- Email: [email protected]
Preventive medicine teaching cases for preventive medicine residents
Preventive Medicine Teaching Cases for Preventive Medicine Residents Mary S. Applegate, MD, MPH Abstract:
Preventive medicine education is unique in that its successes are measured in groups of people. Conveying this population perspective can be difficult, even to preventive medicine residents, some of whom have been in clinical practice for many years. The Case-Based Series in Population-Oriented Prevention (C-POP) was adapted for use in the New York State Preventive Medicine Residency curriculum. Parts of two of the cases were felt to be too clinical for use in this setting, but the other cases were well received and imparted the desired population perspective. Although the C-POP series was produced for undergraduate medical education, it is generally adaptable to the needs of a preventive medicine curriculum. (Am J Prev Med 2003;24(4S):111–115) © 2003 American Journal of Preventive Medicine
Introduction
P
reventive medicine is the only field in medicine that focuses on the health of populations rather than on the health of individuals. The effects of prevention can only be seen at the population level, whereas the effects of clinical interventions—medical or surgical—are readily observable at the individual level. People who are sick or injured receive treatment, and they get better, or not. To know which treatments are truly effective, one needs to study large groups of patients, but the individual patient’s course generally provides enough feedback to make day-to-day judgments about the effectiveness of particular actions. With preventive medicine, success is much harder to gauge at the individual level. Preventive measures lower the odds of developing an illness, but they cannot guarantee that every individual preventively treated will avoid illness or injury, just as there is no way of guaranteeing that a specific individual will become sick or injured if they do not take preventive measures. To see whether the odds have improved, one must look at groups, not individuals. Physicians entering preventive medicine residency (PMR) programs have generally spent many years immersed in clinical medicine. This immersion is true for residents who choose preventive medicine early in their careers and begin preventive medicine training immediately after a clinical internship or residency. It is even truer for residents who choose preventive medicine as a From New York State Preventive Medicine Residency Program, University at Albany (SUNY) School of Public Health, Albany, New York Address correspondence and reprint requests to: Mary Applegate, MD, MPH, University at Albany (SUNY) School of Public Health, Corning Tower 1882, Empire State Plaza, Albany NY 12237-0621. E-mail: [email protected].
mid-career change, after years or even decades of clinical practice. Often a growing awareness of the importance of population-level action is what has led residents to an interest in preventive medicine, but most have had little formal exposure to the principles of public health and population medicine prior to preventive medicine residency training. Helping them make the transition from thinking about individual patients’ illnesses to thinking about the health of populations is one of the perennial challenges for residency programs. The Case-Based Series in Population-Oriented Prevention (C-POP) presented in this supplement to the American Journal of Preventive Medicine can be a useful tool in helping residents make that transition in their perspective.1 The cases deal with a wide range of medical conditions, including tuberculosis (TB),2 community health assessment,3 low birth weight,4 adolescent sexually transmitted diseases (STDs),5 colon cancer,6 bicycle-related head injuries,7 and suicide.8 They help students think about all these conditions from a population perspective, while teaching important concepts in public health. The concepts addressed include sensitivity, specificity, and predictive value of screening tests; attributable risk; age adjustment; cost– benefit; and community health indicators. Most of the cases begin with a clinical scenario—the kind of situation residents are familiar with from their previous training and experience—and move from the individual details to the population implications. Outbreak of Tuberculosis in a Homeless Men’s Shelter,2 for example, begins with the medical history of a homeless man with recent onset of fever, night sweats, and cough. It quickly broadens the view by presenting the cases of several more homeless men with similar symptoms, shifting the perspective from an individual case to
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a cluster of possibly related cases. By the end of the case, the view has broadened further to include individuals hundreds of miles from the original patient, in the process raising many issues vital to the outcome on a population level, but tangential to the clinical outcome of the individual cases. These issues include (among many others) the state’s power to coerce patients to be treated, the mobility of the homeless population, the adequacy of ventilation systems in homeless shelters, access to health care, and public policy about drug abuse. The C-POP cases draw residents in with the familiar details of a clinical case study and get them to explore widening circles of implications connected to the individual case. This process helps residents see the connections between the work they have been doing in clinical medicine and the work they are embarking on in population medicine. This article will describe the experience of one preventive medicine residency program in using the teaching cases with its residents. The New York State Preventive Medicine Residency (NYSPMR) program, jointly sponsored by the University at Albany School of Public Health and the New York State Department of Health, provides training in general preventive medicine/public health to roughly five physicians per year. The program consists of two distinct years: an academic year devoted to completing coursework toward a master’s of public health (MPH) degree and a practicum year divided into three or four rotations in programs at the department of health and affiliated agencies. Throughout the program, residents meet weekly with the program director for a seminar series in which public health professionals from a wide array of disciplines lead discussions about current concerns in public health. The residency program starts with a 2-month orientation period, during which residents meet key individuals at the department of health and other agencies, learn about the major components of the public health system, and begin their transition from clinical medicine to public health. Each week of the summer orientation focuses on a different aspect of the public health system (e.g., communicable disease control, family health, local public health), with the week’s seminar devoted to a related topic and informational interviews arranged with key staff members in that area.
