Finkelstein, Jonathan A. MD, MPH; McMahon, Graham T. MD, MMSc; Peters, Antoinette PhD; Cadigan, Rebecca SM; Biddinger, Paul MD; Simon, Steven R. MD, MPH
Broad agreement exists regarding the need to train physicians in new skills that support the health of populations. Healthy People 2010, a set of comprehensive health objectives for the United States released in 2000 under the auspices of the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services, includes population health targets and also identifies population-based determinants of health that require attention.1 The Institute of Medicine (IOM), in reports in 2002 and 2003,2,3 also emphasized the need to educate physicians in public health, population sciences, and health policy. This includes physicians' development of a broad perspective of the determinants of health, as well as specific skills in epidemiology, biostatistics, informatics, social and behavioral sciences, and others. A more recent IOM panel4 reinforced the premise that all physicians must be trained in public health content areas, though their ultimate relation to public health practice may vary. This group added leadership, clinical and preventive services, and public health emergency preparedness to the list of topics recommended for inclusion in the education of all physicians.
The Association of American Medical Colleges (AAMC), through its Institute for Improving Medical Education, highlighted areas of population health that should be included in all undergraduate medical education programs to ensure that future physicians are able to balance individual and population health needs.5 Furthermore, medical students themselves see the need for better training in public health and population sciences.6 Similar arguments for the need for population sciences training for dentists have been articulated by the American Dental Education Association.7 Dental educators were part of a broad panel of health professions stakeholders that developed a comprehensive curriculum framework of skill areas appropriate for inclusion in the training of health professionals.8
In this article, we describe the development and experience to date of a course at Harvard Medical School that began in 2006–2007 and that seeks to implement population health education early in the education of our students, to meet the needs outlined above.
Origin and Philosophy of the Course
In 2005, Harvard Medical School was selected for funding as a Regional Medicine–Public Health Educational Center by the AAMC and the U.S. Centers for Disease Control and Prevention (CDC).9 A primary initiative of this Center was the development of a new course for first-year medical and dental students entitled Clinical Epidemiology and Population Health, introduced as a component of a major redesign of the curriculum at Harvard Medical School. Course planners (including us, the authors)
* began with the core value, shared by others,8 that population sciences must be effectively integrated into the education of all future physicians and dentists, rather than being the purview of only a subset;
* aimed to design an educational program that would help students view the clinical care of individuals and population-based prevention, screening, and intervention as a single continuum of interlocking approaches; and
* sought to help students view physicians as part of a public health system operating at the local, state, and national levels.
Though one could argue that population health education would be more effective at a later point in the curriculum, subsequent to mastery of basic biomedical sciences and clinical problem solving, we believed that a population health framework should be introduced early in the curriculum as a foundational element, akin to basic biomedical material. We sought to capitalize on the entering students' readiness to engage with population-level issues in health and health care. Although students may not be able to diagnose appendicitis on arrival, they increasingly matriculate with a sophisticated view of some of the challenges our society faces in improving the health of the population overall and with a passion to eliminate the disparities in access to health care in the United States.10
Clinical Epidemiology and Population Health replaced a required course in clinical epidemiology that met once weekly during the first semester. We sought to develop our new course with a completely different structure: daily meetings for a one-month period, use of intrinsically engaging and contemporary population health topics, and integration of a variety of learning settings and pedagogic techniques. Our goals, course structure, choice of content, and methods for student evaluation all reflected our desire to provide experiences that would be effective in helping students develop population health perspectives and competencies.
Course Development and Goals
The course was developed during an eight-month period by a group of eight experienced educators in epidemiology (six physicians and two doctoral-level epidemiologists, most of whom had been faculty of the prior course in clinical epidemiology) and an educational specialist from the Harvard Medical School Academy Center for Teaching and Learning. This group met approximately monthly to develop a shared vision of course objectives, agree on a natural flow for teaching relevant skills, and identify population health content areas with which to link skills teaching.
