Sid (not his real name), a second-year medical student doing an early clinical-continuity rotation, presented a 66-year-old diabetic woman to me (D.S.); she had been grazed by a car as she crossed the street. An ambulance had transported the woman, her walker, and her nine-year-old granddaughter to the emergency department. Sid seemed confused as he tried to identify the chief complaint. “Her knees hurt and they’re bleeding,” he said. “When she fell, she landed on them. That’s really her only injury. But, actually, she’s more concerned about missing her dialysis. She gets it three times a week and has an appointment today. She’s a Spanish speaker, but her granddaughter is with her and translates. I want to get knee x-rays, but she just wants pain medicine and bandages for her knees and for us to send her for her dialysis.”
I could not blame Sid for feeling confused. Up to this point, his medical education had emphasized pathophysiology, anatomy, and other basic sciences. He could describe the bones and ligaments that attached to the knee in great detail as well as the muscles of the leg and their innervations. He could also discuss the possible genetic contributions to diabetes that would be important for this woman and her granddaughter to know so they could understand the long-term risks from those contributions. Thanks to his endocrine and renal pathophysiology course, he could explain how diabetes had led to renal failure and how the renal failure put her at risk for metabolic and infectious complications. All of these topics were important but not very helpful in sorting out the various priorities for care of this woman. We began by requesting a Spanish interpreter because our hospital had several Spanish interpreters available 24 hours a day, and we knew that information from family members who translated might not be reliable.
After we administered Tylenol, which the woman requested for her pain, and reviewed her vital signs, a police officer came by to interview the woman. “That intersection is one of the worst in town,” he said. “People are always turning right without stopping and end up hitting the pedestrians. How is she, doc?”
“So far, she seems okay, though we need to get some x-rays. It sounds like she mostly just fell after the car grazed her, but she has a lot of other medical problems, and even a minor injury can be serious.”
“Thanks, doc. I just need to get a little information and I’ll be out of your hair.”
Two Tracks to Follow
I stepped away from the bed for a moment and discussed the case with Sid. As it happened, I was involved in studying pedestrian injuries in our community with another medical student (A.P.), who had become interested in population health after presentations in our block devoted to the science of health care. We had recently looked at a map of the high-risk areas of town for pedestrian injuries, and there certainly were hotspots where pedestrian injuries occurred frequently. Some of them were associated with areas where entertainment for adults was common—bars, music, shopping. Others had large populations of minority and homeless individuals, who often traveled by foot. The police officer was right about the intersection where our patient had been injured. It was one of the hotspots on our map often involving intoxicated drivers and pedestrians crossing a heavily traveled roadway.
As I imagined this woman navigating the intersection with her walker and her granddaughter through a timed crossing light that was meant for people with average ambulation speed, I was not surprised that trouble had ensued. I found my mind going down two tracks at the same time. One track focused on this complicated patient whose injuries were likely not severe but whose fragility and ongoing chronic needs could easily be disrupted even by a minor injury. The other track was the environmental risk that led to the incident and what responsibility we as health professionals had to improve the safety of the intersection and to consider other injury prevention strategies for pedestrians. Although this lady was not going to die from her injuries, someone else might in the future, and this was a near miss that could serve as a warning to engage those responsible for road design and public safety. Usually those of us involved in acute patient care problems don’t have time to think about prevention, but with Sid’s presence as a student, I felt it was important to include prevention in our discussion.
With the help of the interpreter we learned that our patient and her granddaughter made the trek across the street to shop at a grocery store almost every day. But lately, with increasing daytime temperatures, they had been going in the early morning or evening, when visibility was not as good but temperatures were lower. The little girl was now under the care of her grandmother because her mother was in prison. Our patient had mostly abrasions over each knee where she had fallen but no fractures, and the dialysis shunt in her arm was patent and uninjured. The nurses showed Sid how to clean away the dirt and pebbles that were embedded in the wound.
