Harris, Russell MD, MPH; Kinsinger, Linda S. MD, MPH; Tolleson-Rinehart, Sue PhD; Viera, Anthony J. MD, MPH; Dent, Georgette MD
Although clinical medicine and public health were once intimately tied together, they have drifted apart in recent years.1 Our health care system is on the verge of rediscovering the value of the physician who is able to think and act in population terms. To contribute to the control of the health problems that face us today2; to deal with the issues of quality of care, access to care, and cost of care; to emphasize prevention; to interpret and apply evidence appropriately; and to work collaboratively with our public health colleagues, we need physicians who are equally comfortable in clinical and community settings. Within the clinical system, such physicians will be leaders in organizing care to optimally meet the needs of panels of patients.3 Beyond the clinic, these physicians will work with others to address such issues as lifestyle change, environmental exposure, health literacy, health disparities, and international health.2,3 One sign that such physicians may be in our future is the fact that the number of MD–MPH programs in U.S. medical schools is growing.4 In this article, we describe the MD–MPH program at the University of North Carolina at Chapel Hill (UNC).
Although medical students at UNC have long taken advantage of the close relationship between the schools of public health and medicine, the two schools did not have a formal MD–MPH program until 1997. Since its inception, the MD–MPH program has sought to introduce clinicians to the population sciences and assist them with integrating the clinical and population sciences into a new and different way of thinking and acting. In short, the program does not expect that students will leave the clinical arena, but rather that they will become health professionals who will make a greater contribution to the health of the public because of their ability to think and act at a population level as well as at an individual patient level. We are currently collecting data for an evaluation of the program.
In this article, we discuss the development of the program and the curriculum, the students and faculty, and the current and planned evaluation strategies. Finally, we offer conclusions from our experience and describe some upcoming challenges.
In 1995, unofficial discussions began between faculty members of the UNC School of Public Health (SPH) and School of Medicine (SOM) who were concerned about the current MPH training for people with medical backgrounds (i.e., medical students, fellows, and faculty). These discussions were made easier because of the large number of faculty in the SOM with MPH degrees, many from the UNC SPH.
Two primary problems were identified: (1) clinicians pursuing MPH degrees (primarily fellows along with one to three medical students each year) often had different interests from those of many faculty in the SPH, and (2) few medical students were taking advantage of the opportunity to get MPH degrees.
After a series of meetings, the group developed a plan for a new MPH, the Health Care and Prevention (HC&P) Program, tailored specifically for people coming to the population sciences from the clinical sciences. The dean of the SOM offered $100,000 per year to support appropriate SOM faculty (i.e., those with training in the population sciences) to teach in the SPH; the dean of the SPH developed an infrastructure to house the new program. There was excellent support from both schools for this plan. The HC&P Program admitted its first class of 18 students in the fall of 1997; only three were UNC medical students.
Today, the HC&P MPH Program is a concentration within the Public Health Leadership Program (PHLP) of the SPH. The other concentrations within PHLP are Public Health Nursing and the Leadership Program, which is designed to further develop the leadership and public health perspective of experienced public health practitioners. This structure allows the HC&P MPH Program to take advantage of all SPH departments and to offer a broad, flexible program that can be tailored to the needs of its students.
The HC&P Program has a twofold mission: (1) to provide an educational program of the highest quality that has a focus on population and social sciences for medical students, residents, fellows, and others who have clinical science backgrounds, and (2) to help students in the HC&P program to integrate population and clinical sciences into a life course that will prepare them to contribute to improving the health of the public in a broader manner with a focus on the needs of populations as well as individual patients.
To fulfill this mission, the program's leaders have developed a set of core competencies for its graduates. On completion of the MPH degree, graduates will be able to
* apply the basic principles of the core public health disciplines: clinical epidemiology, biostatistics, prevention science, public policy analysis, and environmental health;
* critically appraise medical and public health literature;
* understand the importance of rigorous analysis of health evidence of many types, including evidence from health economics, health system analyses, effectiveness data, and patient-reported outcomes;
* demonstrate and utilize knowledge of the critical issues facing the health care system today in ensuring access, improving quality of care, and assessing cost of care;
* analyze at least one area of population health and discuss that analysis in depth;
* communicate skillfully, particularly via clear writing and speaking to a variety of stakeholders; and
* demonstrate the skills necessary for leadership within health systems.
