on the chosen topic. By 2005–2006, students were building on the work of previous groups, and in many cases community projects were being “handed down” from one group to another. Stanford established the Office of Community Health (OCH) in late 2005, providing an infrastructure for sustaining these and other community partnerships at an institutional level and identifying the community-defined needs that could best be met through the projects. Beginning in 2006, the OCH also supported the students in developing and implementing their projects. Each student group performed background research on their chosen topic, wrote “foundation papers” describing their topic and its link to the classroom-based material covered in the POM course, defined clear project objectives and outcomes, and concluded their work with a poster symposium at the end of the first year of medical school.
By merging the refined project requirement with the consolidated and expanded population health content, population health faculty and staff at Stanford sought to build a foundation for a coherent program of classroom-based and experiential learning across multiple years of medical education. Whereas all first-year students engage in the core population health curriculum, elective options allow some to delve further into population health scholarship via a medical school concentration and/or pursuit of a master of public health degree at the University of California, Berkeley. This spectrum of opportunities is shown in Figure 1. The public health practicum, currently being planned for year two students, will provide direct field exposure to the public health infrastructure, highlighting the importance of disease surveillance, disaster preparedness, immunization campaigns, and community-level health interventions. A colloquium planned for the third and fourth years will help to solidify and integrate students' understanding of population health in their clinical clerkships. Realizing these plans will help to ensure that population health themes are embedded and reinforced across the entire four years of training and beyond.
Project topics and target outcomes
The Stanford University School of Medicine enrolls 86 students per year. During a four-year period (2003–2007), first-year medical students, working in groups of three to six students, completed 68 population health projects. Course faculty and staff evaluated the projects by topic and areas of intervention as chosen by student and community partners. The project descriptions were individually analyzed by one author (E.H.) to determine the project's topic among the topics of health promotion, health services, health care access, and other. These topic domains were adapted from the existing taxonomy of Chamberlain et al.28 The classification of projects was then reviewed by another author (L.C.), and all differences were resolved by consensus to categorize each project. The target outcomes of the projects were independently categorized into broad themes by highlighting major features and coding key terms. The resulting classification of projects and interventions reflected the range of students' experiences. The present study did not fall under the Stanford University institutional review board's determination of human subjects research.
Whereas topics for the population health projects were selected through different processes, the majority of projects across the years fell under three major topic areas (see Table 1). A total of 35 (51%) of the 68 projects focused on topics related to disease prevention and health promotion, 19 (28%) of the projects focused on topics that address health care access issues, and 10 (15%) aimed at improving health services. Three student projects (4%) focused on preparing for public health emergencies, and one (1%) focused on ethical issues in the practice of medicine. The most common project topic was obesity prevention (13 total), followed by seven projects on health care access for the uninsured and underinsured.
Student projects sought to create change in three areas: health outcomes in the community, health policy, and hospital and clinic systems (including the medical school curriculum). Community-based projects that attempted to change health outcomes in the community represented 31 (46%) of the projects, which involved activities such as community education, health curriculum development, or health screening. The second-most-frequent target (25 projects; 37%) was policy change within local, state, or federal governments. These projects involved activities such as proposing legislative initiatives to policy makers, testifying at local hearings, and writing editorials for local newspapers.
Twelve projects (18%) sought to modify and improve the delivery of services in local hospitals and clinics or to change the medical curriculum. As examples, students enhanced the application of health information technology in a community clinic, whereas another group created an end-of-life curriculum for Stanford medical students. We have described representative projects in greater detail in Table 2.
A goal of the Stanford curriculum in population health is to educate medical students about determinants of health and health disparities at a formative stage of their development so that these physicians will become agents of change as they enter their careers in clinical practice or research. The population health projects evolved because faculty viewed the projects as vital to provide students with firsthand exposure, gained in local communities and clinics, of the health care needs present in their own backyards.
Matching students' interests with partners' needs
Matching students to a project in which they are interested is critical. Providing a wide range of experiences from which to choose increases the opportunities for students to work in an area about which they are passionate. The topics of the population health projects have varied during the four years of the projects. In the first year, the majority of projects initiated were based on students' interests that were then matched to community partners. This approach allowed us to build a network of community partners, year by year, who were knowledgeable about our curriculum. Projects covered a wide range of topics that varied each year; for example, in 2005 there were several projects concerning public health preparedness after Hurricane Katrina.
By the 2006–2007 academic year, the OCH had established a wide range of community partners. As a result, the majority of projects were proposed by community-based organizations, and students were matched to projects of interest. Because many community agencies were concerned about nutrition and obesity, a large number of 2006–2007 projects were related to obesity. Student interests generally aligned with those of community partners, thus facilitating a natural pairing. Projects contributed to different stages of ongoing community-defined initiatives, including needs assessment, planning, implementation, and evaluation (see Figure 2). Viewing their discrete projects as part of a larger cycle increases students' sense of accomplishment and aids in the sustainability of their contributions. The complexity of projects also varied according to the needs of the project partner. In 2006–2007, several advanced students, such as those who had completed prior public health degrees or significant community work, voiced interest in and pursued independent projects.
Projects as part of a population health curriculum
The creation of the population health curriculum helped to formalize partnerships between Stanford University's medical school and community partners. Experts from community-based organizations, county departments of public health, and a local school district contributed significantly to the development of the curriculum and the integration of the projects. The expertise of these community partners was brought into the classroom in the same way that students learn the basic sciences: by providing in-class lectures, presenting case examples, and facilitating small-group discussions.
