Transcript Early Integration of Public Health into Medical Education

Teaching Population Health:
An Essential Component of Context
in Medical Education
IAMSE
June 8, 2014
Heidi Gullett, MD, MPH
Assistant Professor, Department of Family Medicine and Community Health
Population Health Liaison, Cuyahoga County Board of Health
Amy Wilson-Delfosse, PhD
Associate Professor of Pharmacology
Assistant Dean for Basic Science Education
Disclosures
• No Financial Disclosures
Focus Session Objectives
1. Articulate the importance of teaching population
health concepts in undergraduate medical education.
2. Define 2-3 essential components of population
health education for medical students.
3. Describe the value of community-based learning
experiences to underscore the concepts in a
population health curriculum.
4. Describe 1-2 specific ways that population health
could be integrated into an attendee’s curriculum.
Workshop Overview
• Workshop Participant Assessment
• Population Health and Professional Competencies
• Overview of CWRU Curriculum and Block 1
– Block 1 Goals and Philosophy
– Block 1 Structure and Content
– Epidemiology and Biostatistics
• Discussion around integration of specific
population health curricular elements
–
–
–
–
–
Content
Teaching techniques
Faculty selection
Curricular timing
Challenges
•
•
•
•
Welcome!
Name
School
Role
Please tell us something fun you plan to do this
summer.
• What do you hope to gain from this workshop?
• What is a specific area of interest you would
like addressed in this workshop?
What is Population Health
• Institute for Healthcare Improvement (IHI)1
– “Any group of individuals for whom consideration of health
or health care at the level of the group is likely to advance
health.”
• Dr. Kindig’s definition:2
– “The health outcomes of a group of individuals, including
distribution of such outcomes within the group.”
• Concerned with outcomes, as well as determinants and
factors, in an effort to define the “distribution of
health”
• Evolving definition
1www.ihi.org
2Kindig DA,
Stoddard G. What is population health? Am J Public Health 2003; 93:366-369.
Tools of Population Health
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Epidemiology/Biostatistics
Disease surveillance
Data analysis
Education
Advocacy
Policy
Program design and evaluation
Research
Environmental Health
Genetic epidemiology
Process and outcome measures
Quality improvement
Community health and health impact assessments
Bioethics
Teaching Population Health from
Various Perspectives
•
•
•
•
Context depends upon perspective
Community
Patient
Public Health (Local, Regional, National,
International)
• Provider
• Payor
• Government
Why Focus on Population Health?
• Competencies and Certification Exams
– Liaison Committee on Medical Education (LCME)
– Accreditation Council for Graduate Medical
Education (ACGME)
– National Board of Medical Examiners (NBME)
– Specialty Boards
• Context for medical training and career
– Rapidly changing healthcare environment
– More broad understanding of determinants of
health
– Practical introduction to students’ new community
Why Focus on Population Health?
• Much work of population health performed by local
public health
• Public health and clinical care most often function in
isolation
• A move toward integration is critical to improve health
– Institute of Medicine 2012 Report
• Primary Care and Public Health: Exploring Integration
to Improve Population Health
IOM Report 2012
LCME Competencies
• Population Health and Civic
Professionalism
– Identifies community and population-based
health issues
– Demonstrates skills needed to improve health
and healthcare for local, national, and global
communities
LCME Competencies
• Educational Program Objectives and Milestones for
Graduation
– Applies primary and secondary prevention strategies that
improve the health of individuals and populations.
– Demonstrates ability to design community-based health
improvement intervention.
– Integrates emerging information on individuals’ biologic
and genetic risk with population-level factors when
deciding upon prevention and treatment options.
– Considers ethical and legal perspectives, patient
advocacy, health policy, and public health concerns in
clinical care.
ACGME Competencies
• Consistent with Milestone Project for all
specialties
• Six Core Competencies
– Patient Care
– Medical Knowledge
– Practice-based Learning and Improvement
– Interpersonal and Communication Skills
– Professionalism
– Systems-based Practice
In your institutions…
• How do you teach these competencies?
– Separate courses?
– Integrated within other courses?
– Other?
An Introduction to Block 1:
Becoming A Doctor
• Created as part of overall curricular revision in 2004
• Concentrated 5 weeks at beginning of medical
school (July-mid August)
• Opportunity to create a comprehensive
understanding of population health principles
• Create foundation upon which to build throughout
next 4 years
– Other preclinical blocks
– Tuesday seminars (Foundations of Clinical Medicine)
– Core clinical rotations (including IQ+)
Population Health in the WR2 Curriculum
• “Fundamental curricular revision” in 2004
• Two major goals:
1. Create opportunity for all students to conduct
meaningful research culminating in required
medical student thesis
2. Three areas create “backbone” of curriculum
•
•
Mastery of clinical skills
Civic professionalism
–
•
Understanding systems and population health are critical to
effective civic professionalism.
