- Email: [email protected]
Population Health Integration Within a Medical Curriculum
Teaching Preventive Medicine
Population Health Integration Within a Medical Curriculum An Eight-Part Toolkit Lyndal J. Trevena, MBBS (Hons), MPhilPH, Peter Sainsbury, MBBS, MHP, FRACMA, FAFPHM, PhD, Cheryl Henderson-Smart, BA, DipEd, MEd, Rufus Clarke, MA, MD, PhD, MPH, FRACS, FAFPHM, George Rubin, MBBS (Hons), FRACP, FAFPHM, FChAM, FACPM, Robert Cumming, MBBS, MPH, PhD
Introduction
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umerous accreditation bodies around the world have recommended that medical schools include population health as part of their medical curricula.1– 4 These require that medical graduates have an understanding of the determinants of health within communities, health-promotion and disease-prevention strategies, screening, surveillance, health policy, health service structure, quality, safety, and resource allocation. Governments also require workforce education as an important component of their national health strategies to reach targets in areas such as cancer, cardiovascular disease, injury, and mental illness.5,6 However, the incorporation of population health into medical curricula has been limited, with the General Medical Council (United Kingdom)7 reporting in 1999 that few schools had achieved the appropriate standards. It cited limited resources for public health teaching and a lack of student interest as important barriers to this implementation process. In response to the U.S. government strategy, Healthy People 2010, the “Clinical Prevention and Population Health Curriculum Framework” was published in 2004 by the Healthy People Curriculum Taskforce.8,9 It is a comprehensive effort to define the core components of a clinical prevention and population health curriculum to improve clinical health professional education. It aims to standardize learning for health professional licensing and accreditation purposes, facilitate communication and collaboration among health professions, and provide a structure for organizing and monitoring curriculum.10 The basic curriculum has four core components: evidence-based practice (EBP), clinical preventive services-health promotion (CPSHP), health systems and health policy (HSHP), and community
From the School of Public Health (Trevena, Sainsbury, Rubin, Cumming), and Office of Teaching and Learning in Medicine (Henderson-Smart, Clarke), The University of Sydney, New South Wales, Australia Address correspondence and reprint requests to: Lyndal J. Trevena, MBBS (Hons), MPhilPH, School of Public Health, University of Sydney, Room 322, Edward Ford Building (A27), Camperdown, NSW 2006, Australia. E-mail: [email protected].
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aspects of practice (CAP). Within these four components, there are 19 domains that are designed to be flexible in their delivery and integration within curricula across a range of health professions. The framework encourages inclusion of the components throughout a degree program, but to include integration and synthesis of all four components, particularly during the latter part of training. This paper describes a toolkit that can be used by students and faculty to integrate, apply and assess the principles and practice of clinical prevention and population health within a health curriculum. It illustrates how the University of Sydney Medical Program’s (USydMP) population health goals and learning outcomes are implemented via this toolkit and also maps the toolkit against the components and domains of the Clinical Prevention and Population Health Framework. The University of Sydney’s graduate-entry 4-year degree program in medicine started in 1997 and, after the first 5 years of implementation, the population health group (Community and Doctor Theme, CDT) has undertaken major curriculum revision. This has culminated in the development and implementation of articulated learning outcomes within the student toolkit to facilitate a population perspective within health problem solving. While this framework is currently implemented within a problem-based course, we believe it could be adapted readily to other medical curricula.
A Theme-Based Approach to Population Health Medical schools vary in the way that population health learning is implemented. Curricular time and method of delivery are often influenced by institutional traditions, policies and resources. Regardless of the context in which accreditation standards must be met, faculties should define clinically relevant outcomes that will engage medical students in population health, enabling them to apply it after graduation. We have found that it is essential to involve public health experts, clinicians with public health training, medical educators, and students in developing this framework.
Am J Prev Med 2005;29(3) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.05.008
Until 1997, the University of Sydney delivered a traditional lecture-based undergraduate medical degree program. This was replaced by a graduate-entry 4-year problem-based course adopting facets of a number of programs including McMaster (Canada) and Newcastle (Australia). For the first 2 years, students are campus based with 1 day per week in hospitals, while the second 2 years are clinical and school based. To progress through the program, and to graduate, students must achieve competence in four themes: Basic and Clinical Sciences (BCS), core science and clinical disciplines; Patient and Doctor (Pt-Dr), bedside skills in history and clinical examination; Community and Doctor Theme (CDT), population health; and Personal and Professional Development (PPD), ethics, attitudes, group process, and evidence-based medicine. Particularly in the first 2 years of the program, learning in all four themes is structured around a weekly clinical problem, and modeling a holistic approach to the practice of medicine (Figure 1).