We articulated one overarching goal for students: to understand that care for individuals and promotion of the health of populations represents a continuum of strategies, all requiring engagement of physicians.
Our specific objectives were for students to gain knowledge and to achieve skills in the following areas:
* Basic epidemiology and biostatistics, including understanding common study designs, at a level needed to critically interpret both clinical and epidemiological studies
* Elements of causal inference, confounding, and other threats to the validity and generalizability of medical research findings
* Decision sciences, including skills for making clinical decisions and decisions regarding population-level (or policy) interventions
* Population-level prevention and health promotion strategies, including population-based screening and behavior change strategies
* Physicians' roles in the public health system, under both routine conditions and in emergencies
* Population-level surveillance and intervention strategies, including the use of information technology for disease surveillance and the monitoring of adverse effects of drugs and vaccines
Clinical Epidemiology and Population Health was an intensive, four-week block course taught in January of the first year for all 170 medical and dental students. It met for two hours each morning, for a total of 45 student contact hours, in a combination of complementary learning formats, chosen to fit with both the course objectives and the school's educational philosophy, which emphasizes active, problem-based, and student-directed learning. Course faculty were two codirectors, eight conference leaders, and 42 tutorial facilitators. The formats included small-group problem-based learning tutorials, conferences, and lectures (see Figure 1). This combination maximized the opportunity to teach new concepts in a manner that was challenging and engaging without being overwhelming; to balance faculty support with student direction; and to allow students to apply knowledge and practice skills frequently.
Large-group lectures are most effective as a means of transmitting new information, but they are ineffective for learning skills or engaging students in problem solving.11 We used time in lectures to engage students with topical controversies with a population health dimension, deepen their understanding of these issues with information, and provide a conceptual framework to help students understand them. We told our lecturers that instead of being merely more knowledgeable, students should emerge from lecture at least engaged, or even just short of enraged, about a current threat to population health.
Active learning can be achieved in larger groups; teacher-directed, structured discussions can ensure that all learners understand basic concepts.12 Thus, we enlisted eight faculty members to teach the majority of statistical and epidemiologic methods in conference groups of 24 students. This group size balanced the need to have instructors experienced in teaching this challenging material, while keeping the groups small enough to allow active student participation. To achieve standardization, these conference leaders met extensively in the months preceding the course to design the modules, and to share detailed conference guides. Conference leaders optimized engagement by using active problem solving through examples and “chalk talk” sessions to teach basic concepts.
Tutorials are the primary setting for problem-based learning throughout the Harvard Medical School curriculum.13 Our students met in groups of eight, with one or two medical school faculty members as facilitators. The majority (31) of the tutors were academic physicians from a range of specialties, with 11 other faculty with doctorates in epidemiology, public health, or statistics, and one in pharmacy. In these sessions, students critically appraised research articles that used the methods they had been studying, and they reviewed answers to problem sets through which they practiced more quantitative skills. Most students were assigned randomly to tutorial groups, but we allowed those with specific interests in pediatrics or geriatrics to enroll in groups with other students (and tutors) with similar content interests.
Content areas and linkages
Each of the selected content areas was addressed in the three formats described above (see also Table 1). Each topic module opened with an introductory lecture to frame the clinical, epidemiological, and population health issues. The linked conference (either immediately following or preceding the lecture) illustrated the related study design and the epidemiological and statistical content and skills. Finally, a combination of relevant articles and problem sets were discussed in a tutorial the following day to ensure active learning of key concepts and skills and to facilitate practice.
