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Teaching about the Changing U.S. Health Care System: An Innovative Clerkship

Finkel, Madelon L., PhD; Fein, Oliver, MD

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Changes in the U.S. health care system have necessitated modifying the scope and content of existing courses in the medical school curricula. In 1996, the Weill Medical College of Cornell University created a new, integrated public health curriculum to reflect the changes in the ways that medical care is organized, financed, and delivered. Teaching medical students to understand the constantly changing health care system is a primary objective of the new curriculum.

As part of this curriculum, the medical college instituted a required public health clerkship that focused on the health care system, to be taken in either the third or fourth year. Students are prepared for the clerkship by taking courses in epidemiology, biostatistics, and evidence-based medicine in the first year and an introduction to the health system in the second year. The two-week clerkship, which may be unique in U.S. medical education, seeks to present an in-depth exposure to issues in health care financing and delivery by means of lectures, panel discussions with experts in the field, seminars, and field assignments to health care organizations and agencies.

Dr. Finkel is professor of clinical public health and Dr. Fein is associate dean for affiliations and professor of clinical medicine and clinical public health, both at Weill Medical College of Cornell University, New York, New York.

Correspondence and requests for reprints should be addressed to Dr. Fein, Professor of Clinical Medicine and Clinical Public Health, Weill Medical College of Cornell University, 445 E. 69 Street, Suite 420, New York, NY 10021; e-mail: 〈ofein@med.cornell.edu〉.

Understanding the constantly changing health care system is viewed as an important component of the medical school curriculum. The goal is to have the student gain a greater knowledge, understanding, and appreciation of the social, economic, political, and clinical aspects of the current health care delivery system. With this in mind, an innovative public health clerkship was implemented in 1996 at the Weill Medical College of Cornell University. This clerkship, which focuses on the U.S. health care system, is a two-week required rotation that seeks to present an in-depth exposure to issues in health care financing and delivery by means of lectures, panel discussions, seminars, and field assignments to health care organizations and agencies. Students must complete this clerkship, offered every six weeks, in either their third or fourth year in order to graduate. Public health topics such as epidemiology, preventive medicine, biostatistics, health economics, and health system organization are taught in the first two years to prepare students for the clerkship. To our knowledge, this type of public health clerkship is not offered in any other U.S. medical school.

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The Clerkship

Topics

The clerkship focuses on a series of timely themes/topics:

  • Issues in quality of care
  • Managed Medicare
  • Managed Medicaid
  • Prescription drug cost management
  • Health care for the uninsured

Before the clerkship begins, each of the 12–19 students is randomly assigned to one of the five topic areas listed above. Each team of students becomes expert in their assigned topic area and prepares a comprehensive oral presentation for the rest of the class. The oral presentations represent an opportunity for shared learning experiences. In addition to conducting a comprehensive literature review, each team is scheduled to meet with experts in the field to obtain a perspective on how different organizations (public, private, nonprofit agencies) are addressing the issues pertaining to the specific topic.

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Site Visits

Each team is scheduled to visit five sites to be exposed to different organizations or agencies (see Table 1 for a typical site visit schedule for each rotation).

Table 1

Table 1

For example, the prescription drug cost management group will meet with a hospital pharmacist based at an academic medical center and with a pharmaceutical company executive, a union benefit fund manager, a pharmacoeconomist, and a hospital pharmacist based at a community hospital. The students are instructed to prepare interview questions rather than have their host merely lecture. Typical questions might include “What policies are in place to mitigate the rise in prescription drug costs?” and “What are the underlying explanations for the huge rise in prescription drug costs?” The objective of these interviews is to help students better understand how different organizations and agencies are addressing the issue of prescription drug costs.

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Seminars

Seven seminar sessions are scheduled in the afternoons (see Table 2). Students are expected to have read the assigned articles so that they can participate in seminar discussions. The first day of the clerkship focuses on an overview of the U.S. health care system. A historical perspective is presented to illustrate how managed care came to dominate the delivery and financing system in the United States. Terms are defined and the students are asked to answer such questions as “Has managed care improved the delivery of health care?” and “ Has managed care been successful in containing health care costs?” Subsequent seminars focus on specific topics that are relevant to health care policy.

Table 2

Table 2

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Sociocultural factors, health status, and health care delivery.

In this seminar the group is divided into four subgroups. Each subgroup is assigned a specific topic to research and to discuss in the seminar. Topics include gender differences in health care and their effect on health status; the effect socioeconomic and sociocultural factors on health status; differences in health status among racial groups; and geographical variations in health care. The purpose of the seminar is to heighten the student's awareness of how these factors influence health status, access, and health care outcomes.

