- Email: [email protected]
Public Health Area of Concentration
Public Health Area of Concentration A Model for Integration Into Medical School Curricula Samuel Stebbins, MD, MPH, Jason L. Sanders, BA, Charles J. Vukotich, Jr., MS, John F. Mahoney, MD Abstract: Calls for more public health education for medical students date back at least 150 years. In recent years, medical schools have increased their required coursework in core public health topics such as epidemiology, biostatistics, and behavioral determinants of health. Some schools have created more in-depth alternatives, including combined or concurrent master’s degrees; MD/PhD programs with a public health track; certifıcates in public health; or complete re-envisioning of the school into an integrated medical and public health institution. In 2009 the University of Pittsburgh School of Medicine began a Public Health Area of Concentration (AOC) that provides an optional, integrated curriculum that includes key elements of research, practice, and leadership. The AOC is a partnership between two schools at the University of Pittsburgh—Medicine and Public Health—and the local county health department. The result is a program that provides mentorship and training over 4 years of education designed to mend the long historical divide between the skills and constituencies of individual and population health. In addition, the AOC is relatively easy and inexpensive to implement and is modular in nature. The Public Health AOC is a simple model for incorporating many key aspects of public health into medical education and can be duplicated by any university that is willing to create partnerships and work across boundaries. (Am J Prev Med 2011;41(4S3):S237–S241) © 2011 American Journal of Preventive Medicine
History
C
alls for more public health education for student physicians go back to at least 1855.1 In 2003 and 2007, the IOM described specifıc public health competencies that all physicians should acquire during their training. These included “epidemiology, biostatistics, environmental health, health services administration, social and behavioral health sciences, informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, public health ethics, leadership, clinical and community preventive services, [and] public health emergency preparedness.”2,3 The IOM notes that these skills are essential to modern physicians and hold “strong
From the Center for Public Health Practice, University of Pittsburgh Graduate School of Public Health (Stebbins, Vukotich), the University of Pittsburgh Medical Scientist Training Program, University of Pittsburgh School of Medicine (Sanders), and the Offıce of Medical Education, University of Pittsburgh School of Medicine (Mahoney), Pittsburgh, Pennsylvania Address correspondence to: Samuel Stebbins, MD, MPH, Associate Director for Public Health and Medicine, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Room A733, Pittsburgh PA15261. E-mail: [email protected]. 0749-3797/$17.00 doi: 10.1016/j.amepre.2011.06.020
promise for augmenting the quality and effectiveness of clinical practice.”3 The American Association of Medical Colleges’s (AAMC) annual survey of graduating medical students tracks perception of education in the above (and many other) topics. The results indicate some areas of improvement in recent years, with upward trends in students’ rating of appropriate instruction in epidemiology (from 78% to 84% over the past 5 years) and biostatistics (from 74% to 79%).4 However, the survey also identifıes substantial unmet need. In 2010 one quarter of respondents rated public health training as inadequate, and education in occupational medicine, environmental health, and health policy were rated inadequate by 36%– 44% of graduating medical students. Nearly half reported inadequate instruction in biological, chemical, and natural disaster management, and less than half reported participating in a fıeld experience in community health.4 An important development occurred in June 2010 when the Standards for Accreditation of Medical Education Programs were revised; they now include “public health science” as a biomedical science in section ED-11. This area stipulates content that must be included in “the curriculum of a medical education program.”5 Although
© 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.
Am J Prev Med 2011;41(4S3):S237–S241 S237
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Stebbins et al / Am J Prev Med 2011;41(4S3):S237–S241
this change from previous publications of the Standards is substantial, details regarding implementation are left up to the individual school. At the recent (September 2010) AAMC–CDC conference, “Patients and Populations: Public Health in Medical Education,” faculty and students from around the country presented a wide variety of programs meeting this broad mandate in numerous ways. Jefferson Medical College has developed a flexible public health “college within a college” that provides breadth and depth and an option to pursue advanced degrees. At the Tufts University School of Medicine, a combined MD/MPH pathway is offered which provides both degrees in 4 years. The University of New Mexico School of Medicine now requires that all students graduate with a certifıcate in public health. The University of Wisconsin has recently changed both its vision and its name—to the University of Wisconsin School of Medicine and Public Health—to reflect greater integration between public health and medical care. Each of these (and more) programs at U.S. schools of medicine has advantages and disadvantages, though all explore ways to mend the long historical divide between the skills and constituencies of individual and population health. The University of Pittsburgh has recently developed a readily duplicated curriculum and set of activities that may be of interest to other schools looking to advance these same goals.