The HC&P MPH curriculum has been designed to provide a broad education in population health sciences to students who have a clinical background. It is planned to be maximally flexible and to encourage students to take charge of their own education. The curriculum is structured to be completed in 12 months, but students sometimes require a few additional months to complete the master's paper (described later). Some students start in the university calendar's second summer session (early July to mid-August), take courses in the fall and spring semesters, and complete the master's paper and practicum requirements in the first summer semester (early May to late June). Others begin in the fall semester and complete the program after the second summer semester the following year.
The HC&P curriculum's six closely integrated components are
* the core courses, as required by the Council on Education for Public Health (CEPH), usually completed by the end of the fall semester;
* elective courses, usually taken in the spring semester;
* a practicum experience;
* an oral presentation;
* a comprehensive examination; and
* a master's paper.
We describe these components in the following paragraphs.
To receive accreditation by the CEPH, an MPH program must provide instruction in five basic knowledge areas: biostatistics, epidemiology, health services administration, social and behavioral sciences, and environmental health sciences. Whereas the traditional introductory courses in each of these areas taken by UNC SPH students meet this requirement, founders of the HC&P MPH felt that the program would be more attractive and successful if the required courses were made more relevant to clinicians' experience and interests. As such, four of the five required courses were redesigned specifically with clinicians in mind. A comparison of the traditional courses and currently required HC&P courses is shown in Table 1. The required courses provide 17 hours of credits toward the 42 hours required for graduation.
A course entitled Strategies of Prevention for Clinicians replaces the traditional introductory health behavior course and is in many ways the foundational course of the program. The course makes clear that although prevention may be applied to individuals in the clinical setting, it is truly a population-level activity. After a series of readings and lectures on the science of prevention, students undertake critical examinations of several examples of preventive strategies, using a combination of assigned readings, large-group discussions, and small-group meetings. The culmination of the course is the production of a critical review and analysis of preventive strategies for a defined health care problem in a defined population. The goal is that students leave the course with the broadened view that improving health is much more than an individual-level activity and that clinicians can play significant roles in public health, whether through advocacy, research, education, or policy.
We have replaced the traditional epidemiology introductory course with a course entitled Clinical Measurement and Evaluation, which explores the science of testing and randomized controlled trials as well as traditional observational epidemiology. Though not a prerequisite, the course builds on Clinical Epidemiology, a course taught to the second-year UNC medical students. We have also worked to make the traditional biostatistics course more relevant to clinicians. Finally, the HC&P Program has replaced the traditional introductory health policy course with a highly interactive course called Introduction to the U.S. Health Care System, including a strong emphasis on the structural and political determinants of the system. Students read extensively on challenges to the U.S. health system and spend class time discussing and applying the readings to contemporary dilemmas of cost, quality, and access. The course is unusual in its emphasis on the building of strong writing skills through the completion of policy papers that might serve as introductory “white papers” for policy makers on problems chosen by the students themselves. Because the program expects many of the HC&P graduates to move into policy-making positions, the U.S. health system course is designed to prepare them to think like policy analysts, policy advocates, and policy makers.
In addition to tailoring most of the required courses to meet the needs and interests of clinicians, several other courses have been developed with the MD–MPH student in mind. Most of the students take a two-semester course sequence that teaches how to critically appraise the health literature. A spring semester course entitled Master's Seminar enables coverage of various topics not dealt with elsewhere (e.g., survey development, leadership, qualitative methods) while providing guidance on writing the required master's paper using a structured timeline. This seminar course helps students, most of whom are not accustomed to writing graduate-level papers, to complete their papers on time for graduation.
In the first summer semester (early May to late June), students usually complete their practicum experience. In the practicum, the student works with a mentor to develop a set of learning objectives, to be met in part by incorporating some sort of “hands-on” experience working on a public health problem. Some students have completed this requirement by working with a research team studying a population health problem or with a team doing an evaluation of a public health program. Examples of recent practicum experiences include developing decision aids for prostate cancer screening, developing clinical resources for pre- and postoperative care of bariatric surgery patients, and working on the North Carolina state cancer surveillance system. An increasing number of students are meeting the practicum requirement by working on an international project, including traveling to another country. One recent student traveled to India to learn about tuberculosis control in that country, and another examined child malnutrition in Haiti.