Special role-playing exercise: Pandemic influenza
One goal of this course was to introduce students to existing public health systems and to highlight the roles in these systems that the students would have as physicians in both routine circumstances and emergencies. We feared that a lecture about such systems would seem neither interesting nor relevant; more important, it would not provide a model for the level of partnership required among physicians, public health authorities, and others to ensure population health. To illustrate the complexities that physicians face in responding to emergencies, we partnered with the CDC-funded Center for Public Health Preparedness at the Harvard School of Public Health to conduct a role-playing exercise simulating an avian influenza pandemic in which students themselves took on roles of the varied professionals involved in a coordinated and effective response. For preparation before the exercise, students received a one-hour overview lecture on the structure of the public health system in emergencies, highlighting the roles of local, state, and national authorities, and they also received a brief introduction to the threat posed by influenza A virus subtype H5N1.14
The following day, students were randomly assigned, in groups of seven to nine, to take on various roles: first responders (fire, police, emergency medical services [EMS]), emergency physicians, hospital administrators, local and state public health authorities, the local mayor's office, and the press. Each group was “coached” by at least two experts who actually fill these roles in the community, including police and fire chiefs of surrounding cities, the director of EMS for Boston, the director of the Bureau of Communicable Disease Control at the Massachusetts Department of Public Health, and representatives from the Boston Public Health Commission. Each group assembled in its own room in the medical school with computer network access, and the scenario played out through a series of simultaneous emails to the participants. Whereas the key exercise information to drive the scenario was sent from a central “control” e-mail account, the individual groups were also encouraged to e-mail, phone, or make face-to-face contact with other groups.
The scenario began with a call to EMS for a 42-year-old man with flulike symptoms who had recently traveled to a country where a new, highly transmissible strain of influenza was emerging. After the fictional patient was transported to a local hospital and an appropriate diagnosis was made, students began making the appropriate public health notifications and initiating an epidemiological investigation. By day four of the scenario (45 minutes in real time), hospital emergency departments were becoming taxed both by other new cases of this virus and by large numbers of the “worried well”; police were being asked by hospitals to provide additional security (but there were concerns about the safety and health of responding officers); and the press was demanding answers from the mayor and from public health officials. During the course of the two-hour simulation, students further grappled with issues of prioritizing limited resources (from antiviral agents to intensive care unit beds), implementing social distancing and other infection control measures, and communicating both with medical providers and the public at large.
The students became fully engaged in the simulation, and they experienced, firsthand, the complexity and anxiety of a public health emergency. Most important, they experienced the frustration that results from lack of clear and timely communication and from difficulties of coordination among the various actors. After the exercise, many students independently commented on the need to view health care delivery as a “system” connecting the individual providers with the institutions and agencies that deliver and regulate care. Notably, approximately halfway through the simulation, some students took the initiative to set up a “command center” with representatives from each of the groups working together to more effectively manage the outbreak.
The simulation concluded with a group debriefing that included both the students and the professionals from the community, at which each group shared the thought processes behind their actions. The discussion focused on the attributes of successful collaboration in such situations, and it specifically highlighted the roles of health professionals in such a public health emergency. This session, including students, faculty, and public health and safety officials (many in uniform), created a powerful tableau to reinforce the importance of clinicians in public health preparedness.
Assessment of student performance
Student performance in the course was assessed in three ways.
* First, problem sets were assigned throughout the course. Most were composed of questions to answer after critically reading a primary research article. They represented a mix of quantitative problems to test specific skills (e.g., calculation and understanding of a relative risk) and others designed to assess students' understanding of key concepts such as disease surveillance or population-level approaches to prevention. In general, problem sets were reviewed in a tutorial and then handed in to the tutors for review and comment; no formal grades were assigned.
* Second, a final, written examination tested students' ability to critically review a published article (handed out three days before the exam) and interpret its data, methods, conclusions, and limitations. Additional questions focused on criteria for determining causality, issues in cost- effectiveness analysis, screening, and emergency public health response. Almost all students did extremely well on the exam, with a mean score of 24.8 (SD, 1.3) out of 26 points, suggesting mastery of basic material, but also suggesting that the exam did not adequately discriminate levels of achievement among students.