Medical Graduates Should Apply Population Health Principles to Individuals as well as to Communities We agree with the General Medical Council1 in that tomorrow’s doctors need to be able to apply population health principles within individual patient care, as well as considering a population-wide approach to particular health problems and promoting the health of specific groups within the community. The CDT goals and assessment activities have been designed to reflect this two-tiered application (Figure 1). It is important, for example, to be able to discuss meningococcal C vaccination with a 19-year-old patient, and also to understand the distribution of meningococcal meningitis, potential population-level prevention strategies, and economic, social, and political factors that impact on government funding of individual vaccines.
Student Toolkit for a Population Approach to Health Problems Like others, we have found it challenging to bridge the gap between individual- and population-level health care.11–14 To overcome this, we developed an eight-part checklist of questions that form the basis of our entire curriculum and can also be applied to a particular health problem. These are known among our students as “The Eight Essential CDT Questions (Q1-8),” which form a simple mental prompt for considering any health problem from a population perspective. They relate directly to the theme goals shown in Figure 1. For example, during the cardiology block, students consider a patient with cardiac failure. During that week, they learn about the anatomy of the heart and great vessels, clinical signs, and symptoms of heart failure and
the physiology of flow and pressures within the circulation. When considering how the Eight Essential CDT Questions might apply to this problem they learn about the increasing prevalence of heart failure with age, the potential burden from an ageing population, the causes of heart failure, prevention through reducing coronary heart disease, the high costs of hospitalization attributable to heart failure, current government policies, and recommended practices to improve health outcomes and reduce the incidence of heart failure in our community.
Implementing the Toolkit Through Specific Learning Outcomes Despite the utility of the eight-question toolkit, we found that students needed more specific learning outcomes in order to understand the meaning of these question areas. The first draft of these is outlined in Table 1, and these will be revised and updated as the new curriculum is implemented. The use of learning outcomes in problem-based curricula is controversial with an inevitable tension between specified, measurable outcomes and the philosophy of self-directed learning.15–17 Nevertheless, we have developed these outcomes in response to strong student feedback. We have deliberately tried to keep the outcomes generic so that they can be applied to various health problems throughout the course. At this time, we have not specified an increasing level of complexity throughout the course. However, as their learning context becomes more clinical, we require more student-directed learning and use more sophisticated assessment activities.
Teaching, Learning, and Assessment of Population Health in the Program The USydMP is substantially web-supported. Population health learning around the problem of the week can occur in a number of ways. “Learning topics” are faculty-developed summaries of particular topics which have additional references and websites linked to them. They are also linked to online self-assessment questions. Students are expected to work through these resources in the time allocated for independent study between problem-based learning (PBL) sessions. Large group lectures and extended theme sessions are other formats for learning, with guest speakers, videos, panels, and debates being important resources. Within the small-group PBL reasoning process, students are encouraged to consider disease prevention and health promotion issues. Recently we have developed some online self-directed learning activities exploring aspects of the eight essential questions. Our goal is to ensure that medical graduates can apply population health principles within individual patient care and a broader community of people. To assess Am J Prev Med 2005;29(3)
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Figure 1. Population health curriculum overview. BCS, Basic and Clinical Sciences; CDT, Community and Doctor Theme; PPD, Personal and Professional Development; Pt-Dr, Patient and Doctor.