Using the Teaching Cases During summer 2002, the NYSPMR program introduced the preventive medicine teaching cases as a second weekly seminar for all residents. Each session lasted 2 hours, and the topics of the cases were scheduled to coincide, when possible, with the focus of the week’s orientation meetings (e.g., the TB/homeless shelter case during the communicable disease week and the community health assessment case during the 112
local public health week). The residency director and assistant director led the sessions, with assistance from other residency faculty members, depending on the topic of the week. For example, a recent PMR graduate who is an infectious disease specialist co-led the TB/ homeless shelter case, and the Albany County health commissioner co-led the community health assessment case. The orientation period provided an ideal time to use the preventive medicine teaching cases. For new residents, the teaching cases helped them begin the transition to the population perspective. For second-year residents, the cases helped them review and solidify the concepts they learned during the academic year, in preparation for applying those concepts in their practicum projects. The timing may be particularly beneficial for new residents joining a program for the practicum year only, having completed their MPH sometime earlier, perhaps before or during medical school. The summer is also a good time of year to introduce the teaching cases, because most university classes are not in session and there are fewer fixed demands on the residents’ time. The teaching case seminars took the form of structured discussions, built on the scenarios and questions presented in the teaching cases. The cases as written provided a useful framework for the discussions, but logistic and content changes were required for the preventive medicine resident audience. The major logistic change involved the size of the group. The cases were originally designed for use with large classes of students, and, at several points, the instructor is told to divide the class into smaller groups to complete specific assignments. With a group of only four or five residents, dividing into smaller groups was impractical. In most cases, all the residents worked together on all of the components. In cases in which dividing into smaller groups was done simply to reduce the number of repetitive calculations each student would have to do, the instructors reduced the assignment and provided answers from the answer key after the residents had done enough calculations to ensure that they all understood the process. Finally, in one case—Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York4— group assignments were converted to individual assignments, with each resident taking on a different topic independently. One of the challenges of using the teaching cases with preventive medicine residents was the wide variation in residents’ level of expertise and experience. The cases were originally designed for use in medical school classes, in which the students’ level of preparation is fairly homogeneous. In a preventive medicine residency, by contrast, residents come with widely divergent backgrounds. Some have finished only a clinical internship, others an entire residency or even a subspecialty fellowship. Some have been in clinical practice
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for many years. A few have significant public health experience, for instance as Epidemic Intelligence Service (EIS) officers. Moreover, by including all of the residents in the teaching case seminars, the group includes both new residents just joining the program and residents who have finished their MPH coursework. The group that participated in this trial of the preventive medicine teaching cases included five physicians: two senior (practicum year) residents, two junior (academic year) residents, and one “honorary resident,” a physician enrolled in the MPH program who regularly participated in the residents’ seminar series. Of the two senior residents, one was an internist who had been an HIV clinician in New York City and later a primary care provider in rural upstate New York before joining the residency. The other had a strong interest in occupational medicine, having completed a master’s degree in labor relations before medical school. His clinical training consisted of 1 year of family practice. Of the two junior residents, one had done a family practice internship, and the other had completed a pediatrics residency. The honorary resident was the associate director of a local family practice residency program and a former EIS officer. With such a broad array of backgrounds, it is sometimes difficult to find the right level of difficulty to avoid boring some residents or overwhelming others. That challenge was never insurmountable, and the benefits of having such a diverse group of students far outweighed it. Residents with greater knowledge about a particular topic were able to teach their fellow residents, developing their own teaching and communication skills in the process. Because the cases all deal with very different medical conditions and different population issues, no single resident was the expert on every case. Furthermore, the diversity of backgrounds led to rich discussions of issues related to the cases. Another concern in using these cases to teach preventive medicine residents was that they were originally written for medical students at a very different stage of training than the residents. The clinical components of the cases were too easy, especially for the residents with extensive practice experience, and too detailed for this audience, because improving their clinical knowledge was not the goal of the exercise. The clinical scenarios were useful as a hook to help the residents enter into the cases, but the clinical details needed to be pared down to a minimum to allow more time for discussion of the population aspects of the cases. For example, Sexually Transmitted Disease in Adolescents5 includes extensive discussion about which drugs to use for treatment, an issue of limited usefulness to preventive medicine residents. A Critical Look at Prevention: Colorectal Cancer Screening6 includes a series of questions about whether colonoscopy should be recommended in specific clinical situations—again, an issue