Leadership
Western Reserve2 Curriculum
Year I
Year II
Year III
Year IV
Core Clinical Rotations
IQ+ Program
Foundations of Medicine and Health
(20 months, including vacation)
(48 weeks, flexible scheduling)
Research &
Scholarship
BASIC SCIENCES
PHYSICAL DIAGNOSIS
(16 week block +
electives, flexible
scheduling)
COMMUNICATION SKILLS
Advanced Clinical and Scientific
COMMUNITY PATIENT CARE PRECEPTORSHIP
Studies
(CPCP)
Areas of Concentration
Electives
(10 months, flexible scheduling)
Slide courtesy of Scott Frank, MD, MS
CWRU School of Medicine
University Track Basic Science Curriculum
March Year 2
1 Week
Clinical
Immersion
(Endo, Repro,
Development,
Genetics, Mol
Biol, Cancer
Biology)
(14 wk)
Structure
(Anatomy,
Histo-Path,
Radiology)
Foundations
of Clinical
Medicine
Slide courtesy of Scott Frank, MD, MS
1 Week
Clinical
Immersion
(GI, Nutrition,
Energy,
Metabolism,
Biochemistry)
1 Week
Clinical
Immersion
(CV, Pulm,
Renal, Cell
Regulation,
Pharmacology, Cell
physiology)
(14 wk)
1 Week
Clinical
Immersion
(Host Defense,
Microbiology,
Blood, Skin,
Auto-immune)
Reflection, Integration & Assessment
(Public Health,
Inequities,
QI/Patient
Safety/Medical
Error, Bioethics,
Professionalism
Epi/Biostats)
(11 wk)
Host Defense
and Host
Response
Reflection, Integration & Assessment
(11 wk)
Homeostasis
Reflection, Integration & Assessment
(5 wk)
Food to Fuel
Reflection, Integration & Assessment
The Human
Blueprint
Reflection, Integration & Assessment
Becoming a
Doctor
Cognition,
Sensation, and
Movement
(14 wk)
1 Week
Clinical
Immersion
(Neuro, Mind
Musculoskeletal,
Cellular
Neurophysiology
Reflection, Integration & Assessment
July Year 1
CWRU School of Medicine
University Track Basic Science Curriculum
March Year 2
1 Week
Clinical
Immersion
(Endo, Repro,
Development,
Genetics, Mol
Biol, Cancer
Biology)
(14 wk)
Structure
(Anatomy,
Histo-Path,
Radiology)
Foundations
of Clinical
Medicine
Slide courtesy of Scott Frank, MD, MS
1 Week
Clinical
Immersion
(GI, Nutrition,
Energy,
Metabolism,
Biochemistry)
1 Week
Clinical
Immersion
(CV, Pulm,
Renal, Cell
Regulation,
Pharmacology, Cell
physiology)
(14 wk)
1 Week
Clinical
Immersion
(Host Defense,
Microbiology,
Blood, Skin,
Auto-immune)
Reflection, Integration & Assessment
(Public Health,
Inequities,
QI/Patient
Safety/Medical
Error, Bioethics,
Professionalism
Epi/Biostats)
(11 wk)
Host Defense
and Host
Response
Reflection, Integration & Assessment
(11 wk)
Homeostasis
Reflection, Integration & Assessment
(5 wk)
Food to Fuel
Reflection, Integration & Assessment
The Human
Blueprint
Reflection, Integration & Assessment
Becoming a
Doctor
Cognition,
Sensation, and
Movement
(14 wk)
1 Week
Clinical
Immersion
(Neuro, Mind
Musculoskeletal,
Cellular
Neurophysiology
Reflection, Integration & Assessment
July Year 1
Block 1 Goals
1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical
practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure,
and affect the health of populations.
3. Provide a basis for understanding social, behavioral,
structural, and environmental determinants of
health.
4. Provide a broad understanding of health systems.
5. Emphasize continuous process and system
improvement as a mechanism for limiting medical
error and improving both individual and population
outcomes.
Block 1 Goals
1. Provide a strong epidemiology and biostatistics
foundation to support effective application in
clinical practice and interpretation of the scientific
literature.
2. Illustrate effective means to understand, measure,
and affect the health of populations.
3. Provide a basis for understanding social, behavioral,
structural, and environmental determinants of
health.