Background The University of Pittsburgh School of Medicine (UPSOM) fırst initiated Areas of Concentration (AOCs) in 1995. AOCs provide an opportunity for students to pursue an area of personal interest in depth during their 4 years of medical school. This is accomplished with a series of longitudinal elective experiences that supplement the required core curriculum. These para-curricular education tracks provide an opportunity for interested students to explore a potential career plan and uniquely enhance their medical education. Students who complete all components of the AOC receive offıcial recognition through a certifıcate from the School of Medicine although all students may benefıt from the AOC by selectively participating in its various components. The standard curriculum at UPSOM integrates population health and public health and prevention themes into existing courses. These courses start with Introduction to Being a Physician, a week-long course that includes an immersive experience in public and community health in two local Pittsburgh communities. Introduction to Medical Decision Making, Basic
Science of Care, and Clinical Experiences all emphasize major population and public health topics throughout their didactic material, including underserved populations, Healthy People 2020, determinants of care, healthcare fınance, public health preparedness, environmental health, effective patient education, and prevention in its myriad applications. Electives, volunteer experiences in the community, scholarly research projects, and the opportunity to obtain advanced training including an MPH degree program taught by the Graduate School of Public Health (GSPH) are available as well. Prior to the initiation of the Public Health AOC in August 2009, seven other AOCs were already in existence. These included Disabilities Medicine, Geriatric Medicine, Global Health, Medical Humanities, Neuroscience, Service Learning: Underserved Populations, and Women’s Health. This existing structure, along with support from UPSOM leadership, guidance from faculty at the University of Pittsburgh Graduate School of Public Health, and leadership from motivated students facilitated the creation and approval of the Public Health AOC.
Structure The fundamental structure of the AOC is triadic, linking UPSOM and GSPH with the Allegheny County Health Department (Figure 1). This partnership bridges the “separate worlds”6 of medicine, academic public health, and community health. In addition, the integrated curriculum connects didactic, practicebased, and research components (Figure 2). This design helps students understand the false dichotomy between medicine and public health and ensures that they learn how to integrate their individual and population health skills into a synergistic whole.
Participating Faculty Key faculty and students who lead the Public Health AOC bring skills from at least two or more subsets in each of the two triads indicated above. In addition, faculty who have agreed to be student mentors have backgrounds in a varied range of disciplines, to provide at least one expert in each core public health competency identifıed by the IOM.3 These include environmental health, vaccine research, health policy and fınancing, conservation medicine, outbreak modeling, informatics, communicable disease control, vector and pest control, sexually transmitted diseases, cultural competency, occupational health, tobacco and substance control, disaster preparedness and response, and community health planning and evaluation, among others. Students may thus choose from a wide variety of experts and projects as befıts the broad range of public health topics www.ajpmonline.org
Stebbins et al / Am J Prev Med 2011;41(4S3):S237–S241 Medical School
Integrated curriculum experience Public Health Department
Graduate School of Public Health
Figure 1. Public Health Area of Concentration (AOC) organization structure
available. These faculty members also participate in the interest group seminars to ensure exposure to the core public health competencies for AOC and non-AOC students.
Student Leadership Effective leadership by UPSOM students was essential to the creation of the AOC and is important to its future growth and maturation. A steering committee of medical students meets regularly with the AOC director to organize events. They serve as conduits to public health resources for other medical students, thereby helping bridge the gap between the passive many and interested few through peer-level social networking. Steering committee students gain additional experience in public health education, which helps develop the next generation of educators and leaders.
Content: General Requirements for AOC students include didactic sessions, leadership training, faculty mentorship, a scholarly project, a minimum 1-month experiential component at a health department, and self-evaluation. The summer between fırst and second year is often dedicated to a public health research project. These components progress in a logical manner so students expand their skills in sequence (Figure 3). During the fırst 2 years, students learn the theory behind public health and where medicine and public health converge and diverge. A leadership training seminar and internship allow students to integrate academic skills with real-world activities, whether through research or an applied project. In the last 2 years, students fully actualize their knowledge by participating in a 4-week clinical public health elective and completing a scholarly project with a public health focus.