of limited value for nonclinical PMRs. Sections like these can be shortened or eliminated to meet the needs of the particular audience. The population aspects of the cases were of greatest interest to the PMRs and provided numerous opportunities for in-depth discussion. The number and diversity of topics raised by the cases were their greatest strength as a teaching tool for residents, making it easy to upgrade the level of the lessons from medical student exercises to resident seminars. Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York,4 which requires 2 weeks to complete, provided the richest array of discussion topics. During those sessions, the group discussed the variation in infant mortality rates over time and among geographic areas, risk factors for infant mortality, validity of birth certificate data, how data are collected and coded, Medicaid eligibility rules, the effect of recent advances in assisted reproductive technologies on the epidemiology of low birth weight and infant mortality, and many other related issues. A partial list of discussion topics raised by each of the cases is outlined in Table 1. In addition to creating opportunities for class discussion, the cases also raised community health issues that the residents wanted to learn about in more detail, suggesting other residency activities to address those interests. The group is planning a field trip to a homeless shelter to get a clearer sense of the living conditions there, because only one of the residents had worked in a shelter before. They are also planning to interview field staff members from the county health department’s STD program about the process and challenges of doing partner notification, an issue raised by Sexually Transmitted Disease in Adolescents.5
Use of the Teaching Cases to Develop Competency Graduate medical education is increasingly guided by efforts to assure that residents achieve specific competencies. The Accreditation Council on Graduate Medical Education is committed to increasing residency programs’ focus on assuring the competence of their graduates.9 The council recently released a set of generic clinical competencies that all residency programs must address. The American College of Preventive Medicine (ACPM) has been at the forefront in promoting competency-based graduate medical education within the specialty, having developed the first comprehensive set of competencies for preventive medicine residents almost 10 years ago.10 A revised version was published in 1999.11 Interest in preventive medicine competencies has been driven by the recognition that preventive medicine is unlike other specialties in several important respects. As a nonclinical field, it is unfamiliar to the general public and even to most physicians. Prospective employers often do not have a clear sense of where a Am J Prev Med 2003;24(4S)
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Table 1. Partial list of topics discussed in conjunction with each case A Critical Look at Prevention: Colorectal Cancer Screening Length bias, lead-time bias, development of practice guidelines Outbreak of Tuberculosis in a Homeless Men’s Shelter Police powers of the state, dual epidemic of TB and AIDS, living conditions in homeless shelters Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York Causes of infant mortality, historical and geographic variation in rates, paternity laws, birth weight versus gestational age as public health indicators, measures of socioeconomic status, Medicaid eligibility, vital records data Sexually Transmitted Disease in Adolescents Definition of statutory rape, confidentiality laws and HIV testing, partner notification, communicable disease reporting, interventions with adolescents Bicycle Helmet Effectiveness in Preventing Injury and Death Assumptions in cost-effectiveness, study designs, developing a budget Community Health Assessment Local public health funding, influence of politics on public health, qualitative versus quantitative analysis, focus groups, key informant interviews, mental versus physical health, data quality Adolescent Suicide Prevention Stigma of mental illness, death certificate reporting, role of the coroner or medical examiner; environmental versus individual-level intervention, measuring effectiveness, life insurance and suicide, schools as sites for health interventions
preventive medicine physician could be useful to their organization or what they can expect from a PMRtrained physician. Compounding the lack of understanding in the community, there is great diversity within the field of preventive medicine in the specific content of training programs, in the settings where preventive medicine specialists work, in the issues they address, and in the kinds of responsibilities they have. The ACPM Competencies for Preventive Medicine Residents are intended to define what residents should be able to do by the end of their training, defining, in turn, the common principles and concerns that unite the field.12 The surest way of demonstrating competence in an activity is by performing it in a supervised setting observed by faculty members. For this kind of performance-based competency evaluation, medicine residents demonstrate their competence in lumbar puncture by doing a certain number of the procedures, and obstetrics residents demonstrate their competence at performing vaginal and cesarean deliveries by delivering babies. It is more difficult to demonstrate many of the preventive medicine competencies through independent performance during the residency. For example, one of the competencies is to “design and operate a surveillance system,” an activity that few residents will have occasion to demonstrate during residency. Competency requires the understanding of concepts and the development of skills necessary to carry out a particular task, but it does not necessarily require one to have done every task. The NYSPMR program has developed a tracking form for monitoring the resident’s progress in achieving competencies.11 One column of the form lists the competencies. In the next column, the resident describes the activity completed to achieve each competency and in the next indicates the level of autonomy (independent, participated, or observed) in carrying out the activity, recognizing that during a 2-year resi114
dency residents will not be able to achieve every competency through independent performance. Residents are encouraged to achieve as many as possible of the competencies through independent performance or participation in group efforts, and they should at a minimum be exposed through observation and discussion to all of the skills and concepts outlined in the competencies. Teaching cases can play a role in helping residents achieve the competencies, particularly those that do not lend themselves to independent performance. For example, one of the competencies is to “characterize the health of a community.” The exercises and discussions involved in Community Health Assessment provide residents with a much better sense of what is involved in characterizing a community’s health than most would get even during a local public health practicum rotation. Another competency is to “prioritize activities using objective, measurable criteria such as epidemiological impact and cost-effectiveness.” Both Community Health Assessment3 and Bicycle Helmet Effectiveness in Preventing Injury and Death7 provide residents with skills needed in achieving that competency. Table 2 lists other competencies in which the teaching cases can be useful as an adjunct to practicum experiences in developing competency.