When the population health faculty incorporated the population health projects into the comprehensive population health curriculum (Figure 1, Tier 1), classroom sessions reinforced community and policy-based learning and created the academic context to complement experiential learning. For example, a breakout session entitled The Physician's Role in Advocacy gave students an opportunity to create links between the principles of advocacy and their specific projects. Structured assignments also deepened students' understanding of the health challenges they were facing in the community. For example, students were required to research the context of the community agency, the history of their work, and the policy and epidemiologic background of the health topic. A formal evaluation of the student and community partner experiences with the population health projects is currently under way.
Challenges in implementing population health projects
As faculty for the population health curriculum, we experienced many challenges while implementing this curriculum including (1) tension between student and community group interests, (2) a perception by some students that the experience was forced “volunteerism,” and (3) limitations of the time devoted to the curriculum and the projects. We discuss these briefly below.
Tension between interests.
Many medical students had significant prior experience in community engagement and had preconceived ideas about the work they wanted to do in the community. Although the collaborating faculty recognized and appreciated that harnessing these passions contributes significantly to the successful engagement of the students, we were also committed to applying the “principles of partnership” developed by Community–Campus Partnerships for Health.29 These principles, supported by the literature on service learning in the health professions, emphasize the importance of addressing community-identified concerns to create meaningful, lasting change.30,31 With this in mind, we have increasingly placed the definition of the project within the hands of our community partners. We hope that through collaboration with a diverse range of community partners—for example, public health agencies from our two adjoining counties, the public school system, and religious leaders interested in improving the health of their congregations—the project “menu” will be broad enough to engage the interests and passions of all students to the greatest extent possible.
Perception of required volunteerism.
A second challenge that we encountered while implementing the population health projects was overcoming the perception by some students that the experience constituted required volunteer work. To address this perception, it is critical that we frame the projects within the context of civic and professional responsibility and physician leadership. We must also do a better job of helping students to understand that they are being given knowledge and tools to be agents of change.
Finally, having sufficient time to devote to the projects has been a barrier, for both medical students and faculty, since the inception of the program. Gaining access to time in the congested medical student calendar was only possible through significant institutional support. During the course of four years, we have been able to expand lecture and protected class time for students to work with their project partners by seven hours (from three hours in 2003–2004 to 10 hours currently). Despite the competing priorities, we continue to seek protected class time for community engagement activities.
Iterative cycle for addressing population health issues
Throughout our four-year experience, the population health faculty and staff developed an appreciation for the distinct stages of the population health projects. Ideally, projects take place within sustained community–university partnerships and contribute to one of several stages of longer-term initiatives. The “iterative cycle” (Figure 2) of sustained work to address community health challenges has the following stages:
* Stage A, a needs assessment is undertaken, and health-related problems facing the community are described;
* Stage B, key individuals, groups, and agencies are identified who will play an important role in trying to remedy the identified problem; these partners plan a collaborative strategy for change;
* Stage C, the plan for change is implemented; and
* Stage D, the outcomes of the implemented plan are assessed.
The model shown in Figure 2 is based on similar constructs that have been used as the basis for continuous quality improvement.32 Over time, completed work feeds into new initiatives, starting fresh cycles of assessment, strategy building and planning, implementation, and evaluation.
Up to this point, students have chosen projects based primarily on topic area. However, students may have a preference for a particular stage of the iterative cycle. We are interested in exploring how best to highlight the stages of population health projects during the process of project selection. Does student enthusiasm for a project depend on the stage of the project? Do more “advanced” students engage more readily in one stage than in another? Are some students more likely to engage successfully in the needs assessment stage compared with, for instance, the evaluation stage? In addition, as our partnerships evolve into longer-term relationships, we envision developing projects where students engage year after year in projects that advance forward through these stages. Matching a student to a project that is at a stage aligned with his or her interests may become increasingly important.
Limitations and next steps
There are several limitations to our work. Generalizing our method may be difficult because some aspects of our approach are likely community- and institution- specific. For instance, Stanford University School of Medicine gave significant institutional support for integrating population health topics into the curriculum. In addition, our campus is fortunate to be on the boundary line of two counties, and both local health departments (Santa Clara and San Mateo) have been engaging collaborators. Even so, we believe that much of this work, such as program structure and project lifecycle, can be generalized to other medical schools and communities.
Whereas this report summarizes four years of our experience, longitudinal data will be required to assess how this experience influences students' health perspectives, community and civic involvement, and career decisions after training. We are currently undertaking an in-depth evaluation of the full curriculum as part of course evaluation activities. We will assess changes in students' attitudes, knowledge, and skills gained from the curriculum. A comprehensive community partner evaluation is also underway to allow us to optimize our collaboration.
The results from this evaluation will inform our efforts to further embed and reinforce population health concepts throughout the medical school curriculum.
The Projects' Long-Term Value
Creating a sustainable contribution to population health is a primary goal in the development of projects. Through policy changes and building capacity for partnering agency, student projects create lasting changes to impact the health of populations. Simultaneously, some projects may be one-time activities that address an emergent need in the community but may not have a long-term impact.
We view medical student–community collaborations in population health projects as analogous to medical student clerkships in clinical medicine. Although logistically challenging, we believe these experiences provide great value to students within a medical school curriculum. Meaningful projects can be conducted, and, when contextualized into a comprehensive population health curriculum, they can provide future physicians with an experiential counterpart to population health principles that they learn in the classroom.
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