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Managed care and the physician.

In this seminar, a guest speaker who has worked in a large managed care organization and who is now a hospitalist joins the seminar. Discussion focuses on the pros and cons of working in a managed care environment as well as options physicians have in the present system.

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Managed care and its impact on providers.

A guest speaker who is the executive director of a large academic-based physician organization (the medical school's faculty group practice) gives an overview of how hospitals and physicians have adapted to changing economic times. Discussion focuses on the various types of managed care organizations and different practice options for physicians. The economics of health care systems (including reimbursement and managed care contracting) are explained. Students’ readings for this seminar focus on the concepts of managed care management.

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Managed care and its impact on the consumer.

The hospital's patient advocate is the guest speaker at this seminar. Managed care's effect on the physician–patient relationship and how the Internet has changed the way patients interact with health care providers are topics for discussion. Patient satisfaction is another component of this session. Students are expected to have read the assigned readings in order to participate in the discussion.

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David Rogers Health Policy Colloquium.

This is a weekly interdisciplinary seminar series offered from September through June, which all students taking the public health clerkship are required to attend. It is devoted to the presentation, discussion and debate of health policy relevant topics. Experts are invited to give short presentations, followed by questions and discussion. The coordinator (OF) works with an advisory committee from the New York Weill Cornell Medical Center to organize the sessions. This series brings together senior and junior faculty from the biomedical and clinical sciences, hospital and medical school administrators, fellows in epidemiology and health services research and residents. First and second year medical students who are willing to make a commitment to attend more than 50% of the sessions are also invited to participate.

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Risk management and medicolegal issues in health care.

This seminar focuses on medicolegal issues. The guest speaker is a health care lawyer who is also a tort attorney. Discussion includes the issues raised by medical errors and medical malpractice. Assigned readings include articles on these topics.

In addition to the above seminar topics, a student debate is scheduled for the second Wednesday of the clerkship. A listing of ten debate questions is offered on the first day of the clerkship, at which time the group is asked to select three of the ten questions for debate. Of the three topics selected, each student then selects one topic to research and debate. The students are instructed to come prepared to participate by citing findings from the literature or the Internet to make their points.

On the last Thursday of the clerkship, the teams are scheduled to present their oral reports. Thirty minutes are allotted to each team, with ten minutes of questions permitted at the end of the presentation. PowerPoint presentations, handouts, and overhead transparencies are encouraged. The objective is to have the team make a coherent, concise, yet comprehensive presentation to the group in an informative and professional manner. Although the presentation is a group effort, each student is required to hand in an individually written paper based on his or her assigned topic. The written paper must demonstrate an understanding of the current literature and the student's analytic thinking.

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Evaluation

So far, evaluation of the clerkship has been through students’ and faculty members’ self-reports. Each year, these reports have been almost entirely positive and enthusiastic, with such comments as “Thank you for an awesome two weeks. The class was very informative. I learned more than I could have anticipated” and “Fabulous rotation. I now have a better understanding of our health care system.” In the future, we plan to formally evaluate the clerkship, as part of a more comprehensive evaluation of the entire public health curriculum.

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Additional Public Health Training

In addition to the required courses in public health, including the clerkship just described, students are encouraged to take electives in an area of public health that interests them. Approximately 5% of the class usually elects to take a public health elective. For those who want to receive more formal training in public health, a 45-credit MPH degree program is offered at the Mailman School of Public Health at Columbia University as a fully funded extra year to be taken at the end of the third year of medical school. The Josiah Macy Jr. Foundation endowed this Macy Scholars MPH/MD Program. Between 1% and 3% of the class takes advantage of this dual-degree program. After completing the MPH, the student returns to medical school for the fourth year.

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The Curricular Context

The recent unprecedented changes in the ways that medical care is organized, financed, and delivered, brought about in part by the managed care “revolution,” add to the impetus to review and revise medical school public health curricula. Managed care has introduced new management requirements, new fee systems, and a more business-oriented approach to medical care delivery. Teaching physicians to understand this new order and enabling them to function effectively in this new system involves changes in medical education. Almost all physicians trained within the past decade will practice within the context of large organizations, and medical care will be delivered across diffuse networks. The curriculum revision at Weill Medical College of Cornell University that fostered the public health clerkship was designed to provide an integrated, comprehensive public health curricula so that our graduates, most of whom will not be pursuing a career in public health or preventive medicine per se, will be better equipped to practice medicine in a changing health care delivery system.

© 2004 Association of American Medical Colleges