Future Plans to Use the Teaching Cases with Residents This residency program plans to repeat the teaching cases during next year’s orientation period. Because the senior residents will have done the cases already, they can be involved in teaching them next year, solidifying their understanding of the concepts and issues involved. To increase the number of participants in the teaching cases seminars, the series will be open to
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Table 2. Case studies useful in achieving ACPM preventive medicine competencies ACPM Preventive Medicine Competency
Relevant Case Studies
Identify and review relevant laws and regulations
Tuberculosis Outbreak Sexually Transmitted Disease Bicycle Helmet Effectiveness Community Health Assessment Adolescent Suicide Tuberculosis Outbreak Colorectal Cancer Screening Tuberculosis Outbreak Racial Disparities in Low Birth Weight Sexually Transmitted Disease Colorectal Cancer Screening Bicycle Helmet Effectiveness
Assess program and community resources, develop a plan for appropriate resources Characterize the health of a community Design and operate a surveillance system Design and conduct an outbreak or cluster investigation Evaluate the effectiveness of clinical services for both individuals and populations Diagnose and investigate health problems and health hazards in the community Develop policies and plans to support individual and community health efforts ACPM, American College of Preventive Medicine.
other physicians (non-PMRs) enrolled in the MPH program, helping them in their transition from clinical to population thinking. Before teaching the cases next year, the faculty and current residents will work on upgrading them in several ways. They will develop a bibliography of related articles from the medical literature to enrich their education and to provide a common baseline for residents in diverse fields. In addition to using the teaching cases with its own residents, the NYSPMR program plans to use them as an outreach tool to promote interest in preventive medicine among physicians in clinical residency programs in the region. Faculty and residents from the program will offer selected cases as teaching seminars for other residency programs, for instance, offering A Critical Look at Prevention: Colorectal Cancer Screening6 to internal medicine programs or Bicycle Helmet Effectiveness in Preventing Injury and Death7 to pediatric residencies. Even though they were developed as a teaching tool for medical students, the preventive medicine teaching cases, with minor modifications, can be used effectively in the preventive medicine residency setting. They can help residents make the transition from clinical thinking to population thinking. They can help residents develop important competencies that are difficult to achieve through individual experience during a residency. The preventive medicine teaching cases can help residents develop their own teaching and communication skills and can be a useful outreach tool to
inform physicians in other fields about preventive medicine as a career choice. The Case-Based Series in Population-Oriented Prevention (C-POP) is funded by grants from the Josiah Macy, Jr. Foundation and the Health Resources and Services Administration, U.S. Department of Health and Human Services.
References 1. Epling JW, Morrow CB, Sutphen SM, Novick LF. Case-based teaching in preventive medicine: rationale, development and implementation. Am J Prev Med 2003;24(suppl):85–9. 2. Morrow CB, Cibula DA, Novick LF. Outbreak of tuberculosis in a homeless men’s shelter. Am J Prev Med 2003;24(suppl):124 –7. 3. Cibula DA, Novick LF, Morrow CB, Sutphen SM. Community health assessment. Am J Prev Med 2003;24(suppl):118 –23. 4. Lane SD, Tera´ n S, Morrow CB, Novick LF. Racial and ethnic disparity in low birth weight in Syracuse, New York. Am J Prev Med 2003;24(suppl): 128 –32. 5. Novick LF, Tera´ n S, Dolbear G. Sexually transmitted disease in adolescents. Am J Prev Med 2003;24(suppl):133– 8. 6. Epling JW, Morrow CB, Cibula DA. A critical look at prevention: colorectal cancer screening. Am J Prev Med 2003;24(suppl):139 – 42. 7. Novick LF, Wojtowycz M, Morrow CB, Sutphen SM. Bicycle helmet effectiveness in preventing injury and death. Am J Prev Med 2003;24(suppl): 143–9. 8. Novick LF, Cibula DA, Sutphen SM. Adolescent suicide prevention. Am J Prev Med 2003;24(suppl):150 – 6. 9. Leach DC. Changing education to improve patient care. Qual Health Care 2001;10(suppl 2):ii54 –8. 10. Lane DS, Ross V, Parkinson MD, Chen DW. Performance indicators for assessing competencies of preventive medicine residents. Am J Prev Med 1995;11:1–8. 11. Lane DS, Ross V, Chen DW, O’Neill C. Core competencies for preventive medicine residents: Version 2.0. Am J Prev Med 1999;16:367–72. 12. American College of Preventive Medicine residency directors’ manual. Washington DC: ACPM, 2002:Appendix I.