Content: Specific Interest group seminars (Years 1 and 2) are a series of monthly, interactive seminars which provide informaOctober 2011
S239
tion on the theory and practice of public health. The seminars are led by a diverse group of faculty, many of whom are approved mentors for internships and scholarly projects. The seminars are held at UPSOM during the students’ lunch hour, and lunch is typically provided. This facilitates students coming to seminars and also engenders a relaxed atmosphere to spur conversation. Journal Club (Years 1 and 2) is a series of monthly discussions focused on an article of public health signifıcance. Articles are drawn from the scientifıc literature and notable periodicals. Importantly, the article’s content is matched to the basic science curriculum taught at that time to highlight for students the relationships between public health concepts and clinical issues. Because news briefs are also discussed, the journal club incorporates current events. Leadership training (Years 1 or 2) is a day-long exercise which imparts practical skills in leadership, team building, multidisciplinary problem solving, meeting planning, interagency collaboration, project management, and negotiation. Effective leadership is an essential part of being a successful physician, and the skills required can be taught in a straightforward manner. The summer internship (between Years 1 and 2) is a 10- to 12-week experience which exposes students to real-world public health practice or research. Students may work with academic, government, or private entities locally, nationally, or internationally with approval from the AOC director. The AOC helps place students and the experience is supported by the GSPH. The internship may be a stepping stone to the scholarly project and thus it is a mechanism for continued enrichment in public health. The Scholarly Project (Years 1 through 4) is required of all medical students. In the case of the AOC, it provides an opportunity to explore a public health problem in-depth, and fosters analytic thinking, development of tools for rational decision making, and high-quality oral and writ-
Didacc
Integrated educaon Praccebased
Research
Figure 2. Public Health Area of Concentration (AOC) curriculum structure
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ten communication. Faculty mentors serve as role models and resources for • Lead journal club students interested in • Aend journal club • Public health interest • Public health interest public health careers that • Public health elecve • Public health group group • Scholarly project research and/or integrate research, teach• Leadership seminar • Find internship for research pracce project • Determine scholarly ing, and clinical service. the summer • Self-evaluaon project The Public Health Clerkship (Years 3 or 4) is a 4-week fıeld-based experience, working primarily with the Allegheny County Figure 3. Public Health Area of Concentration (AOC) timeline Note: MS 1, MS 2, MS 3, and MS 4 designate first-year, second-year, third-year, and fourth-year medical Health Department, but students, respectively. including other public health agencies as appro3. The Leadership Training held its fırst session in Depriate. There is extensive exposure to environmental health cember 2010. Nine medical students attended this including food safety, water quality, solid waste, lead poison6-hour hands-on seminar and rated the training 4.4 on ing, air pollution control, and housing/vector control, as a Likert scale of 1⫽poor to 5⫽excellent. All participants well as a range of experiences including child death review, indicated yes in answer to the question Would you outbreak investigation, correctional health, and Healthy Start, among others. The fıeld work is supplemented by recommend this training to others? didactic material taught at the GSPH, which covers the legal 4. The Public Health Practicum (which began 2 years basis of public health, the ten essential public health services, prior to the AOC) recently completed a review of outthe organization of health departments and boards of health, comes. Ten third- and fourth-year medical students program and strategic planning, and the National Public who completed the practicum rated the experience as Health Performance Standards7 among others. Students 4.5 on a Likert scale of 1⫽poor to 5⫽excellent. These may also, with permission, elect to work with a health desame students also completed a pre/post assessment of partment or similar entity in another region, state, or counknowledge change, which showed over 14 content artry as an alternative. eas a signifıcant increase from 2.78 to 4.03 using a The self-evaluation component of the AOC allows stuLikert scale of 1⫽no knowledge to 5⫽profıcient.8 In dents to track their own success and reflect on how the addition, all students reported being “more interested” AOC affected their career plans and/or future medical in careers in public health as a result of the experience, practice. In addition, it provides essential feedback for with one having already completed an MPH degree continual program improvement. and two others planning to do so. 5. Research support has also been provided, and over Outcomes and Evaluation the fırst summer internship period, six students applied for and fıve were offered funding from GSPH Although the program is still quite young, some process to support summer research activities. Their proposand evaluation data are already available as follows: als were highly varied and included mapping the 1. Interest group seminars drew nearly one third of association of socioeconomic determinants to incifırst-year medical students (40 –50) on diverse topics dence rates of gonorrhea and chlamydia in San Franincluding the role of zinc in occupational health; the cisco; developing an Internet intervention to procontent of recently legislated health reform; flight mote the health of gay and bisexual male youth; medicine and regionalization of care; and opportucreating a cross-sectional serologic assay study of nities for academic and community-based public immunity to influenza type A—2009 pandemic health research. H1N1; evaluating and improving ob/gyn care for 2. Journal Club averaged 5–15 students per session who low–English profıciency Hispanic/Latina women at (with faculty mentorship) discussed the health of carethe Squirrel Hill Health Center; and analyzing the givers in the community; the economic, legal, social, epidemiology of acute, critical, nontraumatic brain and medical issues surrounding regulation of dietary conditions among U.S. children. salt; control of an infectious disease outbreak; and diBeyond these immediate objectives, the AOC has also saster preparedness, particularly the response to the achieved a number of broader goals, including: 2010 earthquake in Haiti. www.ajpmonline.org
Stebbins et al / Am J Prev Med 2011;41(4S3):S237–S241
1. offering enhanced education and training in public health and leadership to interested medical students at very low cost; 2. advancing the integration of medical/public health curricula; 3. improving the visibility of public health in the medical school; 4. increasing connections among the three main partners, including opportunities for teaching, research, and practice; 5. enabling opportunities for future training innovations by uniting academic medicine and governmental public health (as endorsed by the AAMC9); 6. developing future leaders in public health and preventive medicine education through student participation on the steering committee.
