Garr, David R. MD; Margalit, Ruth MD; Jameton, Andrew PhD; Cerra, Frank B. MD
Dr. Garr is professor of family medicine, Department of Family Medicine, and executive director, South Carolina Area Health Education Consortium, Medical University of South Carolina, Charleston, South Carolina.
Dr. Margalit is associate professor, Department of Health Promotion, Social and Behavioral Health, and director, Service Learning Academy, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
Dr. Jameton is professor, Department of Health Promotion, Social and Behavioral Health, and director, Center for Humanities, Ethics, and Society, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
Dr. Cerra is professor of surgery, McKnight Presidential Leadership Chair, and former senior vice president for health sciences and dean of the medical school, University of Minnesota, Minneapolis, Minnesota.
Correspondence should be addressed to Dr. Garr, South Carolina AHEC, 19 Hagood Ave., MSC 814, Charleston, SC 29425; telephone: (843) 792-4431; e-mail: firstname.lastname@example.org.
The crisis of the rising cost of health care in the United States is stimulating major changes in the way care is being delivered. New models such as patient-centered medical homes and accountable care organizations are being developed with the expectation that health care professionals will address and improve the health of populations. Electronic health records and interprofessional teams will be critical to achieving the goal of better health. It is now time to bring together educators and clinicians at academic health centers, public health educators and practitioners, along with researchers, representatives from the health care delivery and financing systems, and community partners to reengineer health professions education to prepare health professions students for the health care system of the future.
The crisis of rising health care costs in the United States is stimulating major changes in the way health care professionals deliver care. Modifications in reimbursement systems, such as global fees, per-member and per-month Medicare and Medicaid payments, and changes in private insurance and self-insured payments, are playing a major role in this transformation.
Changing the Delivery Model to Improve the Health of Populations
New models of health care delivery, such as patient-centered medical homes and accountable care organizations,1 are becoming more common as health care professionals are increasingly expected to address and improve the health of populations. No longer will clinicians be rewarded only for working downstream—responding to patients’ symptoms and diseases, many of which could have been prevented. Rather, they will need to move upstream—emphasizing wellness and prevention and mobilizing the services of interprofessional teams to facilitate health care.2 These teams will be expected to deliver evidence-based disease prevention and health promotion services as well as evidence-based acute and chronic disease management for the populations for which they will be held accountable. Models such as community-oriented primary care offer a framework for providing care to populations in clinical practice and in the community.3
These new, population-related responsibilities will require a holistic approach to care that recognizes the needs of patient populations as well as an understanding of the global determinants of health.4,5 As characterized by the World Health Organization,4 these include such factors as income, education, the physical environment, and social support networks. Clinicians will need to move beyond traditional medicine to acquire a population-based understanding of such matters as how transportation affects patients’ ability to access clinical care, how costs affect patients’ ability to obtain medications and healthy fresh food, and how prevalent limitations in literacy result in misunderstanding about medications and treatment regimens.
Not only will primary care clinicians be expected to provide evidence of population health improvement, but practitioners in more specialized clinical disciplines will also be held accountable for positive, population-based results. These changes will likely involve an increasing role for team members such as social workers, chaplains, and community health workers who serve at the interface between clinical offices and the communities where patients reside.
Educating Future Clinicians to Care for Populations
The shift toward taking responsibility for the health of populations registered in clinical practices or living in a designated geographical area will require continuing reorganization of clinical care. Health professions and public health educators, clinical and public health practitioners, and lay representatives will need to establish closer working relationships to achieve the goal of changing health professions education and practice to address the health care needs of populations. This metamorphosis will require changing what, how, and where students are taught and integrating population health content into continuing education programming for practicing health care professionals.
Clinicians will be expected to show through meaningful use of electronic health records6 that their patient population is achieving improvements in health outcomes. Thus, students will need to become competent in using health information technology to conduct systematic outcome evaluation. This ability to provide data about patient outcomes—key to the design and function of accountable care organizations—will also apply to the health systems that will employ an increasing variety of providers. These systems will need to facilitate collaboration among clinicians by using quality and cost data to help improve the effectiveness and efficiency of the delivery of health care services.
Interprofessional collaborative practice encourages profession-specific roles and expertise, teamwork, and interdependence, and can foster an engaged, coordinated approach to care designed to serve populations.7 Interprofessional practice should be visible in the curriculum early on, when acculturation of students in their professions can help them appreciate the unique contributions each profession brings to patient care. This emphasis on interprofessional care must be incorporated into clinical learning experiences for students both on campus and in community-based practice settings.8
Preparing for the Health Care System of the Future
Riegelman and Garr9 have advocated equipping students with insights into public health and how it functions in the real world. In 2008, Academic Medicine highlighted population health education as a priority by publishing a series of articles calling for medical educators to prepare well-informed practitioners to provide population health.10 Others have reinforced the need to integrate public health into medical education, using examples of some curricular innovations designed to promote public and population health.11,12 A recent Institute of Medicine report emphasizes the importance of a collaboration between primary care and public health.13 Implementing such recommendations requires deliberate action.
If we expect our health professions graduates to be able to function in the health care system of the future, we need to provide them with opportunities to learn in model clinical practices, both on their campuses and in community settings where they can see population health initiatives in action. It is time to bring together educators and clinicians at academic health centers, public health educators and practitioners, researchers, representatives from the health care delivery and financing systems, and community partners to reengineer health professions education and to create innovative curricula that will prepare health professions students for the future.
Acknowledgments: The authors wish to thank Cydney Carson and Raees Shaikh for their assistance with the preparation of this commentary.
Other disclosures: None.
Ethical approval: Not applicable.
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