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Preventive medicine education is unique in that its successes are measured in groups of people. Conveying this population perspective can be difficult, even to preventive medicine residents, some of whom have been in clinical practice for many years. The Case-Based Series in Population-Oriented Prevention (C-POP) was adapted for use in the New York State Preventive Medicine Residency curriculum. Parts of two of the cases were felt to be too clinical for use in this setting, but the other cases were well received and imparted the desired population perspective. Although the C-POP series was produced for undergraduate medical education, it is generally adaptable to the needs of a preventive medicine curriculum. (Am J Prev Med 2003;24(4S):111–115) © 2003 American Journal of Preventive Medicine
Introduction
P
reventive medicine is the only field in medicine that focuses on the health of populations rather than on the health of individuals. The effects of prevention can only be seen at the population level, whereas the effects of clinical interventions—medical or surgical—are readily observable at the individual level. People who are sick or injured receive treatment, and they get better, or not. To know which treatments are truly effective, one needs to study large groups of patients, but the individual patient’s course generally provides enough feedback to make day-to-day judgments about the effectiveness of particular actions. With preventive medicine, success is much harder to gauge at the individual level. Preventive measures lower the odds of developing an illness, but they cannot guarantee that every individual preventively treated will avoid illness or injury, just as there is no way of guaranteeing that a specific individual will become sick or injured if they do not take preventive measures. To see whether the odds have improved, one must look at groups, not individuals. Physicians entering preventive medicine residency (PMR) programs have generally spent many years immersed in clinical medicine. This immersion is true for residents who choose preventive medicine early in their careers and begin preventive medicine training immediately after a clinical internship or residency. It is even truer for residents who choose preventive medicine as a From New York State Preventive Medicine Residency Program, University at Albany (SUNY) School of Public Health, Albany, New York Address correspondence and reprint requests to: Mary Applegate, MD, MPH, University at Albany (SUNY) School of Public Health, Corning Tower 1882, Empire State Plaza, Albany NY 12237-0621. E-mail: [email protected].
mid-career change, after years or even decades of clinical practice. Often a growing awareness of the importance of population-level action is what has led residents to an interest in preventive medicine, but most have had little formal exposure to the principles of public health and population medicine prior to preventive medicine residency training. Helping them make the transition from thinking about individual patients’ illnesses to thinking about the health of populations is one of the perennial challenges for residency programs. The Case-Based Series in Population-Oriented Prevention (C-POP) presented in this supplement to the American Journal of Preventive Medicine can be a useful tool in helping residents make that transition in their perspective.1 The cases deal with a wide range of medical conditions, including tuberculosis (TB),2 community health assessment,3 low birth weight,4 adolescent sexually transmitted diseases (STDs),5 colon cancer,6 bicycle-related head injuries,7 and suicide.8 They help students think about all these conditions from a population perspective, while teaching important concepts in public health. The concepts addressed include sensitivity, specificity, and predictive value of screening tests; attributable risk; age adjustment; cost– benefit; and community health indicators. Most of the cases begin with a clinical scenario—the kind of situation residents are familiar with from their previous training and experience—and move from the individual details to the population implications. Outbreak of Tuberculosis in a Homeless Men’s Shelter,2 for example, begins with the medical history of a homeless man with recent onset of fever, night sweats, and cough. It quickly broadens the view by presenting the cases of several more homeless men with similar symptoms, shifting the perspective from an individual case to
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a cluster of possibly related cases. By the end of the case, the view has broadened further to include individuals hundreds of miles from the original patient, in the process raising many issues vital to the outcome on a population level, but tangential to the clinical outcome of the individual cases. These issues include (among many others) the state’s power to coerce patients to be treated, the mobility of the homeless population, the adequacy of ventilation systems in homeless shelters, access to health care, and public policy about drug abuse. The C-POP cases draw residents in with the familiar details of a clinical case study and get them to explore widening circles of implications connected to the individual case. This process helps residents see the connections between the work they have been doing in clinical medicine and the work they are embarking on in population medicine. This article will describe the experience of one preventive medicine residency program in using the teaching cases with its residents. The New York State Preventive Medicine Residency (NYSPMR) program, jointly sponsored by the University at Albany School of Public Health and the New York State Department of Health, provides training in general preventive medicine/public health to roughly five physicians per year. The program consists of two distinct years: an academic year devoted to completing coursework toward a master’s of public health (MPH) degree and a practicum year divided into three or four rotations in programs at the department of health and affiliated agencies. Throughout the program, residents meet weekly with the program director for a seminar series in which public health professionals from a wide array of disciplines lead discussions about current concerns in public health. The residency program starts with a 2-month orientation period, during which residents meet key individuals at the department of health and other agencies, learn about the major components of the public health system, and begin their transition from clinical medicine to public health. Each week of the summer orientation focuses on a different aspect of the public health system (e.g., communicable disease control, family health, local public health), with the week’s seminar devoted to a related topic and informational interviews arranged with key staff members in that area.