* Finally, in collaboration with a concurrent course in research methods, students designed an individual research project in basic science, clinical medicine, or population health. For some students, this represented a proposal for a future summer project; for others, it was a hypothetical study in an area of interest. Approximately one third of the students chose topics in an area related to population health. Each submitted a three-page written proposal and did a 15-minute presentation to fellow students, in a tutorial, that framed the problem, identified a study question, described a plan for data collection and analysis, and discussed the potential significance of the work.
One metric of success was the students' rating of the course. Our students are required to rate each of the courses they take on a scale of 1 (high approval) to 5 (low approval), and on several attributes. This course overall was rated 1 or 2 by 84% of the students, and 4 or 5 by only 2%. The mean rating (on the same scale of 1 to 5) for the course overall of 1.7 was substantially better than that for the previous clinical epidemiology course given at Harvard Medical School. Response to the item, “How well did this course improve your ability to bring a population health perspective to your career in medicine?” was also quite positive (mean rating, 1.8), as was the mean response to “How well did this course help you learn the concepts and skills of clinical epidemiology?” (mean rating, 1.7). The problem sets were valued most highly by the students (mean rating, 1.4). The most successful learning setting, on average, was the tutorial (mean rating, 1.6). The pandemic flu exercise was also valued by many students, according to both the mean rating (2.0) and individual comments. Realizing that these are very short-term metrics of success, we are collaborating with the HMS Center for Evaluation include measurement of population health competencies in a longitudinal assessment of students' self-reported attitudes and skills in the first, third, and fourth years of medical school.
To improve future iterations of the role-playing exercise, we asked students to voluntarily complete an eight-item, multiple-choice quiz, which was designed to measure their knowledge of public health preparedness concepts both one day before the role-playing exercise and again immediately after it. Of the 61 (of 170 total) students who completed both the pre- and postexercise quizzes, the mean number of items answered correctly increased from 3.4 before the exercise to 4.2 after it (P < .001, by paired t test).
We received valuable input from the students in a number of areas. We were surprised by the number of students who felt the course content was too elementary. Whereas 55% rated the level of content of the course appropriate, 44% believed it was too “easy.” In moving from a course that met weekly and concurrently with basic biomedical science courses to one that met daily as a primary focus for the students, we may not have fully appreciated the time and intellectual energy that students were willing to devote to clinical epidemiology and population health. In particular, we realize that the level of statistical methods taught could be deeper, and we are planning to revise the curriculum accordingly.
We have outlined above the strong consensus of national groups, including the IOM2,3 and the AAMC,5 for increasing the training of physicians in population-level determinants of health and disease, as well as in population-level interventions. We sought to build a program that would help first-year students develop their capacity to take a population perspective, whether they planned a career focused primarily on research, teaching, clinical work in the community or an academic setting, public health practice, or medical administration. Others have viewed clinical epidemiology as a “basic science for clinicians,”15 and we believe that population health skills are similar in this regard. They are “basic” in terms of serving as a necessary foundation for integration of the information and experiences that constitute medical training. Just as an understanding of human physiology allows students to integrate information about a patient with a particular disease whom they meet in a third-year clerkship, we hope that initial exposures to the paradigms, language, and skills of population health in the first year of medical school will allow students to appreciate the population-level forces that influence the illness of their patient and others. We covered many of the 19 content areas articulated by the IOM2,4 as critical for the education of all physicians, including epidemiology, biostatistics, public health emergency preparedness, and clinical and community preventive services. Others, such as ethics, social and behavioral sciences, global health, and health services administration, are covered in other required courses (Ethics, Social Medicine, Health Policy) during the preclinical portion of the revised curriculum at Harvard Medical School. We hope that through this sequence of courses that parallels the basic biological sciences, students will achieve competency in all of the areas necessary to engender a population-health perspective.