4. Provide a broad understanding of health systems.
5. Emphasize continuous process and system
improvement as a mechanism for limiting medical
error and improving both individual and population
outcomes.
Block 1 Goals
1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical
practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure,
and affect the health of populations.
3. Provide a basis for understanding social, behavioral,
structural, and environmental determinants of
health.
4. Provide a broad understanding of health systems.
5. Emphasize continuous process and system
improvement as a mechanism for limiting medical
error and improving both individual and population
outcomes.
Block 1 Goals
1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical
practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure,
and affect the health of populations.
3. Provide a basis for understanding social, behavioral,
structural, and environmental determinants of
health.
4. Provide a broad understanding of health systems.
5. Emphasize continuous process and system
improvement as a mechanism for limiting medical
error and improving both individual and population
outcomes.
Block 1 Goals
1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical
practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure,
and affect the health of populations.
3. Provide a basis for understanding social, behavioral,
structural, and environmental determinants of
health.
4. Provide a broad understanding of health systems.
5. Emphasize continuous process and system
improvement as a mechanism for limiting medical
error and improving both individual and population
outcomes.
Block 1 Goals
1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical
practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure,
and affect the health of populations.
3. Provide a basis for understanding social, behavioral,
structural, and environmental determinants of
health.
4. Provide a broad understanding of health systems.
5. Emphasize continuous process and system
improvement as a mechanism for limiting medical
error and improving both individual and population
outcomes.
Block 1 Philosophy: The Lens
• Create a strong foundation on which to build during the
remainder of medical school.
• Create context for understanding health in a broad
sense.
– Foundation includes teaching how to measure,
understand, and affect the health of populations
– Foster integration of concepts learned in all activities
• Goal to coordinate with other faculty curricular leaders
to ensure a cohesive curriculum that serves our
students and community well.
Intentional emphasis on…
• Interprofessional importance, team-based
practice
• Diverse faculty: training, expertise, specialty,
experience
• Representation across Cleveland: local health
departments and health systems
• Highlight tremendous community health work
in our area to solidify concepts taught
throughout the block
Block 1 Weekly Themes
Problembased
Learning (IQ)
Case
Unnatural
Causes
Community
Field
Experiences
Team-Based
Learning
Week 1
Population Health
Pandemic Flu
In Sickness and
in Wealth; Not
Just a Paycheck
Week 2
Determinants of Health
Toni Jackson:
Determinants
of Health
When the
Bough Breaks;
Place Matters
Determinants of
Health/Social
Work
Population
Health
Week 3
Health Systems
Mr. Prince:
Medical Error
Collateral
Damage;
Becoming
American
Community
Health
Center/Safety
Net
Global Health
System
Comparisons
Week 4
Patient-centered care
Mrs. Sanchez:
Diabetes
Mellitus
Bad Sugar
Chronic Disease
Week 5
“Bringing It All Together”
Jack Lee: Well
Adult Care
Integration of Curricular Content
• Goal to foster reflection and integration of
core concepts across the block
• Multiple venues to encourage connection of
various learning activities with each IQ case
– Google+ Field Experience reflection posts
• Cases are correlated with the weekly theme
Highlights of longitudinal curricular
threads
•
•
•
•
•
Health promotion step challenge
Bioethics thread across block
Google+ field experience reflection blog
Online modules (IHI, APTR*)
Unnatural causes: Is Inequality Making Us
Sick?
• Epidemiology/Biostatistics
*IHI = Institute for Healthcare Improvement;
APTR = Association for Prevention Teaching and Research
Health Promotion Step Challenge
• Goal: To illustrate health behavior activity,
continuous process improvement
• Foster friendly competition and camaraderie
• Faculty and staff participation
• Prizes
• Top PBL (IQ) group
• Top individuals (staff /faculty and students)