Using the Teaching Cases During summer 2002, the NYSPMR program introduced the preventive medicine teaching cases as a second weekly seminar for all residents. Each session lasted 2 hours, and the topics of the cases were scheduled to coincide, when possible, with the focus of the week’s orientation meetings (e.g., the TB/homeless shelter case during the communicable disease week and the community health assessment case during the 112
local public health week). The residency director and assistant director led the sessions, with assistance from other residency faculty members, depending on the topic of the week. For example, a recent PMR graduate who is an infectious disease specialist co-led the TB/ homeless shelter case, and the Albany County health commissioner co-led the community health assessment case. The orientation period provided an ideal time to use the preventive medicine teaching cases. For new residents, the teaching cases helped them begin the transition to the population perspective. For second-year residents, the cases helped them review and solidify the concepts they learned during the academic year, in preparation for applying those concepts in their practicum projects. The timing may be particularly beneficial for new residents joining a program for the practicum year only, having completed their MPH sometime earlier, perhaps before or during medical school. The summer is also a good time of year to introduce the teaching cases, because most university classes are not in session and there are fewer fixed demands on the residents’ time. The teaching case seminars took the form of structured discussions, built on the scenarios and questions presented in the teaching cases. The cases as written provided a useful framework for the discussions, but logistic and content changes were required for the preventive medicine resident audience. The major logistic change involved the size of the group. The cases were originally designed for use with large classes of students, and, at several points, the instructor is told to divide the class into smaller groups to complete specific assignments. With a group of only four or five residents, dividing into smaller groups was impractical. In most cases, all the residents worked together on all of the components. In cases in which dividing into smaller groups was done simply to reduce the number of repetitive calculations each student would have to do, the instructors reduced the assignment and provided answers from the answer key after the residents had done enough calculations to ensure that they all understood the process. Finally, in one case—Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York4— group assignments were converted to individual assignments, with each resident taking on a different topic independently. One of the challenges of using the teaching cases with preventive medicine residents was the wide variation in residents’ level of expertise and experience. The cases were originally designed for use in medical school classes, in which the students’ level of preparation is fairly homogeneous. In a preventive medicine residency, by contrast, residents come with widely divergent backgrounds. Some have finished only a clinical internship, others an entire residency or even a subspecialty fellowship. Some have been in clinical practice
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for many years. A few have significant public health experience, for instance as Epidemic Intelligence Service (EIS) officers. Moreover, by including all of the residents in the teaching case seminars, the group includes both new residents just joining the program and residents who have finished their MPH coursework. The group that participated in this trial of the preventive medicine teaching cases included five physicians: two senior (practicum year) residents, two junior (academic year) residents, and one “honorary resident,” a physician enrolled in the MPH program who regularly participated in the residents’ seminar series. Of the two senior residents, one was an internist who had been an HIV clinician in New York City and later a primary care provider in rural upstate New York before joining the residency. The other had a strong interest in occupational medicine, having completed a master’s degree in labor relations before medical school. His clinical training consisted of 1 year of family practice. Of the two junior residents, one had done a family practice internship, and the other had completed a pediatrics residency. The honorary resident was the associate director of a local family practice residency program and a former EIS officer. With such a broad array of backgrounds, it is sometimes difficult to find the right level of difficulty to avoid boring some residents or overwhelming others. That challenge was never insurmountable, and the benefits of having such a diverse group of students far outweighed it. Residents with greater knowledge about a particular topic were able to teach their fellow residents, developing their own teaching and communication skills in the process. Because the cases all deal with very different medical conditions and different population issues, no single resident was the expert on every case. Furthermore, the diversity of backgrounds led to rich discussions of issues related to the cases. Another concern in using these cases to teach preventive medicine residents was that they were originally written for medical students at a very different stage of training than the residents. The clinical components of the cases were too easy, especially for the residents with extensive practice experience, and too detailed for this audience, because improving their clinical knowledge was not the goal of the exercise. The clinical scenarios were useful as a hook to help the residents enter into the cases, but the clinical details needed to be pared down to a minimum to allow more time for discussion of the population aspects of the cases. For example, Sexually Transmitted Disease in Adolescents5 includes extensive discussion about which drugs to use for treatment, an issue of limited usefulness to preventive medicine residents. A Critical Look at Prevention: Colorectal Cancer Screening6 includes a series of questions about whether colonoscopy should be recommended in specific clinical situations—again, an issue