Oral presentation and comprehensive examination
Students are required to give a formal oral presentation before an audience and to receive feedback on the effectiveness of their communication. The presentations are most commonly on the student's practicum or master's paper topic. The purpose of the presentation is to improve the student's skills in oral communication. Thus, from the program's standpoint, the focus is not the content per se but, rather, the delivery. Most students meet this requirement by delivering their presentations to core faculty and student colleagues during times set aside specifically for student presentations. A few students meet this requirement by giving presentations at national or regional meetings.
Students must also pass a comprehensive examination, usually taken after the end of the spring semester. The examination includes questions from five areas (i.e., health policy, clinical epidemiology, prevention, critical appraisal, and communication of health information to the public). The student has a single day to complete answers to three of the questions in an acceptable manner.
Students commonly develop their master's paper topics by early January in the beginning of the spring semester. Because the program is usually only 12 months in length, few students are able to collect primary data for a research article. Some students work with faculty in the SPH and/or SOM to perform a secondary analysis of previously collected data. For example, students have analyzed survey data from a population of patients receiving HIV care who have substance use disorders; others have examined data from focus groups of minority community leaders about community interest in participation in research studies. Other students satisfy the master's paper requirement by conducting a systematic review of a focused health question. Recent examples of topics examined by systematic reviews are diabetes as a coronary heart disease risk equivalent, and the magnitude of overdiagnosis and overtreatment in screening for prostate and breast cancers. Students may also conduct a policy analysis of an important public health issue. A recent example of such a policy analysis in global health is an analysis of the feasibility of adopting alternatives to pap smears in poor and remote regions of Honduras. Another example in the U.S. context is an analysis of the decision in New York City to ban trans fats in restaurants and its likely consequences. Students may also conduct evaluations of public health programs. A recent example includes evaluation of HIV screening in an inner-city adolescent health care clinic.
Students must have two readers for the master's paper; often, these are faculty from the two different schools. Students work most closely with their first reader, usually completing at least three or four drafts before the paper is accepted. An important aspect of the master's paper is demonstrating facility in written communication. Most master's papers are 40 to 60 double-spaced pages, with multiple references. Each year, several students write shorter versions of their master's papers for publication in peer-reviewed journals.
For most students, the master's paper is the last requirement that they must meet. Although many students are able to complete the program in 12 months, some continue to work on their master's papers during the next year of medical school. This is often because they have chosen an especially challenging topic, or sometimes it is because they need additional time to learn the process of communicating effectively within the longer master's paper format. These students usually graduate with their MPH degree in December rather than the previous August.
The HC&P Program has 8 to 10 primary faculty who teach core courses. All of them have faculty appointments in both the SPH and the SOM. Another 10 to 12 faculty (most, once again, with dual appointments) are very familiar with the program and serve as mentors (and often readers for master's papers) for several students each year. Another group of faculty (some from the SPH and some from the SOM) have a general understanding of the program and occasionally serve as mentors or readers. Finally, a larger group of faculty, primarily from the SOM, are asked to serve as mentors to students with a special interest in a particular area. These faculty often have little initial understanding of the program; core HC&P faculty provide an orientation to the program for them.
The program seeks to have every student develop a strong relationship with at least one faculty member with a background in the population sciences—a mentor. One of the tacit goals of such mentorship is for the MD–MPH student to interact closely with someone whose work combines the clinical sciences with an understanding of the population sciences. In this way, students can get a better idea of how they can use what they are learning in the master's program. A mentor is also someone with whom the student can talk about career options and future plans. Because these relationships depend much on personalities and interests, students are encouraged to seek out their own mentors, with help from the program. In some cases, the program provides lists of faculty for students to contact. Another goal of the mentorship is to provide guidance on practicum development and writing the master's paper. As such, mentors often provide content and/or methods expertise. Students are encouraged to meet with their mentors on a regular basis throughout the year. Because core faculty know the SPH courses best, they serve as the primary advisers about courses.