• Students who achieve average of 10,000 steps every day
= 280,000 steps
2013 IQ Winner!
2013 Individual Winner!
Bioethics
• Incorporation into key elements of Block 1:
• Two general Bioethics introductory sessions – Week 1
• Pandemic flu exercise – Week 1
• Incorporation into individual v. population health
didactics (theory) – Week 1
• Health disparities – Week 2
• Field experiences (practical application) – Weeks 2-4
• IQ discussions – Weeks 2-4
Field Experiences
•
•
•
•
•
Determinants of Health/Social Work
Community Health Center/Safety Net
Chronic Disease
Neighborhood Correlations
PBL (IQ) facilitators receive guide for each
week with trigger questions to facilitate
Google+ posts and small group discussion
Google+
• Field experiences
– Social work
– Community health center/safety net providers
– Chronic disease
• Google+ IQ group pages (“communities” –
hidden and secure) for reflection blogs to
facilitate integrated discussion during IQ
sessions
• IQ student leaders asked to protect time in
Friday session for discussion
Online modules
• IHI Quality Improvement
– Option for certificate of completion though IHI
– Free for enrolled US medical students
• Association for Prevention Teaching and
Research (APTR)
– Population Health
– Public Health Learning
Unnatural Causes
• Health disparities documentary series
– 4 hours, 7 episodes
– Associated health policy exercises for all
stakeholders regarding health equity
– www.unnaturalcauses.org
Organization of Epi/Biostats Curriculum
• Total of 11 hours of class time
• Large-group lectures with interactive answering
options
• Background of core concepts
– Epidemiology
– Biostatistics
– Introduction to clinical study designs
• Critical evaluation of studies
– Practice using “journal club”
Slide courtesy of Doug Einstadter, MD, MPH
Epidemiology
Topics Covered
• Introduction to Epidemiology
• Association and Cause
• Samples and populations
• Use and interpretation of diagnostic tests
• The role of screening and prevention
Slide courtesy of Doug Einstadter, MD, MPH
Biostatistics
Topics Covered
• Types of Data
• Descriptive Statistics
• Hypothesis testing
• Chance and the p-value
• Confidence Intervals
• Potential errors (Type I and II)
• Power
Slide courtesy of Doug Einstadter, MD, MPH
Critical Evaluation Skills
 Study Designs Introduced:
• Cross-sectional studies
• Case-Control studies
• Cohort studies
• Randomized Controlled Trials
 Journal Club(s) to practice critical review
skills.
Slide courtesy of Doug Einstadter, MD, MPH
Block 1 Student Assessment
• Weekly during block:
– Short essay questions
– Multiple choice questions
– IQ facilitator feedback on reflections and
participation in PBL (IQ) sessions
• Following completion of block:
– Essay questions
Discussion
• Small group discussion on the following areas
of population health integration (30 min):
– Content
– Teaching techniques
– Faculty selection
– Timing in curriculum
• Small groups report on 1-2 ideas for
population health curricular integration in
your programs
Discussion
• Teaching Content
– Concept of population health
– Tools for understanding and applying population
health principles
– Epidemiology/Biostatistics
– Determinants of health
– Health systems
• Patient Protection and Affordable Care Act implications
– Quality improvement
– Integration with basic science concepts
Discussion
• Teaching Techniques
– Problem-based learning (IQ)
– Team-based learning (TBL)
– Pandemic flu tabletop exercise (medium-sized group
activity)
– Field experiences
– Google+/Social Media Tools
• Reflection
• Encouragement of participation
– Online modules
– Documentary series
Discussion
• Faculty Selection
– Content expertise
– Student exposure to interprofessional nature of population
and community health
– Local laboratory for understanding and applying
population health principles: Future research options
•
•
•
•
Cuyahoga County Board of Health population health expertise
Other local health departments
Better Health Greater Cleveland multi-stakeholder collaborative
Health Improvement Partnership-Cuyahoga
– Other considerations?
Discussion
• Timing in Curriculum
– Early inclusion of principles
– Relevance and variable interest among entering
students
– Timing of relevance evaluation
– Changing content
• Evolving field of population health
• Rapidly changing health policy
– New session in 2014 on Medicaid expansion and PPACA
impact within Cuyahoga County
Discussion
• Challenges
– Variable uptake for students from diverse
backgrounds
– Lack of context for some entering medical
students
– Timing challenges for interprofessional activities
– Large number of meaningful community field
experience sites are necessary
Block 1 in the Literature
Ornt DB, Aron DC, King NB, Clementz LM, Frank SH, Wolpaw T,
Wilson-Delfosse A, Wolpaw D, Allan T, Carroll M, ThompsonShaheen K, Altose M, Horwitz R. Population Medicine in a Curricular
Revision at Case Western Reserve. Academic Medicine, 2008; 83
327-331
Carney JK, Schilling LM, Frank SH, Biddinger PD, Bertsch, TF, Grace
CJ, Finkelstein JA. Planning and Incorporating Public Health
Preparedness Into the Medical Curriculum. American Journal of
Preventive Medicine. 2011;41 (4S3):S193-S199
Frank SH. Principles for Authentic Population Health. American
Journal of Preventive Medicine. 2011;41 (4S3):S152-S154
Thank you!
Please feel free to contact me anytime!
[email protected]