of limited value for nonclinical PMRs. Sections like these can be shortened or eliminated to meet the needs of the particular audience. The population aspects of the cases were of greatest interest to the PMRs and provided numerous opportunities for in-depth discussion. The number and diversity of topics raised by the cases were their greatest strength as a teaching tool for residents, making it easy to upgrade the level of the lessons from medical student exercises to resident seminars. Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York,4 which requires 2 weeks to complete, provided the richest array of discussion topics. During those sessions, the group discussed the variation in infant mortality rates over time and among geographic areas, risk factors for infant mortality, validity of birth certificate data, how data are collected and coded, Medicaid eligibility rules, the effect of recent advances in assisted reproductive technologies on the epidemiology of low birth weight and infant mortality, and many other related issues. A partial list of discussion topics raised by each of the cases is outlined in Table 1. In addition to creating opportunities for class discussion, the cases also raised community health issues that the residents wanted to learn about in more detail, suggesting other residency activities to address those interests. The group is planning a field trip to a homeless shelter to get a clearer sense of the living conditions there, because only one of the residents had worked in a shelter before. They are also planning to interview field staff members from the county health department’s STD program about the process and challenges of doing partner notification, an issue raised by Sexually Transmitted Disease in Adolescents.5
Use of the Teaching Cases to Develop Competency Graduate medical education is increasingly guided by efforts to assure that residents achieve specific competencies. The Accreditation Council on Graduate Medical Education is committed to increasing residency programs’ focus on assuring the competence of their graduates.9 The council recently released a set of generic clinical competencies that all residency programs must address. The American College of Preventive Medicine (ACPM) has been at the forefront in promoting competency-based graduate medical education within the specialty, having developed the first comprehensive set of competencies for preventive medicine residents almost 10 years ago.10 A revised version was published in 1999.11 Interest in preventive medicine competencies has been driven by the recognition that preventive medicine is unlike other specialties in several important respects. As a nonclinical field, it is unfamiliar to the general public and even to most physicians. Prospective employers often do not have a clear sense of where a Am J Prev Med 2003;24(4S)
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Table 1. Partial list of topics discussed in conjunction with each case A Critical Look at Prevention: Colorectal Cancer Screening Length bias, lead-time bias, development of practice guidelines Outbreak of Tuberculosis in a Homeless Men’s Shelter Police powers of the state, dual epidemic of TB and AIDS, living conditions in homeless shelters Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York Causes of infant mortality, historical and geographic variation in rates, paternity laws, birth weight versus gestational age as public health indicators, measures of socioeconomic status, Medicaid eligibility, vital records data Sexually Transmitted Disease in Adolescents Definition of statutory rape, confidentiality laws and HIV testing, partner notification, communicable disease reporting, interventions with adolescents Bicycle Helmet Effectiveness in Preventing Injury and Death Assumptions in cost-effectiveness, study designs, developing a budget Community Health Assessment Local public health funding, influence of politics on public health, qualitative versus quantitative analysis, focus groups, key informant interviews, mental versus physical health, data quality Adolescent Suicide Prevention Stigma of mental illness, death certificate reporting, role of the coroner or medical examiner; environmental versus individual-level intervention, measuring effectiveness, life insurance and suicide, schools as sites for health interventions
preventive medicine physician could be useful to their organization or what they can expect from a PMRtrained physician. Compounding the lack of understanding in the community, there is great diversity within the field of preventive medicine in the specific content of training programs, in the settings where preventive medicine specialists work, in the issues they address, and in the kinds of responsibilities they have. The ACPM Competencies for Preventive Medicine Residents are intended to define what residents should be able to do by the end of their training, defining, in turn, the common principles and concerns that unite the field.12 The surest way of demonstrating competence in an activity is by performing it in a supervised setting observed by faculty members. For this kind of performance-based competency evaluation, medicine residents demonstrate their competence in lumbar puncture by doing a certain number of the procedures, and obstetrics residents demonstrate their competence at performing vaginal and cesarean deliveries by delivering babies. It is more difficult to demonstrate many of the preventive medicine competencies through independent performance during the residency. For example, one of the competencies is to “design and operate a surveillance system,” an activity that few residents will have occasion to demonstrate during residency. Competency requires the understanding of concepts and the development of skills necessary to carry out a particular task, but it does not necessarily require one to have done every task. The NYSPMR program has developed a tracking form for monitoring the resident’s progress in achieving competencies.11 One column of the form lists the competencies. In the next column, the resident describes the activity completed to achieve each competency and in the next indicates the level of autonomy (independent, participated, or observed) in carrying out the activity, recognizing that during a 2-year resi114
dency residents will not be able to achieve every competency through independent performance. Residents are encouraged to achieve as many as possible of the competencies through independent performance or participation in group efforts, and they should at a minimum be exposed through observation and discussion to all of the skills and concepts outlined in the competencies. Teaching cases can play a role in helping residents achieve the competencies, particularly those that do not lend themselves to independent performance. For example, one of the competencies is to “characterize the health of a community.” The exercises and discussions involved in Community Health Assessment provide residents with a much better sense of what is involved in characterizing a community’s health than most would get even during a local public health practicum rotation. Another competency is to “prioritize activities using objective, measurable criteria such as epidemiological impact and cost-effectiveness.” Both Community Health Assessment3 and Bicycle Helmet Effectiveness in Preventing Injury and Death7 provide residents with skills needed in achieving that competency. Table 2 lists other competencies in which the teaching cases can be useful as an adjunct to practicum experiences in developing competency.
