U.S. Medical Students' Rotations in Epidemiology and Public Health at State and Local Health Departments

Abstract

Elective rotations in health departments expose medical students to public health practice and career opportunities in applied epidemiology and preventive medicine. State and county epidemiologists and health officers can serve as excellent role models for medical students. In 2000-2001, the authors identified such electives by consulting medical schools' Web sites and by contacting state epidemiologists, teachers of preventive medicine, and medical school associate deans. The authors found that electives were offered in nine state and five local health departments; these are described in detail. Those electives usually focused on infectious diseases, involved students in outbreak investigations when possible, lasted four or more weeks, were open to other students and medical residents, and were overseen by a health department preceptor with a medical school faculty appointment and a commitment to train students. Some electives included more didactic components, encouraged the student to publish a manuscript, or were coordinated by a preventive medicine residency director.

The authors observe that health departments can benefit from training enthusiastic medical students via such electives; these students bring fresh ideas to the departments. Medical school catalogs, Web sites, and word of mouth are important means for promoting these electives. Ideally, in the future every medical school will offer a state or local health department elective so that all medical students will become aware of epidemiology and public health career options. The electives reported in this article can help guide additional medical schools and health departments as they initiate such rotations.

The Association of American Medical Colleges (AAMC) recently recommended strengthening medical schools' curricula on the health of populations.¹ Compared with clinicians, few physicians in public health practice are visible role models for medical students, so students are largely unaware of public health career opportunities. While public health and epidemiology lectures may fail to attract significant interest compared with clinical topics, learning through participation in public health activities such as an outbreak investigation may create greater enthusiasm among medical students.

The Centers for Disease Control and Prevention (CDC) has provided six-to-eight-week elective rotations in applied epidemiology since 1975 for senior medical students and, since 1982, for veterinary students.² At least one fifth of the 530 medical and veterinary students who completed the CDC epidemiology elective through June 1995 subsequently returned to the CDC for postgraduate training in the Epidemic Intelligence Service³ and/or became certified in the specialty of preventive medicine. However, in recent years the CDC has been able to find headquarters placements for only about one half of the 100 students who request an epidemiology rotation each year.

Epidemiology rotations in state and local health departments can fill this unmet need and introduce medical students to careers in public health and epidemiology. Health departments can also benefit from training bright, enthusiastic medical students who bring fresh ideas that may enrich the public health work environment. In this report, we describe some best practices among epidemiology and public health electives for medical students in state and local health departments. It is hoped that these examples will encourage other epidemiologists and health officers to create new or improve existing student electives.

DATA COLLECTION

In 2000, notices were sent by electronic mail to members of the Council of State and Territorial Epidemiologists and of the Association of Teachers of Preventive Medicine, inviting recipients and their colleagues to describe their experiences for this report if they currently offered an epidemiology or public health elective for medical students that was health-department-based. A similar invitation was posted by the AAMC on its electronic listserve, which is read by associate deans of undergraduate medical education and their colleagues. We also searched the Web sites⁴ of the nation's 125 medical schools for information about student electives based in state or local health departments.

Since a potential barrier to offering a medical student elective at the state health department is the physical distance between state health departments and medical schools, we measured these distances in an atlas for the nation's 125 medical schools.⁵ These schools are located in 44 states and in the District of Columbia and Puerto Rico (which were considered equivalent to states for this report).

CHARACTERISTICS OF HEALTH DEPARTMENT ROTATIONS

We identified 13 health departments that had supervised at least three medical students on elective rotations over the five-year period from 1996 to 2001 and one state medical school that arranged student electives at either the state or a local health department. In addition, one medical school listed in its catalog a health department rotation that no student has done in recent years. At the time of our investigation, at least four state epidemiologists worked with medical students occasionally on individually arranged electives. One state epidemiologist commented that no such elective was currently offered in his state but information about how to start one would be welcome.

Key features of the 14 medical student electives are summarized in Table 1. Students learn about the electives from school catalogs, Web sites (such as those presented in List 1), or word of mouth from other students or participating faculty. Most rotation sites work primarily with students from local medical schools but can accept students from elsewhere. Most sites also offer rotations to public health students, preventive medicine residents, and other trainees. In different electives, student involvement in outbreak investigations is highly variable, depending on the unpredictable timing of outbreaks. Although the electives have much in common, each has unique features that are described below.

Table 1: Characteristics of Medical Student Electives at Selected State and Local Health Departments and at the Centers for Disease Control and Prevention, 2001

Table 1: Continued.

