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Population Health Rounds: A Novel Vehicle for Training in Population Medicine and Clinical Preventive Medicine

Jadotte, Yuri T. MD, PhD, MPH; Lane, Dorothy S. MD, MPH

Author Information
Journal of Public Health Management and Practice: May/June 2021 - Volume 27 - Issue - p S139-S145
doi: 10.1097/PHH.0000000000001326

Abstract

Context

The specialty area of public health and general preventive medicine (PM) encompasses public health, population health, and health and wellness,1 and focuses on health promotion and protection and the prevention of disease, disability, and premature death of individuals in defined communities and populations.2 The Accreditation Council for Graduate Medical Education (ACGME) requirements for PM residents to demonstrate specialty-specific competence in patient care, procedural skills, and practice-based learning and improvement,2 as shown in Table 1, create 2 major accreditation directives for PM residency programs. First, residents must train both in public health practice, which when performed within health care systems is known as population medicine (ie, the epidemiologic approach to the management of clinical services),3 and in clinical preventive medicine or CPM (ie, the clinical practice of PM, including lifestyle medicine and clinical preventive services).4 Second, residency training in population medicine and CPM must be practice-oriented and go beyond didactics in a degree-granting program (such as the MPH) or residency program–specific coursework.

TABLE 1 - Learning Outcomes for Summative Resident Evaluations During Population Health Rounds, Relative to the ACGME Program Requirements They Map Onto
Item Learning Outcome Mapped PHR Activities Mapped ACGME Program Requirements and Competencies (Where Applicable) PHR Approach for Meeting ACGME Competencies and Program Requirements
1 Perform a complete medical interview tailored for prevention, health, and wellness. Patient case rounds “Each resident must have progressive responsibility for direct patient care and the management of health and provision of health care for a defined population, as specified for his/her area of preventive medicine.” (IV.C.5.b)
“Residents must demonstrate competence in their knowledge of factors that impact the health of individuals and populations, including lifestyle management and social determinants of health.” (IV.B.1.c) (Medical Knowledge Competency)
The PHR program's gradated responsibility model between the juniors and seniors helps meet this program requirement.

This aspect of the medical knowledge competency is met via 24 mo of resident engagement in hands-on learning in lifestyle medicine, MI, and BAP during the PHR sessions.
2 Present a clinical case based on the medical interview tailored for prevention, health, and wellness. Patient case rounds “For programs with a concentration in public health and general preventive medicine, residents must demonstrate competence in counseling individuals regarding the appropriate use of clinical preventive services and health promoting behavior changes, and providing immunizations, chemoprophylaxis, and screening services, as appropriate.” (IV.B.1.e.5) (Interpersonal and Communication Skills Competency) PHR offers an opportunity for residents to engage in the practice of clinical preventive medicine and to present and discuss clinical cases with peers and faculty, covering all the areas listed in this competency statement, in a continuous fashion throughout their 2 y of PM residency training.
3 Use MI and BAP to encourage health behavior change. MI practice rounds “For programs with a concentration in public health and general preventive medicine, residents must demonstrate competence in clinical preventive medicine [...].” (IV.B.1.b.1.e.ii) (Patient Care and Procedural Skills Competency)
“Rotations in direct patient care should be of sufficient length to allow residents to develop skills in providing ongoing, prevention-oriented care.” (IV.C.1.a)
TPM was implemented as an advanced-level direct patient care rotation for PM residents that helps meet this requirement for individual patient care, allowing residents to practice MI and BAP behavioral counseling skills continuously as the physicians delivering direct patient care (for 3 mo as the TPM senior resident), and as the physician learner working to hone MI and BAP skills during the 2 y of PHR.
4 Implement telehealth tools in clinical preventive medicine and population medicine practice. Data demonstration rounds “Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.” (IV.B.1.d) (Practice-Based Learning and Improvement Competency)
“Residents must demonstrate competence in their knowledge of the use of available technology, such as telemedicine, to reduce health disparities.” (IV.B.1.c) (Medical Knowledge Competency)
Senior residents rotating on the TPM service (which provides patient cases for PHR sessions) demonstrate the capacity to identify and evaluate a population health problem and to implement a quality improvement intervention informed by their analytic findings. They also actively apply telehealth tools (namely, video visits) to address gaps in preventive care for targeted populations, and they make recommendations for clinical service delivery.
5 Retrieve and analyze population health data from large national or regional databases. Data practice rounds and data demonstration rounds “For programs with a concentration in public health and general preventive medicine, residents must demonstrate competence in public health practice [...].” (IV.B.1.b.1.e.i) (Patient Care and Procedural Skills Competency) Residents participate in population-based care activities for the entire 2-y duration of the PHR including retrieval and analysis of data from clinically relevant national or regional data sets, and application of findings for a population cared for by the residents, when appropriate.
6 Retrieve and analyze population health data from clinical care data sets, including from electronic health record systems. Data practice rounds and data demonstration rounds “For programs with a concentration in public health and general preventive medicine, residents must demonstrate competence in public health practice [...].” (IV.B.1.b.1.e.i) (Patient Care and Procedural Skills Competency) Our program implemented TPM as a mandatory advanced-level direct patient care rotation for PM residents that helps meet this requirement, both for individual patient care (ie, 3 mo for the TPM senior resident) and for population-based care (ie, 24 mo of the entire duration of the PHR sessions for all residents).
7 Perform quality assessment, improvement, control, or other population-based interventions to address a given population health problem. Data demonstration rounds “Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.” (IV.B.1.d) (Practice-Based Learning and Improvement Competency) As part of PHR, all residents demonstrate competence in identifying and evaluating a population health problem and recommending a quality improvement intervention informed by their analytic findings. This experience culminates with the senior resident rotating on the TPM service who proposes and carries out quality improvement for that service.
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; BAP, brief action planning; MI, motivational interviewing; PHR, Population Health Rounds; PM, preventive medicine; TPM, telepreventive medicine.