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Table 1. Population health learning outcomes Q1. DISTRIBUTION How common is the problem in the total population and in different subgroups? Definition and measurement of populations and their health 1.1 Describe common definitions of health 1.2 Define a population using appropriate parameters (EBP4,5) 1.3 Describe population groups using appropriate demographic factors (age, sex, ethnicity, SES) (EBP4,5) 1.4 Describe the health of a population using appropriate measures (mortality, morbidity) (EBP4,5) 1.5 Find and summarize Australian and global data on particular population subgroups (e.g., war victims, indigenous Australians, elderly, children) (EBP3) Patterns of disease and injury 1.6 Identify and interpret appropriate measures of disease frequency in a population (incidence, prevalence) (EBP1) 1.7 Identify and access appropriate sources of information on patterns of noncommunicable disease and injury in populations (EBP4) 1.8 Find and summarize Australian and global data on the distribution of major noncommunicable diseases and injury (e.g., musculoskeletal, drug and alcohol, respiratory, hematology, cardiac) (EBP4) 1.9 Identify and access relevant resources for obtaining information about the patterns of communicable diseases in populations (EBP1) Q2. CAUSE What causes the problem? Determinants of health in a population 2.1 Describe the relationship between key determinants (social context, environment, culture, education, occupation, genetic factors, nutrition, infectious agents) and health (EBP5) 2.2 Discuss some of the limitations of measures of determinants (e.g., SES, education, occupation) (EBP5) Risk factors; measures of association 2.3 Identify modifiable and nonmodifiable risk factors for disease and injury 2.4 Identify and interpret appropriate measures of association between risk factors and noncommunicable disease and injury (OR, RR) (EBP1) 2.5 Identify infectious diseases of public health concern and the rationale for that concern 2.6 Define an infectious disease outbreak 2.7 Find and summarize data on the cause of a given health problem in a population Q3. PREVENTION How can the problem be prevented? Levels and principles of prevention of noncommunicable disease and injury 3.1 Define primary, secondary, and tertiary prevention 3.2 Find and summarize data on strategies for the prevention of a given health problem 3.3 Describe common methods of surveillance of noninfectious disease and injury (EBP4) 3.4 Understand the principles of screening for noncommunicable diseases (CSPHP1) Surveillance and control of communicable disease 3.5 Understand the principles of disease surveillance and the investigation of a disease outbreak (CAP2) 3.6 Describe the principles of immunization programs and the current Australian schedule (CSPHP2) Health promotion and advocacy 3.7 Describe the fundamental principles of health promotion and its potential role in improving the health of a population 3.8 Describe the components of an effective health promotion intervention 3.9 Identify examples of effective health promotion strategies in Australia and internationally 3.10 Identify the key elements of an effective public health advocacy campaign 3.11 Identify and describe examples of advocacy as an effective health promotion strategy Q4. MANAGEMENT What is the most appropriate management of the problem at individual system and population levels, and how can systems be continually improved? Decision-making models and theory 4.1 Describe key models for decision making at an individual and community level in health care Principles of evaluation 4.2 Define the key components of an effective evaluation of a population health intervention Economic evaluation 4.3 Find and interpret appropriate economic evaluations for health interventions Influences of decision making (political, media, resource allocation, ethical, evidence) 4.4 Discuss (using appropriate examples) the role of politics, the media, community values, ethics, and evidence in individual and population-level decision making Clinical protocols/guidelines 4.5 Identify relevant clinical protocols and guidelines for the management of both individual- and system-level health problems Q5. EVIDENCE BASE How strong is the evidence about the distribution and cause of the problem, its prevention, and its management? 5.1 Critically appraise the use of appropriate study design to describe patterns of disease in populations (EBP2) 5.2 Critically appraise the evidence for causality of a health problem within a population (EBP2) 5.3 Critically appraise the evidence for the effectiveness of strategies for prevention of disease and injury (EBP2)
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Table 1. (continued) 5.4 Critically appraise the evidence for the effectiveness of strategies for the management of health in populations (include protocols, guidelines, health systems, community interventions) (EBP2) Q6. PERSONAL EFFECTS What are the personal effects of having the problem? Health-related outcomes in the individual 6.1 Define terms commonly used to describe the impact of illness on an individual (impairment, disability, activities of daily living, handicap, quality of life, quality-adjusted life years [QALY], disability-adjusted life years [DALY], potential years of life lost [PYLL], health outcome) (EBP3) 6.2 Interpret appropriate measures of the impact of illness on an individual for a given disease or injury (see 6.1) (EBP3) Individual’s response to illness/injury 6.3 Identify and describe areas of impact on the lives of individuals due to illness (economic, psychological, occupational, sociocultural) Q7. SOCIETAL EFFECTS What are the effects of the problem (and its management) on, and in, society? Health, financial, and social outcomes of illness and injury at the societal level. 7.1 Describe and discuss the health impact of a given illness or injury at a societal level (burden of illness) (EBP5) 7.2 Describe and discuss the financial impact of a given illness or injury at a societal level 7.3 Describe and discuss the social impact of a given illness or injury at a societal level (effects on family structures, stigmatization, discrimination, litigation) Q8. SOCIETAL RESPONSE How does (and could) society respond to the problem? Policy in health 8.1 Identify and describe the National Health Priority Areas (NHPAs) for Australia 8.2 Discuss the rationale for the NHPAs (HSHP4) 8.3 Describe policies and evaluations relating to NHPAs and other health issues where appropriate (HSHP4) 8.4 Discuss the impact of key nonhealth policies on the health of populations (welfare, housing, social, etc.) (HSHP4) Legislation and health care 8.5 Identify appropriate legislation and regulation relating to a given health issue (Coroner’s Act, Mental Health Act, Guardianship, Occupational Health and Safety, Roads and Traffic Authority, Public Health Act) (HSHP3) The media and consumer involvement in health care 8.6 Discuss (using examples) the role of the media and consumer involvement in healthcare decision making (CAP1) Medical care and its funding 8.7 Describe the basic organization and funding of the Australian health system (HSHP1) 8.8 Define microeconomic terms such as opportunity cost, margin, discounting, and efficiency (HSHP2) 8.9 Discuss the impact of health system policy (Medicare, private insurance) on access and equity in the provision of health care (HSHP4) 8.10 Identify and describe components of the health system that are relevant to improving health outcomes for a specific health problem CAP, community aspects of practice; CPSHP, clinical preventive services-health promotion; EBP, evidence-based practice; HSHP, health systems and health policy; SES, socioeconomic status; OR, odds ratio; RR, relative risk.