List 1. Web Sites for Medical Student Electives in Health Department^*

California Department of Health Services

Public health rotations through the California Department of Health Services (DHS) have been offered since the early 1980s and are usually coordinated through the DHS preventive medicine (PM) residency program. Depending on geographic flexibility and interests, students are placed in the state health department or in one of California's 61 local health departments. A student's preceptor may be a local health officer, an assistant health officer, a director of a public health program, or an epidemiologist. Electives usually last four weeks; requests for two-week rotations can sometimes be accommodated.

The co-program manager of the DHS preventive medicine residency orients the student to the structure and function of state and local public health departments and recommends appropriate textbooks and other references. Students interested in communicable diseases are usually placed with the DHS Division of Communicable Disease Control, while those interested in general public health are usually placed with a county health department for a “survey” experience. Students usually undertake one project during the rotation, such as summarizing county communicable disease statistics, conducting a focus group for the DHS preventive health care for the aged program, and developing health education fact sheets for the DHS cancer control branch. Medical students may also attend seminars of the DHS preventive medicine residency and the DHS-coordinated public health grand rounds that are held for all California public health professionals. One former rotating medical student recently joined the DHS preventive medicine residency; another former student completed that residency and became the assistant director of a chronic disease control program in a California local health department.

Los Angeles County Department of Health Services, California

The Los Angeles County health department's public health rotation for medical students and primary care residents was formally established by the county's medical director for public health within the past three years. Students from California and elsewhere are accepted for the elective if the medical director for public health and the student's faculty advisor agree on the student's learning goals. The students and residents rotate through Tuberculosis Control, STD Control, Acute Communicable Disease Control, and other programs for one to two months and may participate in outbreak investigations. An environmental health rotation is also an option. Appropriate program staff serve as preceptors during the rotation.

The rotation's objective is to help medical students and residents understand the activities of health departments and the role of clinicians in assisting health departments by timely reporting of communicable diseases and other health events. Although the rotation was not designed to recruit public health physicians, two of the eight medical students or residents who completed their public health rotations and clinical residencies during 1995-2000 subsequently obtained Master of Public Health degrees and returned as preventive medicine residents. As adjunct faculty, the medical director for public health and other health department staff also regularly give guest lectures at local teaching hospitals for primary care residents and medical students.

Miami—Dade County Health Department, Florida

Since the early 1990s, the medical executive director of the Miami—Dade County Health Department has served as the primary preceptor for the department's two-week public health elective for medical students. The student meets with the preceptor for an initial overview of public health and the department, and then spends a few days in each of several departmental programs, including public health administration, epidemiology and disease control, environmental health, and patient care activities. Additional days are spent in areas of special interest to the student. Students often assist in follow-up field visits to interview patients or their contacts after the health department is notified of a patient with a reportable disease. Students are encouraged to spend a second two weeks with the department focusing on a special project if they are interested in learning more about the field. The preceptor has a faculty appointment at the University of Miami School of Medicine and serves as the liaison between the school and the health department. She regularly lectures to first-year medical students and encourages them to consider the elective. Both the county health officer and the medical school have been supportive of the elective. Most students who complete the elective subsequently choose to enter primary care residencies.

Indiana State Department of Health

The one-month elective at the Indiana State Department of Health gives medical students a broad exposure to public health. Students observe the range of public health activities within the department and usually meet the state health commissioner and other senior staff. Based on each student's interests, a health department committee identifies a primary supervisor who is one of the department's physicians or the state epidemiologist. Each medical student is expected to select and write up an individual project that is evaluated by their supervisor as part of the grade for the elective. Recent projects have included a review of smoking cessation programs and an examination of attitudes about maternal and child health programs among Hispanics. Although the health department welcomes interested medical students, it does not actively recruit students for the elective because of the time needed to supervise each one. Health department staff seldom teach in medical student courses, but do teach regularly in courses for the Indiana University Master of Public Health program.

Iowa Department of Public Health

Since 1996, the Center for Acute Disease Epidemiology of the Iowa Department of Public Health (IDPH) has offered one-month rotations for medical, nursing, and public health students and for medical residents. The students participate in outbreak investigations, contribute to projects that involve writing, and listen to telephone consultations. Because the two largest universities are located elsewhere in the state, subsidized housing for visiting students has been identified within bicycling distance of the IDPH. Each year, approximately two medical students, one graduate student, and one resident participate in these rotations.