To achieve this dual competence, residents must learn both the art and science of PM. This art is best taught via residency training, transcends the measurable competencies and milestones,5 and helps trainees learn to overcome the challenges to the integration of evidence into practice, such as organizational culture, technology, and community characteristics.6 Mastering this art, however, requires learners to actively participate in a community of practice and undertake the complex process of acquiring and converting both explicit and tacit knowledge into clinical activities.7 A community of practice is a forum that supports formal and informal interaction between novices and experts, emphasizes learning and sharing knowledge, and fosters a sense of belonging among members.7

The case for supporting PM residency, as an established training pathway to skillfully care for both individuals and populations simultaneously, has long been evident but remains only partially fulfilled.8 For example, the ACGME does not require that PM training in population medicine and CPM be concurrent and for the same population. Given the many practice settings, health systems, and levels of prevention that PM specialists engage in,1 the lack of such an ACGME criterion creates training variation across programs. This variation is a source of strength in that it exposes residents to diverse settings reflective of the types of employed positions held by PM specialists. However, residents may consequently experience a dissociation of population and CPM in their experiential learning at rotation sites.

Furthermore, inadequate funding for PM residency programs continues to threaten the public health physician workforce9 and limit their capacity to innovate in optimizing resident practice–based learning. Many programs rely on funding from local public health or health care systems that may not be attuned to the need for PM residents to engage in this dual concurrent training. Depending on their mission, they may instead insist that residents focus on either clinical or public health practice alone. This dual training is critical for preparing PM physicians to lead value-based health care and population health,10 where the capacity to simultaneously care for individuals and the population they belong to is paramount. Through the opportunity provided by the Health Resources & Services Administration in the 2018-2023 PM residency training funding cycle, our program addressed these gaps by developing a community of practice titled Population Health Rounds (PHR) designed to optimize PM residency training.

Program Description

The PHR integrates population health as a guiding framework for determinants of health and medical rounds as a practice-oriented model for teaching clinical medicine. Population health consists of health outcomes and their distribution, driven by patterns of health determinants (eg, medical care, socioeconomic status, physical environment, behavior, genetics, and public policies and interventions).11 Medical rounds are the socioprofessional practice whereby more experienced physicians (eg, attending doctors) interact with less experienced trainees (eg, residents) in numerous ways (eg, making bedside visits, reviewing medical charts, and providing feedback) to facilitate professional growth and learning the norms of medical practice.12