individual patient-level application, we use modified essay questions during the first 3 years of the course. These questions are integrated with the BCS questions stemming from a series of case scenarios. Students work their way sequentially through each case and cannot turn back or look forward in the case booklet. For example, a case about a gentleman with non-insulin-dependent diabetes might include a number of BCS questions about the pathophysiology of diabetes and its clinical complications as well as diagnosis and management, but might also include a question from CDT about strategies for prevention of diabetes or about diabetes as a national health priority area. As students progress through the program, we expect them to become increasingly autonomous and clinically competent. Hence in the final year, individual patient CDT skills are assessed via a trigger or springboard case derived from the students’ own experience in clinical placement. For example, a child and adolescent health presentation on scalds in the community 238
might be triggered by a burn case seen in the emergency department. Students are also expected to achieve an increasingly sophisticated application of population health outcomes at a community level as they progress through the program. In Year 1 they undertake a group project and produce a poster on a different theme each year (e.g., “war and health” or “food, fat, and famine”). In Year 2, they are required to write an essay under exam conditions addressing the eight essential questions around a particular topic (e.g., alcohol, childhood obesity, meningococcal C vaccination). Students are expected to describe the patterns and trends of the particular health problem in the community and to highlight areas of public health concern. They are often asked to appraise the evidence for strategies to address the problem, discuss its implementation, and consider the way that public health decisions might be made, including the political, media, and community influences on these decisions. In Year 3, pairs of students lead a small group tutorial on 14 CDT topics
American Journal of Preventive Medicine, Volume 29, Number 3
during the year. In Year 4, springboard cases in pediatrics lead to an abstract and conference-style presentation, to an oral presentation on clinical services during the community term with particular focus on access in rural areas, and a theme paper on a topic of the student’s choice in women’s health or psychiatry. Student performance in these assessment activities has been of a high quality, and whether this translates into altered clinical behavior in our graduates remains to be evaluated. Early assessment of the impact of this curriculum is promising.
Conclusion Medical school accreditation and student learning require the integration of population health in a clinically relevant and engaging manner. We believe that the clear articulation of learning outcomes and the use of a student toolkit of eight questions can provide a simple framework to help students adopt a population perspective to clinical problems. The eight essential questions can also be used to develop learning outcomes, learning activities and assessments to achieve the goal of integrating population health in a clinically relevant and engaging manner within medical curricula. We are grateful for the contributions of Garth Alperstein, Stephen Leeder, Simon Chapman, and Susan Quine, and students and other members of the Community and Doctor Theme committee who have contributed to the development of the curriculum. No financial conflict of interest was reported by the authors of this paper.