In addition, public health grand rounds are held at the IDPH approximately twice a month. The University of Iowa medical students doing their community medicine rotation in Des Moines are required to attend two of these sessions, and some choose to attend more. The medical students are required to read articles on various public health issues, including Morbidity and Mortality Weekly Report articles on recent outbreaks in Iowa. At the second meeting, they are asked to compare two articles on the same public health issue—one from the lay media and one from a scientific journal—to understand how the information differs. During grand rounds, the Center staff join the students for one and a half hours to discuss current outbreaks, unusual phone calls, and national and international health topics. During the next one and a half hours, students and staff physicians discuss the scope of public health careers and public health policy development. Usually at least three medical students attend each grand rounds session, but up to 15 students and residents attend on occasion. In addition, interested college students are welcome to attend the grand rounds and to shadow an IDPH staff member for a day to learn more about public health.

University of Maryland School of Medicine, with State and Local Health Departments

Since 1990, the University of Maryland Department of Epidemiology and Preventive Medicine has offered a four-week elective for senior medical students. Established and coordinated by the preventive medicine residency program director, the elective is an abbreviated version of a preventive medicine residency practicum rotation. The elective began after a discussion among preventive medicine residency directors regarding ways to interest medical students in careers in preventive medicine. Students are placed in either the state or a local health department under the supervision of the state epidemiologist and other preventive medicine physicians, who also serve as preceptors for preventive medicine residents. Students often work directly with those residents.

The rotation may include work in health department clinics, exposure to legislative and regulatory procedures, and participation in an outbreak investigation. The student maintains a daily activity logbook that is submitted at the end of the rotation and can be used to inform other students about potential rotation activities. During the rotation, the student and site preceptor design a project on a topic of mutual interest. The course director bases the final grade on the preceptor's evaluation and the student's written project summary. Student projects have included investigation of a food-borne outbreak of gastroenteritis at a wedding; analysis of county infant mortality data; development of a resource guide for parents of children with attention deficit hyperactivity disorder; and conduct of a needs assessment for an urban mobile immunization program. Student and preceptor evaluations of this elective have been uniformly favorable; some students report feeling more warmly welcomed at health departments than at many of their hospital rotations. Most students who choose this elective subsequently enter primary care careers. No extra funds support the program; the only cost is the time spent by the preceptors.

Nevada State Division of Health

The public health elective for University of Nevada medical students was re-established in 1998 by the chair of the school's Department of Family and Community Medicine and by the Nevada state health officer, who served as the primary preceptor and had formerly worked many years as a medical epidemiologist at the CDC. During the elective, students are introduced to a wide range of public health activities at the state level in Carson City as well as on the county level in Washoe County (Reno and vicinity). A public health elective in Las Vegas, supervised by the Clark County Health Officer, is also available.

Recent student activities have included investigating the impact of a broken sewer line at a casino, observing a restaurant inspection, following a health-related bill through the legislative process, conducting interviews as part of a partner notification program for HIV prevention, and accompanying a health department investigator to a local brothel as part of a sexually transmitted disease prevention program. On several occasions, the health department has provided transportation costs for a student to observe the policy-setting process at a state board of health meeting in Las Vegas. The state health officer lectures at the medical school, thus providing further visibility for the elective. Among the eight medical students who have taken the elective so far, several later became active in an anti-smoking community coalition, one subsequently took the student epidemiology elective at the CDC (List 1), and one decided to obtain a Master of Public Health degree.

New Jersey Department of Health and Senior Services

The primary preceptor for medical students at the New Jersey Department of Health and Senior Services (NJDHSS) is the state's preventive medicine residency program director. There is a close relationship between the residency program and the University of Medicine and Dentistry of New Jersey (UMDNJ) that fosters interaction between health department staff and medical students. The NJDHSS offers both research and non-research public health rotations tailored to the interest of each student. In recent years, two medical students worked on research projects on the incidence of vancomycin-resistant enterococcal bacteremia (presented at a national conference) and on trends in imipenem-resistant gram-negative bacilli in New Jersey hospitals. During the non-research elective, one medical student did a literature review as part of developing health department recommendations for reducing the risk for perinatal HIV transmission. A fourth medical student helped the NJDHSS respond to a biological incident of non—naturally-occurring anthrax by assisting with telephone consultations. This student also submitted for publication two papers on the clinical role of rapid diagnostic HIV testing.

