Commentary: Health Systems and Health Policy: A Curriculum for All Medical Students

Abstract

A companion article in this issue of Academic Medicine provides an example of a method for electively integrating health systems and health policy issues into medical education. However, a curriculum in health systems and health policy is crucial to the education of all future physicians and other health professionals. The Clinical Prevention and Population Health Curriculum Framework of the Healthy People Curriculum Task Force has recently recommended a health systems and health policy curriculum that includes the domains of organization of clinical and public health systems; health services financing; health workforce; and health policy process. The curriculum should commence prior to year three and continue in years three and four so that students have a framework for integrating and subsequently sharing their experiences. Current Liaison Committee on Medical Education data indicate that on average less than 70% of medical schools require any curriculum in these four domains and only 40% of medical schools include all four of these domains in their required curriculum. Incorporation all of these domains into well-defined, required curricula that are broad in scope has the potential to change the attitudes of future clinicians toward efforts to control costs, collaborate with other health professions, and influence health policies.

In this issue of Academic Medicine, Madelon Finkel and Oliver Fein describe an innovative approach to teaching comparative health care systems to medical students in an article titled “Teaching Medical Students about Different Health Care Systems.” The international student exchange they describe culminates in a case write-up that includes a critical assessment focused on costs, organization and delivery of care, quality of outcomes of care, and the politics and cultural context of health care in the host country. This approach provides a useful framework for participating students to appreciate the broader implications of the specific patient issues that they encounter.

The authors indicate that since 1999 there have been 56 case studies written by students. The exchange program, while valuable for those who participate, only touches the tip of the student iceberg. Finkel and Fein indicate that in some instances the student case studies have been incorporated into coursework at Weill Medical College of Cornell University devoted to understanding health systems and policy; yet all medical students at all institutions of medical education need to understand the key health systems and health policy issues that will confront them and their patients as they enter clinical training and practice.

How should medical students be introduced to issues of health systems and health policy? As with sex education, if students are not provided with a carefully constructed curriculum, they will learn the mechanics and adopt the attitudes of those who are only slightly more experienced. Thus it is key to ask: what should medical students know and when should they know it?

This basic question has been addressed by the Healthy People Curriculum Task Force as part of the Clinical Prevention and Population Health Curriculum Framework. I have served as a facilitator for this group, which was convened by the Association of Academic Health Centers and the Association of Teachers of Preventive Medicine and has representation from seven clinical health professions—allopathic medicine, dentistry, nursing, nurse practitioners, osteopathic medicine, pharmacy, and physician assistants—as well as their educational associations.

The Clinical Prevention and Population Health Curriculum Framework recommends four basic components for improving health professions education, including a curriculum on health systems and health policy, based on the recognition that “a systematic approach to this component has not been part of most clinical health professional curricula. The development of a coherent curriculum that provides a framework for students to use as they experience the U.S. health care system is essential.”¹

What should be included in a required curriculum in health systems and health policy? The Task Force recommended that the aims of such a curriculum must be well-defined and broad in scope, in order to prevent the curriculum from focusing exclusively on coverage provided by current insurance system such as Medicare, Medicaid, or employment-based insurance. To prepare students to understand health systems, the aim should be to equip all medical students with basic frameworks from which to think through the evolving issues of health systems throughout their careers, not merely until the system changes with the next act of Congress.

The health systems and health policy component of the Clinical Prevention and Population Health Curriculum Framework defines the following four domains as fundamental to the expected curriculum:

• ▪ Organization of clinical and public health systems
• ▪ Health services financing
• ▪ Health workforce
• ▪ Health policy process

A number of underlying principles are included in this framework, the first of which is the importance of connecting the pieces of the system. The need for continuity of clinical care and the connections of clinical care with public health structures is crucial. Health services financing should focus on the underlying determinants of cost and options for payment and cost containment. Here the Task Force recognized the need for a global focus so that students can place the U.S. system in context and consider a spectrum of options.

The focus on the health workforce includes an understanding of the roles and responsibilities of physicians. However, it also includes the seldom discussed roles and responsibilities of other health professionals. Too few medical students graduate with adequate knowledge of the structure, function, or legal authority of nurses, pharmacists, physician’s assistants, and other health professionals.

Teaching about health policy has not been a traditional component of medical education; accordingly, institutions may not have given much thought to the goals for such curricula.

The Task Force defined its basic goals for instruction in health systems and health policy as introducing students to the impacts of policy on health and clinical care, the processes involved in developing policies, and the opportunities to participate in those processes.

What is the best time in the medical school curriculum to teach health systems and health policy? Ideally students should understand the basic structure of health systems prior to their third year so that they can integrate their clinical experiences into a broader framework. Continuing the curriculum into the third and fourth years allows students to share their own experiences, discuss the role of other health professionals that they have observed, and reflect upon the positive as well as the negative aspects of the U.S. health system.

What tangible benefits can we expect from such a curriculum? Subtle and not so subtle changes in attitudes can make a big difference in how future clinicians behave. Understanding the driving forces behind the cost of care—including technology, patient aging, inefficiencies, and rising expectations—can influence how clinicians react to efforts to change the system. Understanding the roles of other health practitioners can influence attitudes toward collaborative practice and legal rights and responsibilities, as well as efforts to transform the roles of existing health professions. Understanding the process of developing and influencing health policy can affect the attitudes of future health professionals toward involvement in and responsibilities for the evolution of the health system in the U.S. and abroad.

How well are medical schools doing in accomplishing these goals? The only currently available data comes for the Liaison Committee on Medical Education Annual Medical School Questionnaire Part II.² The survey is a self-report instrument and the instructions do not define minimal versus appropriate content; therefore, a positive answer may indicate only minimal content in the required curriculum. The data suggest that on average, less than 70% of allopathic medical schools include any required curriculum for the specific domains within health systems and health policy. The percentages are lowest for the domains of health workforce (54%) and health policy (59%). The latter two are among the lowest of any domains included in the curriculum framework.^* Only 40 % of medical schools indicate that they include all four domains in their required curricula.

A formal curriculum in health systems and health policy is essential if physicians are to understand and participate in the future development of health systems. Learning exclusively on the job went out of practice in medicine nearly a century ago. It’s time that future physicians learn about health systems and health policy through more than their day-to-day encounters and conflicts with the current health system. The program described by Finkel and Fein is a laudable step in the right direction. The time has certainly come for all medical students to have similar learning experiences; for the benefit of patients and future physicians alike, medical educators would do well to learn from this example.

Acknowledgments

The author wishes to acknowledge Rika Maeshiro, MD, MPH, Assistant Vice President for Public Health and Prevention Division of Medical Education of the Association of American Medical Colleges (AAMC), for her assistance in reviewing this Commentary and providing the data.