Future Plans to Use the Teaching Cases with Residents This residency program plans to repeat the teaching cases during next year’s orientation period. Because the senior residents will have done the cases already, they can be involved in teaching them next year, solidifying their understanding of the concepts and issues involved. To increase the number of participants in the teaching cases seminars, the series will be open to
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Table 2. Case studies useful in achieving ACPM preventive medicine competencies ACPM Preventive Medicine Competency
Relevant Case Studies
Identify and review relevant laws and regulations
Tuberculosis Outbreak Sexually Transmitted Disease Bicycle Helmet Effectiveness Community Health Assessment Adolescent Suicide Tuberculosis Outbreak Colorectal Cancer Screening Tuberculosis Outbreak Racial Disparities in Low Birth Weight Sexually Transmitted Disease Colorectal Cancer Screening Bicycle Helmet Effectiveness
Assess program and community resources, develop a plan for appropriate resources Characterize the health of a community Design and operate a surveillance system Design and conduct an outbreak or cluster investigation Evaluate the effectiveness of clinical services for both individuals and populations Diagnose and investigate health problems and health hazards in the community Develop policies and plans to support individual and community health efforts ACPM, American College of Preventive Medicine.
other physicians (non-PMRs) enrolled in the MPH program, helping them in their transition from clinical to population thinking. Before teaching the cases next year, the faculty and current residents will work on upgrading them in several ways. They will develop a bibliography of related articles from the medical literature to enrich their education and to provide a common baseline for residents in diverse fields. In addition to using the teaching cases with its own residents, the NYSPMR program plans to use them as an outreach tool to promote interest in preventive medicine among physicians in clinical residency programs in the region. Faculty and residents from the program will offer selected cases as teaching seminars for other residency programs, for instance, offering A Critical Look at Prevention: Colorectal Cancer Screening6 to internal medicine programs or Bicycle Helmet Effectiveness in Preventing Injury and Death7 to pediatric residencies. Even though they were developed as a teaching tool for medical students, the preventive medicine teaching cases, with minor modifications, can be used effectively in the preventive medicine residency setting. They can help residents make the transition from clinical thinking to population thinking. They can help residents develop important competencies that are difficult to achieve through individual experience during a residency. The preventive medicine teaching cases can help residents develop their own teaching and communication skills and can be a useful outreach tool to
inform physicians in other fields about preventive medicine as a career choice. The Case-Based Series in Population-Oriented Prevention (C-POP) is funded by grants from the Josiah Macy, Jr. Foundation and the Health Resources and Services Administration, U.S. Department of Health and Human Services.
References 1. Epling JW, Morrow CB, Sutphen SM, Novick LF. Case-based teaching in preventive medicine: rationale, development and implementation. Am J Prev Med 2003;24(suppl):85–9. 2. Morrow CB, Cibula DA, Novick LF. Outbreak of tuberculosis in a homeless men’s shelter. Am J Prev Med 2003;24(suppl):124 –7. 3. Cibula DA, Novick LF, Morrow CB, Sutphen SM. Community health assessment. Am J Prev Med 2003;24(suppl):118 –23. 4. Lane SD, Tera´ n S, Morrow CB, Novick LF. Racial and ethnic disparity in low birth weight in Syracuse, New York. Am J Prev Med 2003;24(suppl): 128 –32. 5. Novick LF, Tera´ n S, Dolbear G. Sexually transmitted disease in adolescents. Am J Prev Med 2003;24(suppl):133– 8. 6. Epling JW, Morrow CB, Cibula DA. A critical look at prevention: colorectal cancer screening. Am J Prev Med 2003;24(suppl):139 – 42. 7. Novick LF, Wojtowycz M, Morrow CB, Sutphen SM. Bicycle helmet effectiveness in preventing injury and death. Am J Prev Med 2003;24(suppl): 143–9. 8. Novick LF, Cibula DA, Sutphen SM. Adolescent suicide prevention. Am J Prev Med 2003;24(suppl):150 – 6. 9. Leach DC. Changing education to improve patient care. Qual Health Care 2001;10(suppl 2):ii54 –8. 10. Lane DS, Ross V, Parkinson MD, Chen DW. Performance indicators for assessing competencies of preventive medicine residents. Am J Prev Med 1995;11:1–8. 11. Lane DS, Ross V, Chen DW, O’Neill C. Core competencies for preventive medicine residents: Version 2.0. Am J Prev Med 1999;16:367–72. 12. American College of Preventive Medicine residency directors’ manual. Washington DC: ACPM, 2002:Appendix I.
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