References 1. General Medical Council. Tomorrow’s doctors. Recommendations on undergraduate medical education. Available at: www.gmc-uk.org/med_ed/ default.htm. Accessed July 2005. 2. Australian Medical Council. Assessment and accreditation of medical schools : standards and procedures. Kingston, Australian Capital Territory: Australian Medical Council Inc., 2002. 3. Schwarz M, Wojtczak A. Global minimum essential requirements: a road towards competence-oriented medical education. Med Teach 2002;24:125–9. 4. Medical School Objectives Project. Contemporary issues in medicine— medical informatics and population health: Report II of the Medical School Objectives Project. Acad Med 1999;74:130 – 41. 5. Secretary of State for Health. Saving lives: our healthier nation, 1999. London: The Stationery Office, 1999. 6. Department of Health and Aging. National health priority areas, 2002. Kingston, Australian Capital Territory: Commonwealth Department of Health and Aging, 2002. 7. General Medical Council. Implementing Tomorrow’s Doctors. Report of the Education Committee’s informal visits to UK medical schools between 1995 and 1998. Available at: www.gmc-uk.org/med_ed/default.htm. Accessed July 2005. 8. Allan J, Barwick T, Cashman S, et al. Clinical prevention and population health: curriculum framework for health professions. Am J Prev Med 2004;27:471– 6. 9. Carmona R. Healthy People Curriculum Taskforce. Am J Prev Med 2004;27:478 –9. 10. Riegelman R, Evans C, Garr D. Why a clinical prevention and population health curriculum framework? Am J Prev Med 2004;27:477. 11. Riegelman R. Medical student myopia syndrome: a recently recognized pan-epidemic. Am J Prev Med 1991;7:252. 12. Stone D. Public health in the undergraduate medical curriculum— can we achieve integration? J Eval Clin Pract 2000;6:9 –14. 13. Woodward A. Public health has no place in undergraduate medical education. J Public Health Med 1994;16:389 –92. 14. Trevena LJ, Clarke RM. Self-directed learning in population health: a clinically relevant approach for medical students. Am J Prev Med 2002;22:59 – 65. 15. Harden R. Developments in outcome-based education. Med Teach 2002;24:117–20. 16. Harden R. Learning outcomes and instructional objectives: is there a difference? Med Teach 2002;24:151–5. 17. Rees C. The problem with outcomes-based curricula in medical education: insights from educational theory. Med Educ 2004;38:593– 8.
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Population Health Integration Within a Medical Curriculum An Eight-Part Toolkit Lyndal J. Trevena, MBBS (Hons), MPhilPH, Peter Sainsbury, MBBS, MHP, FRACMA, FAFPHM, PhD, Cheryl Henderson-Smart, BA, DipEd, MEd, Rufus Clarke, MA, MD, PhD, MPH, FRACS, FAFPHM, George Rubin, MBBS (Hons), FRACP, FAFPHM, FChAM, FACPM, Robert Cumming, MBBS, MPH, PhD
Introduction
N
umerous accreditation bodies around the world have recommended that medical schools include population health as part of their medical curricula.1– 4 These require that medical graduates have an understanding of the determinants of health within communities, health-promotion and disease-prevention strategies, screening, surveillance, health policy, health service structure, quality, safety, and resource allocation. Governments also require workforce education as an important component of their national health strategies to reach targets in areas such as cancer, cardiovascular disease, injury, and mental illness.5,6 However, the incorporation of population health into medical curricula has been limited, with the General Medical Council (United Kingdom)7 reporting in 1999 that few schools had achieved the appropriate standards. It cited limited resources for public health teaching and a lack of student interest as important barriers to this implementation process. In response to the U.S. government strategy, Healthy People 2010, the “Clinical Prevention and Population Health Curriculum Framework” was published in 2004 by the Healthy People Curriculum Taskforce.8,9 It is a comprehensive effort to define the core components of a clinical prevention and population health curriculum to improve clinical health professional education. It aims to standardize learning for health professional licensing and accreditation purposes, facilitate communication and collaboration among health professions, and provide a structure for organizing and monitoring curriculum.10 The basic curriculum has four core components: evidence-based practice (EBP), clinical preventive services-health promotion (CPSHP), health systems and health policy (HSHP), and community
From the School of Public Health (Trevena, Sainsbury, Rubin, Cumming), and Office of Teaching and Learning in Medicine (Henderson-Smart, Clarke), The University of Sydney, New South Wales, Australia Address correspondence and reprint requests to: Lyndal J. Trevena, MBBS (Hons), MPhilPH, School of Public Health, University of Sydney, Room 322, Edward Ford Building (A27), Camperdown, NSW 2006, Australia. E-mail: [email protected].
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aspects of practice (CAP). Within these four components, there are 19 domains that are designed to be flexible in their delivery and integration within curricula across a range of health professions. The framework encourages inclusion of the components throughout a degree program, but to include integration and synthesis of all four components, particularly during the latter part of training. This paper describes a toolkit that can be used by students and faculty to integrate, apply and assess the principles and practice of clinical prevention and population health within a health curriculum. It illustrates how the University of Sydney Medical Program’s (USydMP) population health goals and learning outcomes are implemented via this toolkit and also maps the toolkit against the components and domains of the Clinical Prevention and Population Health Framework. The University of Sydney’s graduate-entry 4-year degree program in medicine started in 1997 and, after the first 5 years of implementation, the population health group (Community and Doctor Theme, CDT) has undertaken major curriculum revision. This has culminated in the development and implementation of articulated learning outcomes within the student toolkit to facilitate a population perspective within health problem solving. While this framework is currently implemented within a problem-based course, we believe it could be adapted readily to other medical curricula.