The PHR consists of a 1-hour weekly meeting, totaling 100 hours of practice-oriented learning during the 2 years of PM residency, engaging residents and supervising PM physicians in both population medicine and CPM concurrently. Table 2 details the structure and content of PHR sessions. Like other medical rounds, the clinical content for PHR is drawn from real or simulated patient cases, principally but not exclusively from the telepreventive medicine (TPM) service, a new clinical preventive care program at the sponsoring institution where residents practice CPM primarily under indirect supervision, as part of the gradated preparation of the learner for independent practice. The PHR sessions are structured to allow the resident to gradually assume greater responsibility for individual- and population-level care and master the specialty's competencies.2,5 Junior residents (PGY-2) assume principal responsibility for mining clinical data from the TPM service and leading discussions centered upon patient cases from TPM or other clinical care provided during rotations. Senior residents (PGY-3) assume principal responsibility for providing direct preventive patient care in TPM and leading the data-driven sessions. These weekly practical activities repeat on a monthly basis from September to June annually. During the summer months (July and August), senior residents gain practice with statistical software tools (eg, SPSS) and electronic health record systems, and junior residents focus on achieving knowledge competence in lifestyle medicine, motivational interviewing, and brief action planning. In addition, targeted practical learning activities further hone resident skills in the art of PM, including advanced skills in motivational interviewing, statistical analyses, and applications of electronic health record analytics for population health management. The Supplemental Digital Content appendix, available at https://links.lww.com/JPHMP/A754, provides a full description of the instructional materials and activities that PHR entails.

TABLE 2 - Structure and Content of the Population Health Rounds, Organized on a Repeating Monthly Cycle
Week Session Focus Responsible Party and Frequency Description of Population Health Rounds Activities
1 Patient case rounds Junior residents on a monthly basis The junior residents, assisted by the TPM senior resident, review the TPM or other clinical care notes, identify 2-3 clinically relevant aspects from the patient cases of the last 4 wk, and lead a focused discussion on these topics, which span the breath of clinical preventive medicine (including lifestyle medicine, behavioral counseling, screening, and chemoprophylaxis).
2 Data practice rounds All residents on a monthly basis The senior residents identify 1-2 clinically relevant data-related topics or questions generated from either the TPM service or the rotation sources of clinical outcome or population health data. All residents practice how to retrieve, mine, and dissect that data to identify and quantify a population health problem.
3 MI practice rounds All residents on a monthly basis Residents review the assigned reading materials and come to rounds prepared to practice the hands-on exercises contained in the text, under the guidance of course faculty.
4 Data demonstration rounds Senior residents on a monthly basis, and the rotating TPM resident on a quarterly basis The senior residents choose 1 clinical data set and come prepared to either demonstrate their analytic approach for this data set or discuss their findings from their analysis of this data set, focusing on a relevant population health problem. At the end of the TPM rotation each quarter, the rotating TPM resident presents his or her analysis of the TPM service clinical data and makes recommendations for population health improvement.
Abbreviations: MI, motivational Interviewing; TPM, telepreventive medicine.

Evaluation and Results

The implementation of the PHR began with targeted analytics, didactics, and simulated TPM patient cases in September 2019, but the 2020 pandemic provided a temporal focus on COVID-19 and its effects on the sponsoring institution's hospital employee population that catapulted the value of PHR as a learning model. The senior residents rotating in the Employee Health and Wellness service provided job-related clinical preventive services for hospital employees, including those who were exposed to COVID-19–positive patients or had themselves recently recovered from COVID-19. They were also tasked with evaluating the institutional data set tracking the spread of COVID-19 among hospital employees. Drawing from their direct patient care experience with affected employees, combined with their analysis of this emerging occupational COVID-19 case data set, the residents made recommendations to hospital leadership on COVID-19's institutional epidemiology, including incidence, prevalence, and predictive factors. Working with supervising PM faculty in the PHR, the residents trended the incidence and prevalence of positive cases within the institution's employee population (while providing ongoing occupational care for employees exposed to COVID19); determined that these cases followed a propagated epidemic curve13; identified which type of employees experienced a higher rate of positive tests and provided plausible explanations for this finding (demonstrating that nonclinical staff, and not health care professionals as would otherwise be suspected, were the most likely to contract the disease in the occupational context prior to widespread community transmission); pinpointed the time period when the implementation of nonpharmaceutical public health interventions (such as wearing masks and social distancing)14 began to reduce disease transmission; and made recommendations for improving data collection to increase the validity and utility of the data set.

A preliminary qualitative open-ended 2-question survey, with a 75% response rate (n = 6 out of 8 current residents in the program), was conducted in October 2020 to formatively evaluate resident perceptions of the value and learning outcomes of this new model. Manifest content analysis15 was then used to identify themes, which are presented in the Figure. Overall, this evaluation suggests that residents believe that learning population and CPM during PHR facilitates framing population and individual health, addressing gaps between the data and the person, and debriefing and coming together, but it requires overcoming virtual tool limitations, practicing ahead of time and live, and support for resident creativity and self-learning.