The UMDNJ offers medical students exposure to preventive medicine through courses at both its school of medicine and its school of public health. Four faculty members for the residency program have faculty appointments to the UMDNJ, where they teach popular courses in preventive medicine, disease prevention, and infectious disease epidemiology. These courses encourage interactions with students, raising their awareness and interest in health department rotations. Recruitment for the electives include an annual roundtable session at the UMDNJ for faculty and medical students to discuss the specialty of preventive medicine and meetings of the residency program director with students in the MD—MPH program.

New Mexico Department of Health

Since the mid-1980s, the New Mexico Department of Health Office of Epidemiology has offered four-week epidemiology and public health rotations for medical students from the University of New Mexico and elsewhere. The objectives of the rotation are to become familiar with medicine at the population level and to identify and apply resources to detect, investigate, and control acute outbreaks of disease. Much time is spent conducting disease surveillance and associated case management and control activity (such as prophylaxis of contacts of pertussis cases). The Office of Epidemiology has a staff of over 45 people, including eight doctoral-level and 11 masters-level or nurse epidemiologists. The Office investigates acute outbreaks of infectious and environmental disease and analyzes conditions affecting public health, including HIV/AIDS, injury, cancer, asthma, substance abuse, lead poisoning, and environmental contamination. Students usually work closely with one primary preceptor in the Office, who coordinates both daily activities and also a research project. At the end of each day, the Office's senior epidemiologists hold a wrap-up session with the students as a means to share daily phone calls, review collective knowledge, and determine the need for other literature review or consultation.

Many students have worked on major outbreaks, such as the hantavirus investigation in 1993. When outbreaks are not available, students focus on conducting a special project such as analyzing statewide data on drug-resistant Streptococcus pneumoniae. Other practicum objectives include understanding the principles of public health surveillance and of descriptive and analytic epidemiology and how these techniques are used to detect and prevent disease. The students are also encouraged to critically review scientific literature and present their findings orally and in writing.

New York City Department of Health

The New York City Department of Health helps educate medical students and residents about their role in protecting the public's health and about career options in public health. The department's preventive medicine residency offers a formal public health elective for medical students that was first publicized to deans of New York City medical schools in 1997. Students from other medical schools are eligible but must arrange their own lodgings. Although more students currently request this elective than resources allow, it is hoped that the department will soon be able to accommodate additional students. During the month-long elective, each medical student rotates for one week through the department learning how local government fulfills core public health responsibilities, and then spends three weeks on a project in the student's area of interest. Students also attend seminars with preventive medicine residents, thus becoming familiar with this option for graduate medical education. Medical students' projects have included participating in a tuberculosis contact investigation; developing hospital-specific tuberculosis surveillance reports; assessing availability of appointments for prenatal care and cervical cancer screening; measuring expenditures for public health services; and assessing the health impact of the Welfare Reform Act on immigrant women and children.

In addition, the department's Health Research Training Program (List 1) offers paid internships to graduate and undergraduate students to develop their public health competencies. Among the 509 interns who participated in the program from summer 2000 through summer 2001, 19 medical students worked on projects that included the control of West Nile virus, prevention of HIV infection, prevention of tuberculosis, food safety, and analysis of health-services-accessing behaviors.

Akron Health Department, Ohio

The Akron Health Department serves as a “teaching health department” (a role similar to that of a teaching hospital) for the Northeastern Ohio Universities College of Medicine (NEOUCOM), with which it has a formal affiliation agreement.⁶ The primary preceptor of the medical student elective serves both as the director of the health department and as associate dean of the Division of Community Health Sciences at NEOUCOM. During the four-week elective, the preceptor orients the medical student to the functions of the health department, especially those activities most relevant to community clinicians. Students attend staff meetings and may participate in an outbreak investigation if timing permits. Students are required to select a project and write a report on an area of interest. One student recently reviewed the literature and local community programs for reducing smoking in pregnant women, and made recommendations for how to address this issue further. Students often learn about the elective by contact with the preceptor, who works part time at the school each week. The health department also provides public health rotations for many nursing, public health, and other students in its role as a teaching site.

Oregon Department of Human Services, Office of Disease Prevention and Epidemiology

Oregon Department of Human Services epidemiologists and public health physicians interact with medical students from the Oregon Health and Science University in several ways. First, health department staff participate in the curriculum for first- and second-year students by leading regularly scheduled small-group discussions about epidemiology. In addition, those staff give lectures on public health topics, such as vaccination guidelines and the purpose of disease reporting, to instill public health awareness in the state's future physicians. Twelve health department staff (including the state epidemiologist) and two local county health officers hold adjunct faculty appointments at the medical school. Health department epidemiologists are occasionally featured at public health grand rounds and give lectures to graduate students in epidemiology.