A Theme-Based Approach to Population Health Medical schools vary in the way that population health learning is implemented. Curricular time and method of delivery are often influenced by institutional traditions, policies and resources. Regardless of the context in which accreditation standards must be met, faculties should define clinically relevant outcomes that will engage medical students in population health, enabling them to apply it after graduation. We have found that it is essential to involve public health experts, clinicians with public health training, medical educators, and students in developing this framework.
Am J Prev Med 2005;29(3) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.05.008
Until 1997, the University of Sydney delivered a traditional lecture-based undergraduate medical degree program. This was replaced by a graduate-entry 4-year problem-based course adopting facets of a number of programs including McMaster (Canada) and Newcastle (Australia). For the first 2 years, students are campus based with 1 day per week in hospitals, while the second 2 years are clinical and school based. To progress through the program, and to graduate, students must achieve competence in four themes: Basic and Clinical Sciences (BCS), core science and clinical disciplines; Patient and Doctor (Pt-Dr), bedside skills in history and clinical examination; Community and Doctor Theme (CDT), population health; and Personal and Professional Development (PPD), ethics, attitudes, group process, and evidence-based medicine. Particularly in the first 2 years of the program, learning in all four themes is structured around a weekly clinical problem, and modeling a holistic approach to the practice of medicine (Figure 1).
Medical Graduates Should Apply Population Health Principles to Individuals as well as to Communities We agree with the General Medical Council1 in that tomorrow’s doctors need to be able to apply population health principles within individual patient care, as well as considering a population-wide approach to particular health problems and promoting the health of specific groups within the community. The CDT goals and assessment activities have been designed to reflect this two-tiered application (Figure 1). It is important, for example, to be able to discuss meningococcal C vaccination with a 19-year-old patient, and also to understand the distribution of meningococcal meningitis, potential population-level prevention strategies, and economic, social, and political factors that impact on government funding of individual vaccines.
Student Toolkit for a Population Approach to Health Problems Like others, we have found it challenging to bridge the gap between individual- and population-level health care.11–14 To overcome this, we developed an eight-part checklist of questions that form the basis of our entire curriculum and can also be applied to a particular health problem. These are known among our students as “The Eight Essential CDT Questions (Q1-8),” which form a simple mental prompt for considering any health problem from a population perspective. They relate directly to the theme goals shown in Figure 1. For example, during the cardiology block, students consider a patient with cardiac failure. During that week, they learn about the anatomy of the heart and great vessels, clinical signs, and symptoms of heart failure and
the physiology of flow and pressures within the circulation. When considering how the Eight Essential CDT Questions might apply to this problem they learn about the increasing prevalence of heart failure with age, the potential burden from an ageing population, the causes of heart failure, prevention through reducing coronary heart disease, the high costs of hospitalization attributable to heart failure, current government policies, and recommended practices to improve health outcomes and reduce the incidence of heart failure in our community.
Implementing the Toolkit Through Specific Learning Outcomes Despite the utility of the eight-question toolkit, we found that students needed more specific learning outcomes in order to understand the meaning of these question areas. The first draft of these is outlined in Table 1, and these will be revised and updated as the new curriculum is implemented. The use of learning outcomes in problem-based curricula is controversial with an inevitable tension between specified, measurable outcomes and the philosophy of self-directed learning.15–17 Nevertheless, we have developed these outcomes in response to strong student feedback. We have deliberately tried to keep the outcomes generic so that they can be applied to various health problems throughout the course. At this time, we have not specified an increasing level of complexity throughout the course. However, as their learning context becomes more clinical, we require more student-directed learning and use more sophisticated assessment activities.
Teaching, Learning, and Assessment of Population Health in the Program The USydMP is substantially web-supported. Population health learning around the problem of the week can occur in a number of ways. “Learning topics” are faculty-developed summaries of particular topics which have additional references and websites linked to them. They are also linked to online self-assessment questions. Students are expected to work through these resources in the time allocated for independent study between problem-based learning (PBL) sessions. Large group lectures and extended theme sessions are other formats for learning, with guest speakers, videos, panels, and debates being important resources. Within the small-group PBL reasoning process, students are encouraged to consider disease prevention and health promotion issues. Recently we have developed some online self-directed learning activities exploring aspects of the eight essential questions. Our goal is to ensure that medical graduates can apply population health principles within individual patient care and a broader community of people. To assess Am J Prev Med 2005;29(3)
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Figure 1. Population health curriculum overview. BCS, Basic and Clinical Sciences; CDT, Community and Doctor Theme; PPD, Personal and Professional Development; Pt-Dr, Patient and Doctor.