Clinical epidemiology and population health have traditionally been undervalued within U.S. medical schools. We sought to overcome this hurdle by using a curricular plan to create engagement by illustrating controversy and by providing appropriate tools to facilitate effective problem solving (see Figure 1). Students worked together on the problem sets to attain and demonstrate mastery, and they reacted positively to the new course, suggesting that the model could be useful to other educators as they design their own curricula.
We viewed the pandemic flu exercise as particularly effective. It was an example of the type of “active learning” through which teaching population health is likely to be most effective. It afforded students an opportunity to learn important content (such as the functions of the public health system in a time of crisis), but it also gave them a deep appreciation of the need for collaboration among physicians and many others to safeguard the health of the public. The fact that a large number of professionals from public safety, public health, and other professions donated a half day to teach at the medical school conveyed a very powerful message.
We faced three fundamental challenges in implementing this course. The first was to distill the content covered from the universe of topics and methods that fall under the umbrella of population health. We left aside many topics and issues (international health, many functions of public health departments, and others) that we would have liked to include. Second, we had to balance the desire of some students for a list of facts to memorize with our goal to help them develop a new framework for thinking through complex issues in health and health care. We created handouts of key points for each module that helped focus their study and allowed them to develop a sense of mastery of important material. Finally, we grappled with the view, expressed by 44% of students, that the course was too “easy.” In our next iteration, we plan to raise the level of statistical rigor taught, to meet students' stated appetite for skills needed to critically appraise today's literature on both clinical and population health issues. We will also continue to reevaluate the topic areas chosen so that they remain intrinsically interesting to first-year students, reflecting our core belief that the content must be energizing in order for students to put the time and intellectual effort into learning epidemiological and statistical methods. We also will seek to incorporate more opportunities for active learning experiences, such as that afforded by the pandemic flu exercise.
We acknowledge that our course likely has elements in common with others at schools across the country. However, this course represented a reinvigoration of our school's commitment to population health, not only in the first year, but throughout the four-year curriculum. Students are expected to be able to critically review and incorporate findings from the published medical literature in their problem-solving tutorials throughout their second year, and participate in additional exercises in evidence-based practice in their third year. We now face the challenge to provide consistent exposure to population health themes through these other courses, required clinical rotations, and electives, but we are optimistic that the lessons learned from this experience will usefully inform those efforts. The innovations described in this issue of Academic Medicine to integrate population health into clinical rotations can help move ongoing efforts at our and other medical schools toward the ultimate goal of full integration.
Broad agreement exists on the urgent need to repair the schism, developed during the last century, between clinical medicine and population health approaches.16 Epidemic infectious disease persists, but “epidemics” of noninfectious conditions, such as obesity, are now seen as the biggest threats to health, requiring societal as well as individual responses.17,18 Furthermore, the growing realization that health care for the population, individual by individual, is becoming unaffordable in the United States, also demands more creative, population-based approaches. The ongoing experimentation across the United States in teaching population health will help to identify the fundamental components that most usefully inform the education of physicians to meet these challenges. It will be critical to evaluate the success of programmatic efforts in the long term and their effects on the attitudes of physicians, their participation in the public health system, and their ability to contribute to improvements in overall health of the populations they serve.
The authors would like to acknowledge the conference leaders who helped to shape this course and make its content come alive for the students: Matthew Gillman, Tracy Lieu, Howard Sesso, Til Sturmer, and Adrienne Randolph, as well as the 42 tutorial leaders. The authors also acknowledge our center coordinator, Irene Shui. Richard Platt, chair of the Department of Ambulatory Care and Prevention, gave us critical advice and support. Howard Koh, director of the Center for Public Health Preparedness at the Harvard School of Public Health, provided advice and collaboration. The authors also acknowledge the leadership of Jules Dienstag, dean for medical education, in helping to bring these themes into the preclinical curriculum at Harvard. Finally, the authors thank the students of Harvard Medical School and Harvard School of Dental Medicine for their engagement and feedback.