Third- and fourth-year medical students occasionally select one-month clerkships at the Oregon Department of Human Services, usually as a result of advice from faculty mentors. Supervised by the manager of the Acute and Communicable Disease Prevention section, students observe epidemiologists' responses to public health issues, participate in outbreak investigations, become familiar with the CDC's Epi-Info software, and prepare reports based on epidemiologic analyses. Since 1996, projects completed by students have included an analysis of data from a case-control study of Salmonella paratyphi B infection, a search for cases of intussusception possibly associated with rotavirus vaccine, a comparison of different surveillance systems for hemolytic—uremic syndrome, and a study of the antimicrobial susceptibility of Shigella in Oregon. The findings of some of these studies have been presented at national meetings or published.⁷

Cabell—Huntington Health Department, Huntington, West Virginia

Since 1987, the Cabell—Huntington Health Department has offered a public health rotation to senior medical students from the Marshall University School of Medicine in coordination with its Department of Family and Community Medicine. The County Health Officer serves as the rotation supervisor. The rotation exposes medical students to the work of public health professionals and their impact on the health of the general population, and helps the students understand the role of public health in the prevention and control of communicable diseases. In addition, it teaches students about the role of the health department in policy development and legal enforcement for issues such as clean-indoor-air regulations.

During the rotation, students work with the Environmental Health Division to inspect food establishments or investigate complaints. Some students become involved in current outbreak investigations if possible. Other students learn about public health response and the importance of timely disease reporting by using a tabletop scenario of an outbreak investigation. During 1998-2001, 20 students completed this two-week rotation. Since 2000, the health department has hosted a one-day visit for third-year medical students as part of their internal medicine clerkships. This visit gives the students an overview of public health and encourages them to consider participating in the two-week elective. In addition, the health department oversees a one-week rotation for first-year pediatrics residents from the Marshall University School of Medicine; seven residents participated in this experience in the past two years.

Wisconsin Department of Health and Family Services, Division of Public Health

Since 1980, an average of three senior medical students each year have completed electives in applied epidemiology at the Wisconsin Division of Public Health. The elective now includes primary preceptors in the Bureaus of Communicable Diseases, Environmental Health, and Occupational Health. Students usually read CDC applied epidemiology curriculum materials before their elective begins and select a primary project with guidance from their preceptor. Although the projects are designed to be completed during the elective, at least 17 students have done the additional work needed to publish their findings,^8,9,10 often as the student's first peer-reviewed publication. Recent projects have included a statewide assessment of group B streptococcus laboratory reporting practices and perinatal infection prevention policies, an examination of the impact of Haemophilus influenzae type b conjugate vaccines on meningitis in Wisconsin, an assessment of the occurrence of mesotheliomas in women, and the development of a model to establish health priorities.

The elective's preceptors, the state chief medical officers and state epidemiologists for communicable diseases and for environmental and occupational health, have faculty appointments in the University of Wisconsin Departments of Preventive Medicine, Pediatrics, and Environmental Studies. The electives have been sustained through institutional interest and personal commitment of state epidemiologists and other Division of Public Health epidemiology staff. Many of the elective students have worked closely with Epidemic Intelligence Service (EIS) officers who are on field assignments from the CDC. At least nine elective or longer-term research students subsequently became EIS Officers with the CDC, and all are currently employed in public health; at least five other students have pursued other avenues to training or careers in preventive medicine.

Geographic Considerations

Table 2 lists the medical schools located close enough to their state health departments' offices that students may consider commuting for an elective. Sixty-four of the 125 U.S. medical schools (51%) in 37 states, the District of Columbia, and Puerto Rico are located within a one-hour drive (approximately 60 miles) of their state health departments. While the other 61 medical schools (49%) are located more than a one-hour drive from their state health departments, all medical schools potentially have access to a nearby county or city health department for electives.

Table 2: The 64 U.S. Medical Schools Located within Commuting Distance (Approximately 60 Miles) of State or Territorial Health Department Offices^*

DISCUSSION

Most medical student electives that were being offered in state and local health departments at the time of our study focused on infectious diseases, involved students in outbreak investigations when feasible, lasted four or more weeks, and were overseen by a health department preceptor with a medcal school faculty appointment and a personal commitment to training students. Our findings show that almost all electives involve the student in a specific project selected to be of interest to the student and of value to the health department. Several sites encourage the students to publish their project results. Most of the health departments offer a similar elective experience to other trainees, including public health students, clinical housestaff, and preventive medicine residents.