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Table 1. Population health learning outcomes Q1. DISTRIBUTION How common is the problem in the total population and in different subgroups? Definition and measurement of populations and their health 1.1 Describe common definitions of health 1.2 Define a population using appropriate parameters (EBP4,5) 1.3 Describe population groups using appropriate demographic factors (age, sex, ethnicity, SES) (EBP4,5) 1.4 Describe the health of a population using appropriate measures (mortality, morbidity) (EBP4,5) 1.5 Find and summarize Australian and global data on particular population subgroups (e.g., war victims, indigenous Australians, elderly, children) (EBP3) Patterns of disease and injury 1.6 Identify and interpret appropriate measures of disease frequency in a population (incidence, prevalence) (EBP1) 1.7 Identify and access appropriate sources of information on patterns of noncommunicable disease and injury in populations (EBP4) 1.8 Find and summarize Australian and global data on the distribution of major noncommunicable diseases and injury (e.g., musculoskeletal, drug and alcohol, respiratory, hematology, cardiac) (EBP4) 1.9 Identify and access relevant resources for obtaining information about the patterns of communicable diseases in populations (EBP1) Q2. CAUSE What causes the problem? Determinants of health in a population 2.1 Describe the relationship between key determinants (social context, environment, culture, education, occupation, genetic factors, nutrition, infectious agents) and health (EBP5) 2.2 Discuss some of the limitations of measures of determinants (e.g., SES, education, occupation) (EBP5) Risk factors; measures of association 2.3 Identify modifiable and nonmodifiable risk factors for disease and injury 2.4 Identify and interpret appropriate measures of association between risk factors and noncommunicable disease and injury (OR, RR) (EBP1) 2.5 Identify infectious diseases of public health concern and the rationale for that concern 2.6 Define an infectious disease outbreak 2.7 Find and summarize data on the cause of a given health problem in a population Q3. PREVENTION How can the problem be prevented? Levels and principles of prevention of noncommunicable disease and injury 3.1 Define primary, secondary, and tertiary prevention 3.2 Find and summarize data on strategies for the prevention of a given health problem 3.3 Describe common methods of surveillance of noninfectious disease and injury (EBP4) 3.4 Understand the principles of screening for noncommunicable diseases (CSPHP1) Surveillance and control of communicable disease 3.5 Understand the principles of disease surveillance and the investigation of a disease outbreak (CAP2) 3.6 Describe the principles of immunization programs and the current Australian schedule (CSPHP2) Health promotion and advocacy 3.7 Describe the fundamental principles of health promotion and its potential role in improving the health of a population 3.8 Describe the components of an effective health promotion intervention 3.9 Identify examples of effective health promotion strategies in Australia and internationally 3.10 Identify the key elements of an effective public health advocacy campaign 3.11 Identify and describe examples of advocacy as an effective health promotion strategy Q4. MANAGEMENT What is the most appropriate management of the problem at individual system and population levels, and how can systems be continually improved? Decision-making models and theory 4.1 Describe key models for decision making at an individual and community level in health care Principles of evaluation 4.2 Define the key components of an effective evaluation of a population health intervention Economic evaluation 4.3 Find and interpret appropriate economic evaluations for health interventions Influences of decision making (political, media, resource allocation, ethical, evidence) 4.4 Discuss (using appropriate examples) the role of politics, the media, community values, ethics, and evidence in individual and population-level decision making Clinical protocols/guidelines 4.5 Identify relevant clinical protocols and guidelines for the management of both individual- and system-level health problems Q5. EVIDENCE BASE How strong is the evidence about the distribution and cause of the problem, its prevention, and its management? 5.1 Critically appraise the use of appropriate study design to describe patterns of disease in populations (EBP2) 5.2 Critically appraise the evidence for causality of a health problem within a population (EBP2) 5.3 Critically appraise the evidence for the effectiveness of strategies for prevention of disease and injury (EBP2)
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Table 1. (continued) 5.4 Critically appraise the evidence for the effectiveness of strategies for the management of health in populations (include protocols, guidelines, health systems, community interventions) (EBP2) Q6. PERSONAL EFFECTS What are the personal effects of having the problem? Health-related outcomes in the individual 6.1 Define terms commonly used to describe the impact of illness on an individual (impairment, disability, activities of daily living, handicap, quality of life, quality-adjusted life years [QALY], disability-adjusted life years [DALY], potential years of life lost [PYLL], health outcome) (EBP3) 6.2 Interpret appropriate measures of the impact of illness on an individual for a given disease or injury (see 6.1) (EBP3) Individual’s response to illness/injury 6.3 Identify and describe areas of impact on the lives of individuals due to illness (economic, psychological, occupational, sociocultural) Q7. SOCIETAL EFFECTS What are the effects of the problem (and its management) on, and in, society? Health, financial, and social outcomes of illness and injury at the societal level. 