F1
FIGURE:
Results of a Formative Evaluation of Resident Perceptions, Based on a Qualitative Open-Ended Survey That Asked Residents to Provide Their General Thoughts About How Population Health Rounds Are Going So Far This Year and Describe Something(s) That They Have Learned From the Roundsa aKey themes are placed centrally, while summaries of the residents' comments are situated peripherally.

Discussion and Conclusion

The COVID-19 pandemic was a major challenge that arose during the development of this new training model. The novelty and urgency of COVID-19 at the onset of the pandemic required the allocation of some PHR sessions to conduct resident didactics on the emergent and rapidly changing evidence base for this disease. Some PHR sessions served as an opportunity for residents to debrief in a safe space of peers and the residency program leadership about any difficulties they were experiencing in delivering evidence-based care and the state of social and political affairs pertaining to the pandemic. This was not an initially planned use of the rounds but was consistent with the aim of fostering a sense of belonging among members of a community of practice.7 Based on the residents' feedback, the residency program will systematically incorporate similar debriefing opportunities into at least 1 PHR session per month moving forward.

The PM residency program is commissioned by the Department of Family, Population and Preventive Medicine,10 its home within the medical school, to address gaps in clinical preventive services for the department's Patient-Centered Medical Home, focusing on patients who are not meeting quality metrics for breast and colorectal cancer screening, and pneumococcal vaccination. The PM residents are actively delivering these services through telehealth, examining the data generated from these clinical encounters both at an individual and population level during PHR and making evidence-informed recommendations for service delivery improvements. This approach is consistent with recent calls to redefine preventive care by focusing on remote care delivery, enhancing data collection methods, and addressing disparities.16

A number of challenges must be overcome to launch and sustain PHR as a regular didactic model for PM residency training. The program leadership must provide a 1-hour protected time period each week for all residents to participate in PHR simultaneously. Incorporating this time slot into the residency program's existing didactic schedule may facilitate implementation. There must also be at least 1 specific patient population that the PM residents can engage with at both the individual and population levels concurrently. The most important factor that may impact the sustainability of PHR is lack of faculty participation due to its novelty. The program director and the associate program director, if any, must lead by example and demonstrate that they truly value PHR for their own professional development, so that other faculty will adopt a similar stance. The additional time burden that this model poses for residents could be addressed partly by identifying ways for residents to gain MPH credits, if possible, for some of the work involved in PHR. Finally, adequate data and analytic tools must be made available by the sponsoring institution and program for the residents to successfully undertake the learning required in PHR.

Other endeavors aligned with the creation of the PHR are emerging at the institution. For example, PM faculty are developing plans to expand the populations served by the PHR to include a comprehensive virtual lifestyle medicine service for employees of the sponsoring institution. Scaling of the PHR to serve underprivileged populations while emphasizing ongoing interprofessional and telehealth training is a potential future application of PHR. Seven summative learning outcomes tied to this new training model are proposed as benchmarks for resident evaluations, as shown in Table 1. Replication of the PHR model is recommended to assess its effectiveness as a learning tool for dual training in population medicine and CPM within PM residency programs.

Implications for Policy & Practice

  • Population Health Rounds consists of the concurrent application of CPM and population medicine for the same patient population as a vehicle for training PM residents to be optimally prepared to lead value-based health care and population health improvement efforts within health care systems, while meeting multiple ACGME program requirements.
  • Sustaining the provision of this dual training opportunity for PM residents depends on the creation of a community of practice at the sponsoring training institution, including adequate support for the teaching faculty, and availability and allocation of appropriate resources to facilitate advanced data analytics.
  • Population Health Rounds is a training tool that can be seamlessly integrated into the existing curricular schedule of PM residency programs and facilitated by the program leadership's commitment of sufficient protected time for the residents to engage in this activity, but one drawback may be the lack of faculty involvement due to its novelty.

References

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10. Gourevitch MN, Curtis LH, Durkin MS, et al. The emergence of population health in US academic medicine: a qualitative assessment. JAMA Netw Open. 2019;2(4):e192200.
11. Kindig DA. Understanding population health terminology. Milbank Q. 2007;85(1):139–161.
12. Roegman R, Riehl C. Playing doctor with education: considerations in using medical rounds as a model for instructional rounds. J Sch Leadersh. 2012;22(5):922–952.
13. Torok M, Nelson A, Alexander L, Mejia GC, MacDonald P. Epidemic curves ahead. Focus Field Epidemiol. 2003;1(5). https://nciph.sph.unc.edu/focus/vol1/issue5/1-5EpiCurves_issue.pdf. Accessed January 5, 2021.
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Keywords:

clinical preventive medicine; population health rounds; population medicine; preventive medicine; public health

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