Some electives include didactic components such as attendance at departmental public health grand rounds or preventive medicine residency seminars. At least one health department holds daily wrap-up sessions that allow the medical students to discuss current issues with the office's senior epidemiologists. A few sites offer electives as short as two weeks; short rotations may be more attractive to students with limited elective time, but make it more difficult for the student to become involved in a substantial project.

Some sites focus on teaching applied epidemiology, especially where the state epidemiologist is the primary preceptor. Although student involvement in an outbreak investigation is an exciting and visible component of public health practice and often the highlight of the rotation, the occurrence of an outbreak is unpredictable, and student involvement cannot be ensured in every rotation. At least one site offers a tabletop exercise in outbreak investigation for students unable to participate in an actual outbreak; two such exercises are available as computer-based training programs from the CDC.^11,12 Other sites focus on ensuring broad exposure to public health practice in their electives, especially where a health officer is the primary preceptor. Activities in these electives may include analyzing disease surveillance data, conducting a needs assessment for a public health program, observing relevant legislative hearings, and inspecting a food establishment with a sanitarian, as well as participating in an outbreak investigation, if available.

We identified three models for the creation and maintenance of these medical student electives.

• For nine electives (given at Los Angeles, Miami—Dade, Indiana, Iowa, Nevada, New Mexico, Oregon, Cabell—Huntington WV, and Wisconsin), the state epidemiologist, state or county health officer, or other senior health official took direct responsibility for establishing and supervising students on these electives.
• For four electives, the director or staff of the preventive medicine residency program at the health department (California, New Jersey, New York City) or state medical school (Maryland) took responsibility for coordinating these electives or providing personal supervision of the students.
• For one elective (in Akron), the preceptor works directly with medical students in his capacity both as health department director and as medical school associate dean.

One barrier to student electives in health departments is lack of awareness among medical students that these opportunities exist, which could be improved by listing the electives in medical school catalogs and by increased visibility on the Web sites of medical schools (List 1) and the Web site of the American Medical Student Association.¹³ In addition, medical students and health department supervisors involved in such electives can publicize the opportunity by presenting their experiences and publishing highlights in school newspapers.

For the 64 medical schools located within a one-hour drive of their state health departments, the logistics of setting up a state health department elective should not be difficult. For medical schools at greater distances, the state health department can assist with logistics, as is done in Iowa with subsidized student housing. Medical schools can also collaborate with nearby city or county health departments to set up rotations, as described in this report. Other sites at which medical students can gain public health experience include fellowships sponsored by the American Medical Student Association,^13,14 international health electives,¹⁵ Indian Health Service rotations,¹⁶ and MD/MPH dual-degree programs.^17,18 In addition, medical students may be able to take public health courses, especially if their medical schools are near schools of public health.

Several limitations of this report should be considered. We cast a broad net to identify medical student electives in health departments, but cannot estimate how many were missed. We examined the online catalogs of all 125 U.S. medical schools, but not all schools list their elective offerings on the Web. We invited state epidemiologists, preventive medicine teachers, and medical school associate deans to describe their electives, but did not conduct a formal survey or make further contact with non-respondents. We did not evaluate the educational value of specific activities within different electives. We did not examine health department electives that were individually arranged on an occasional basis, or medical school courses that included lectures by health department staff¹⁹ or visits to a health department.²⁰ Finally, only anecdotal information was available about the career choices of the students who did these electives.

Despite these limitations, this report is, to our knowledge, the first published description of likely best practices among health departments that offer medical student electives. Health departments that are creating new electives can examine the range of common and innovative activities described in this report and select those activities most suitable for their settings.

Medical student electives at health departments are critical to recruiting in the field of public health because they expose students to physician role models for careers in public health and preventive medicine. Ideally, every medical school will, in the future, have a formal rotation with a state or local health department, and the elective will be listed in the school catalog and on its Web site.

Cooperation between health departments and medical schools is necessary for these medical student rotations to work. Essential elements include identifying a faculty liaison in the medical school interested in public health²¹ and an epidemiologist or other professional at the health department interested in mentoring students. The AAMC, the Council of State and Territorial Epidemiologists, the National Association of County and City Health Officials, and the CDC can all facilitate the establishment and growth of these medical student electives. As new electives are developed in a variety of health departments, sharing these experiences will be critical to help improve existing and future electives.