Learning for the Preclinical Student in the Clinical Environment
As I discussed with Sid how he might organize his learning for this case, we reviewed an article by Chen et al1 that describes entrustable professional activities for preclinical students like him. Chen et al identified activities such as information gathering, information sharing with providers, information sharing with patients, patient advocacy, quality improvement, and information management for lifelong learning for students in the preclinical years. We decided that Sid could provide a valuable contribution by contacting the social worker assigned to the emergency department, who might be able to find a way for the woman to get groceries that would not require the dangerous trip across the intersection. We could also investigate whether the woman was able to provide adequate supervision to her granddaughter and what other options might exist. Sid contacted the dialysis center to let them know that the woman would be delayed for her appointment and would be coming over for dialysis later.
I also reviewed with Sid what would be expected of him on his upcoming clerkships. In those clerkships, he would work with residents and faculty and develop skills to prepare him for residency based on the core entrustable professional activities developed by Englander et al.2 While Englander et al list 13 activities, those that Sid would likely be using most frequently would involve gathering a history, performing a physical, prioritizing a differential diagnosis, and presenting the case. We did those together with the interpreter as the woman began to feel some relief from her pain. Unfortunately, on the list of core entrustable professional activities there was no mention of identifying the social and environmental risks for the patient and developing an interventional plan.
Recognition of this gap in medical education reminded me of the recommendations of Gonzalo et al3 in their call for a third pillar of health education, health systems sciences, which would encompass areas such as population health, social and psychological systems, health finance, quality, safety, health policy, and advocacy. Such a gap in education not only has serious consequences for patients; lack of attention to these areas could also increase costs of care for patients who incur preventable injuries that can require expensive treatments. In the case of our patient, social and environmental factors such as lack of transportation could lead to missed dialysis treatments, resulting in hyperkalemia, congestive heart failure, and another trip to the emergency department. Even worse, not preventing environmental risks could lead to more serious injuries in the future that could result, at worst, in the woman’s death or that of her grandchild.
Including Injury Prevention in the Curriculum
Unfortunately, injury prevention has not been given sufficient priority in our health professions education and delivery systems. Perhaps this is partly because the term accident has been used to describe many injury events, suggesting that the event is random and unpredictable. Yet many injuries are predictable and preventable. Pedestrian crashes can be mapped just like infectious diseases, high-risk areas and populations can be identified, and interventions such as improved roadway design with better lighting or traffic calming could be implemented with resulting reductions in pedestrian crashes.4
In addition, it may not be widely known that injury has become the leading cause of death in some age groups in the United States. For example, in children and adolescents (ages 1–19), injury was responsible for 60.6% of deaths in 2016.5 If we wish to reduce childhood mortality, we will need to include education about the causes and prevention of injury just as we have taught students about prevention of diarrheal diseases, meningitis, and pneumonia. The injury prevention model of Runyan,6 which includes analysis of vulnerabilities of individuals and the social context in which injuries occur, identifies actions we can take to make a safer walking environment. The concepts of injury prevention share much with current work in patient safety7 that recognizes the importance of creating a safety culture through education and research. We can establish a safe walking culture in the same way. The third pillar of health professions education3 distinguishes itself through its emphasis on a broad understanding of the social and environmental factors involved in an illness or injury rather than using a narrow acute care approach.
Applying Principles of the Science of Health Care Delivery Locally
After reading in a local newspaper that our own county had the worst pedestrian mortality in the country, we (D.S., A.P.) decided to apply the principles of the science of health care delivery8 to the problem.
This involved collecting data on the location of pedestrian injuries, reviewing autopsies, and organizing meetings with traffic engineers and health department personnel. We developed an initial model of local pedestrian injury that includes modifiable factors for individuals such as alcohol use and education, and modifiable factors for traffic and roadway design such as lowered speed in high-risk areas and changes in law enforcement. We decided to target high-risk crash areas, such as the one involving our patient, through working with community groups and expert consultants.