The backgrounds of the students in the HC&P Program have changed over the years of the program. In its early years, most students were clinical fellows in the SOM, often from primary care but sometimes from specialty programs. In addition, Duke University School of Medicine students had often chosen to pursue an MPH in the HC&P Program. The number of UNC medical students gradually increased for several years, and then it increased rapidly after 2003. At present, more than 20% of the students in the UNC medical school class of 160 pursue an MPH at some time during medical school, primarily between their third and fourth years. Although some students choose to go elsewhere for their MPH, and some choose a departmental MPH (primarily Maternal and Child Health or Health Policy and Administration) at UNC SPH, the great majority of UNC medical students pursue their MPH within the HC&P Program. These are students with wide clinical and public health interests; not all are interested in primary care disciplines.
The numbers of students entering the HC&P MPH Program and UNC medical students entering all MPH programs are shown in Table 2.
The number of Duke medical students coming to UNC to complete the HC&P program has been mostly stable at four to seven students each year. Two years had larger numbers (1999 had 13 students, and 2002 had 14).
From 2004 to the present, a larger percentage of UNC medical students in the MPH program (either HC&P or any program) are from minority groups and are women than is the case for UNC students as a whole (see Table 3). The program has not systematically studied the motivations of students who pursue an MPH. One can only speculate as to why women and minority students are more likely to pursue the MPH than others. Although students with MPH degrees go into a number of specialties, the majority gravitate toward the primary care specialties (family medicine, internal medicine, pediatrics, and obstetrics– gynecology). This may explain the overrepresentation of women, because they tend to choose primary care specialties more than men do. African American students often report that their interest in medicine stems from an interest in learning more about health care disparities and improving health access for disadvantaged and underserved populations. We believe that students from underrepresented groups may be more likely to pursue an MPH because they believe this training will give them additional tools to address these issues.
How does one measure the success of programs such as the HC&P program at UNC? Rigorous program evaluations of such curricula can be hard to execute; in particular, it is often not feasible to conduct “before and after” studies. Nonetheless, it is important to devise ongoing measures of the program's likelihood of meeting its graduates' needs at the same time that it is seeking to create the kind of population health awareness and skills we envisioned for the program. To this end, the HC&P faculty designed online and print versions of a survey to ascertain students' goals and students' assessment of how their training has prepared them to reach those goals.
This initial survey, now in the field, will be a “Time 1,” or baseline, measurement in a longitudinal study of UNC medical student HC&P graduates and their career progression. The study design involves at least three cross-sectional snapshots— in 2007–2008, 2012, and 2017 (and, perhaps, at future five-year intervals)—of HC&P graduates. In addition to these students, other UNC medical students in their graduating classes will also be surveyed. At each five-year time interval, new students will be added to the cohort. The comparison of cross-sectional and longitudinal cohort studies will help us determine both “contextual change” (change that might arise from the graduates' reaction to a changing environment) and what social scientists call “life cycle change” (change that arises from movement through the life cycle, and all that such change suggests for professional and intellectual maturation).
Because the program did not survey HC&P students before they began their studies, no true “before and after” study is possible. Instead, this longitudinal panel study will compare HC&P graduates with all graduates of the UNC SOM who are in the same cohorts as the HC&P students. This includes those who completed other ancillary programs—such as PhD or MBA programs—as well as those who added other enrichment experiences (e.g., research year) to their medical studies. This will allow investigators to form three analytic groups: (1) those who simply completed medical school without time away for an enrichment experience, (2) those who had other educational or enrichment experiences, and (3) those who completed the HC&P MPH program.
In 2006, the program faculty investigators developed and pilot tested a survey of attitudes, orientations, and assessments of skills, using extant, earlier validated items as well as new questions intended to probe graduates' evaluations of their education. After receiving IRB approval to survey alumni, the Time 1 phase of the study began with an e-mail message from three of us (G.D., R.H., and S.T.-R.). The message went to all graduates of the UNC SOM and/or HC&P graduates (some of whom may not have finished their final year of medical school, and some of whom attended medical school elsewhere, only completing the HC&P MPH at UNC) between 2002 and 2006. The message reached the first potential respondents with known e-mail addresses. The investigators have made subsequent attempts to seek additional working e-mail addresses and to mail a printed version of the survey for those without known e-mail addresses.