7.1 Describe and discuss the health impact of a given illness or injury at a societal level (burden of illness) (EBP5) 7.2 Describe and discuss the financial impact of a given illness or injury at a societal level 7.3 Describe and discuss the social impact of a given illness or injury at a societal level (effects on family structures, stigmatization, discrimination, litigation) Q8. SOCIETAL RESPONSE How does (and could) society respond to the problem? Policy in health 8.1 Identify and describe the National Health Priority Areas (NHPAs) for Australia 8.2 Discuss the rationale for the NHPAs (HSHP4) 8.3 Describe policies and evaluations relating to NHPAs and other health issues where appropriate (HSHP4) 8.4 Discuss the impact of key nonhealth policies on the health of populations (welfare, housing, social, etc.) (HSHP4) Legislation and health care 8.5 Identify appropriate legislation and regulation relating to a given health issue (Coroner’s Act, Mental Health Act, Guardianship, Occupational Health and Safety, Roads and Traffic Authority, Public Health Act) (HSHP3) The media and consumer involvement in health care 8.6 Discuss (using examples) the role of the media and consumer involvement in healthcare decision making (CAP1) Medical care and its funding 8.7 Describe the basic organization and funding of the Australian health system (HSHP1) 8.8 Define microeconomic terms such as opportunity cost, margin, discounting, and efficiency (HSHP2) 8.9 Discuss the impact of health system policy (Medicare, private insurance) on access and equity in the provision of health care (HSHP4) 8.10 Identify and describe components of the health system that are relevant to improving health outcomes for a specific health problem CAP, community aspects of practice; CPSHP, clinical preventive services-health promotion; EBP, evidence-based practice; HSHP, health systems and health policy; SES, socioeconomic status; OR, odds ratio; RR, relative risk.
individual patient-level application, we use modified essay questions during the first 3 years of the course. These questions are integrated with the BCS questions stemming from a series of case scenarios. Students work their way sequentially through each case and cannot turn back or look forward in the case booklet. For example, a case about a gentleman with non-insulin-dependent diabetes might include a number of BCS questions about the pathophysiology of diabetes and its clinical complications as well as diagnosis and management, but might also include a question from CDT about strategies for prevention of diabetes or about diabetes as a national health priority area. As students progress through the program, we expect them to become increasingly autonomous and clinically competent. Hence in the final year, individual patient CDT skills are assessed via a trigger or springboard case derived from the students’ own experience in clinical placement. For example, a child and adolescent health presentation on scalds in the community 238
might be triggered by a burn case seen in the emergency department. Students are also expected to achieve an increasingly sophisticated application of population health outcomes at a community level as they progress through the program. In Year 1 they undertake a group project and produce a poster on a different theme each year (e.g., “war and health” or “food, fat, and famine”). In Year 2, they are required to write an essay under exam conditions addressing the eight essential questions around a particular topic (e.g., alcohol, childhood obesity, meningococcal C vaccination). Students are expected to describe the patterns and trends of the particular health problem in the community and to highlight areas of public health concern. They are often asked to appraise the evidence for strategies to address the problem, discuss its implementation, and consider the way that public health decisions might be made, including the political, media, and community influences on these decisions. In Year 3, pairs of students lead a small group tutorial on 14 CDT topics
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during the year. In Year 4, springboard cases in pediatrics lead to an abstract and conference-style presentation, to an oral presentation on clinical services during the community term with particular focus on access in rural areas, and a theme paper on a topic of the student’s choice in women’s health or psychiatry. Student performance in these assessment activities has been of a high quality, and whether this translates into altered clinical behavior in our graduates remains to be evaluated. Early assessment of the impact of this curriculum is promising.
Conclusion Medical school accreditation and student learning require the integration of population health in a clinically relevant and engaging manner. We believe that the clear articulation of learning outcomes and the use of a student toolkit of eight questions can provide a simple framework to help students adopt a population perspective to clinical problems. The eight essential questions can also be used to develop learning outcomes, learning activities and assessments to achieve the goal of integrating population health in a clinically relevant and engaging manner within medical curricula. We are grateful for the contributions of Garth Alperstein, Stephen Leeder, Simon Chapman, and Susan Quine, and students and other members of the Community and Doctor Theme committee who have contributed to the development of the curriculum. No financial conflict of interest was reported by the authors of this paper.
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