Although it is too early to begin to see results from our efforts, what is worth sharing is the process of analysis of the injury problem and the importance of including injury in our health professions educational programs. Our approach—of collecting and analyzing data and involving a coalition of community and health professionals in finding solutions—could be applied to numerous other injury problems such as homicide, suicide, motorcycle crashes, unintentional gun-related injury, drug overdose, and drowning. Although applying this approach widely may not lead to improved revenue streams for the academic health center, if it was successful, it could reduce health care spending. Phelan et al9 have described strategies for including injury prevention curricula in undergraduate medical education by incorporating them into existing curricula and clinical care experiences. We believe that a more generic approach of incorporating injury prevention into a larger population health initiative, such as described by Starr et al,8 might be more successful.
Inclusion of Population Health
In this issue of Academic Medicine, Gourevitch and Thorpe10 describe the creation of the Department of Population Health at NYU Langone School of Medicine, where much of the content and expertise about injury prevention as well as other important problems could be located and taught. This department has four core approaches: “engage community, turn information into insight, transform health care, and shape policy,” with the goal of improving population health and health equity. They explain the synergies in alignment of the clinical care delivery system with the public health perspectives of a population health department and describe current efforts to integrate population health, primary care, and health system sciences into the curriculum.
While the designation of an institutional department provides an organizing location for population health activities, there is also a risk of separating it from clinical care delivery rather than making it a central core of all health care activities. Current health care payment systems have reinforced separation of population health from clinical care because fee-for-service financial models provide incentives for increased clinical volume of services such as hospitalization or performance of expensive procedures, while population health activities attempt to reduce unnecessary hospitalizations and procedures. Recent changes in payment incentives, with penalties for readmissions related to heart failure, pneumonia, and myocardial infarction, may begin to reward a more population- and value-based approach. However, hints of unintended consequences such as increased mortality related to this policy will require continued study to understand the effects of payment policy changes on patient outcomes.11 Population health education will increasingly question previous models of health care delivery and will confront philosophical, financial, and political principles embedded in policy debates.
Questioning our previous approaches and models in health systems and services should be built into the research and scholarly expectations of our students in the health professions. As curriculum reforms have provided new opportunities for students to pursue their interests, it has not been clear what impact the changes might have on students’ scholarly publication activity. There is some reassuring information from Munzer et al,12 who report that articles by students and residents published in this journal have increased to 18.85% of all published articles in 2016, which indicates that some students and residents do have the opportunity to participate in scholarly publication during their medical school careers. This is an encouraging sign that health education scholarship is valued by students and residents. We believe that pursuit of population health problems provides the opportunity for medical students and residents to engage in creative problem solving and the sharing of solutions in a scholarly way. However, not all students have supported the implementation of health system sciences in their medical school curricula.13
Resolving Conflicts of Interest Between Financial Self-Interest and Public Interest
If we are to truly embrace health system sciences, population health, and public health as important contributors to health professions education, we will have to confront the potential conflicts of interest of payment incentives to physicians related to sickness rather than health. It will be difficult to convince students and residents that health promotion and disease prevention are important when they will get paid only when health promotion and disease prevention fail. The work of Gourevitch, Gonzalo, and Starr—some of which is cited in this issue—attempts to more fully align public interests for better care and lower costs of care with our medical education curriculum. Their ideas will add to the conversations about advocacy and social medicine described by Geiger14 in this journal two years ago. These conversations are not strictly about educational questions but are also about political and philosophical decisions concerning the creation of safer, healthier environments for our population; the fostering of better educational priorities for our students; and reestablishing the public’s trust in the health professions through our demonstrated advocacy on the public’s behalf.
Second-year student, Mayo Clinic Alix School of Medicine, Phoenix, Arizona.
David P. Sklar, MD
Editor-in-chief, Academic Medicine.
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