At this writing, 135 respondents have completed the online survey. Investigators have completed preliminary analysis of the first 85 of them. Of these first 85 surveys, 30 (35%) are from MPH graduates, and 55 (65%) are from non-MPH graduates. The 85 respondents come from an original pool of 733 UNC SOM graduates between 2002 and 2006, and 36 additional HC&P graduates who were not SOM graduates because they were graduates of other medical schools attending UNC fellowship or degree programs, or because they will not be graduating from UNC medical school before 2007.
The activities surveyed in this first Time 1 questionnaire were devised and tested (or used from other validated instruments) to reflect the competencies expected of both public health and medicine graduates. The number of cases reported on here is too small to discuss in terms of statistical significance (although many relationships are significant even in this preliminary sample), but if the present trends hold, then, clearly, physicians who graduated from the HC&P MPH program assess themselves to be more active and more confident about their ability to act in most of the competency domains than is true of their peers who did not complete MPH degrees. This is especially true for domains like critical appraisal of the medical literature, where MPH graduates are overwhelmingly more likely (80% vs. 33%) than are other medical school graduates to say they are confident they can engage in the activity. Similarly, MPH graduates are much more likely not only to feel confident about critically appraising the literature but to say that their training prepared them to do it (87% vs. 46%). These kinds of differences seem to persist across most of the activities that might be viewed as at the intersection of medicine and public health, including working in population terms and identifying and adjusting to different patient beliefs. Measuring graduates' perceptions of their own capabilities and their confidence in exercising them is not the same as measuring demonstrated manifestations of those capabilities. Subsequent waves of the survey will seek career development and volunteer activity information that will allow further analysis of whether graduates are operating in domains for which the program was intended to prepare them.
A comparison over time of the HC&P MPH graduates' career development with the career development of their peers who did not earn MPH degrees will eventually provide an important evidence base from which to draw lessons about training physicians in the population sciences.
Conclusions and Challenges
Although we can measure the program's substantial growth over the past decade, we do not have similar systematic data on the motivations of the increasing number of students entering the curriculum. Our qualitative assessment is that some students (especially faculty, fellows, and some students) enter the HC&P program to prepare for research careers. Among medical students (which is the primary source of the recent increase in enrollment), students focused on a research career are a minority. Most medical students undertaking the HC&P program seem to be doing so to prepare themselves to better serve the health of the public. Their interests are increasingly health care disparities, getting care to disadvantaged groups, changing the health care system, and international health.
The HC&P Program is a true collaboration between the UNC SOM and SPH. Both schools provide support in various ways. Faculty from both schools are instrumental in the program. Core faculty receive financial compensation for their time, although many faculty mentor students without extra compensation. Students do not receive funding for the program, although in-state tuition is relatively low.
With educational programs, it is sometimes difficult to know what good we are doing. Our vision is to train physicians to integrate population thinking with their clinical thinking. Our hope is that this will help develop physicians who will make a greater contribution to the health of the public. We realize that a single year of training is likely insufficient to change the direction of a physician's career. We further realize that the students who choose to pursue MPH degrees during medical school are already different from their peers. It is uncertain what additional contribution programs such as ours provide. This issue is worth studying, and we plan to do so.
In the immediate term, we continue to face challenges. Both the SOM and the SPH support the program, but we are continually working to find ways to compensate faculty for the time and effort they contribute to our students. Although coordination between the two schools has been superb, we have recently formed an oversight committee with representatives from each school appointed by each dean to further enhance coordination and communication. Although program visibility among the medical students is high, we are working to increase program visibility within the faculties of both the SOM and the SPH. We are developing a new independent Web site that may assist us in this effort.
In summary, the University of North Carolina has made a substantial effort to provide a more in-depth educational experience in the population sciences to complement the traditional medical curriculum. The program has been popular among students. Our hope is that it will lead, over time, to a new and more population-minded physician, who can make a greater contribution to the health of the public.