Discussion The trend in medical school curricular development is clearly to expand opportunities for public health education. Different schools provide unique opportunities— including offering a combined 4-year MD/MPH program, requiring a public health certifıcate of all students, or integrating medical and public health concepts at all levels. These approaches may be appropriate for many students, but are typically highly resource-intensive and may not be the optimum choice for many schools looking to manageably increase and improve their public health programming. The AOC also has potential weaknesses. Seminars and research mentorship rely on continued participation from busy faculty members who receive little or no compensation for their participation. The faculty advisor for the AOC’s position is within the GSPH, and he receives a small amount of funding from the GSPH Dean’s Offıce for integrative projects such as the AOC. Student steering committee members may turn over at varying rates given their progression through medical school and competing responsibilities and interests. While providing exceptional opportunity, the medical–public health– health department triad can also be encumbering because it requires buy-in from partners that may or may not gain from the relationships at different times. Although the AOC has shown early success and its dissolution is not anticipated, it nonetheless must prove to be sustainable. The genesis of the Public Health Area of Concentration at UPSOM lies in a combination of student demand, faculty leadership, and the presence of adequate resources to bring it to fruition. These resources have
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little to do with money and much more to do with the priority placed on the project. The AOC is an approach that is relatively simple and builds on existing skills, interests, and resources. It is modular in that students can make use of individual components even if not offıcially enrolled in the AOC. In addition, the AOC curriculum expands important linkages among research, education, and practice, is portable to other schools looking to expand their public health offerings, and positions a school to develop further public health– oriented and population-based courses and programming. In a world where 80% (12/15) of the leading causes of disability-adjusted life-years lost in the U.S. are preventable by the application of currently understood public health practices,10 it is essential to facilitate integration of public health and medicine in medical training programs. Publication of this article was supported by the CDC-AAMC (Association of American Medical Colleges) Cooperative Agreement number 5U36CD319276. No fınancial disclosures were reported by the authors of this paper.
References 1. Maeshiro R. Responding to the challenge: population health education for physicians. Acad Med 2008;83(4):319 –20. 2. IOM. Who will keep the public healthy? Educating health professionals for the 21st century. Washington DC: National Academies Press, 2003. 3. IOM. Training physicians for public health careers. Washington DC: National Academies Press, 2007. 4. GQ Medical School Graduation Questionnaire: All Schools Summary Report. Association of American Medical Colleges, 2010. www.aamc. org/data/gq/allschoolsreports/gq_alllschools_2010.pdf. 5. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Washington DC/Chicago IL: Liaison Committee on Medical Education, 2010. https://www.aamc. org/download/140716/data/2010_gq_all_schools.pdf. 6. Boex JR, Keck CW, Piatt E, Nunthirapikorn TN, Blacklow RS. Academic Health Centers and Public Health Departments: Partnerships Matter. Am J Prev Med 2006;30(1):89 –93. 7. National Association of County & City Health Offıcials. National Public Health Performance Standards Program. www.naccho.org/topics/ infrastructure/NPHPSP/index.cfm. 8. Stebbins S, Tackett S, Vukotich CJ. An innovative approach for training medical students for the real world of public health. Medical Education Development 2011;1(1). www.pagepress.org/journals/index. php/med/article/view/med.2011.e3/html_73. 9. AAMC–CDC Cooperative Agreement. www.aamc.org/initiatives/cdc/. 10. Shortell SM, Swartzberg J. The physician as public health professional in the 21st century. JAMA 2008;300(24):2916 – 8.
History
C
alls for more public health education for student physicians go back to at least 1855.1 In 2003 and 2007, the IOM described specifıc public health competencies that all physicians should acquire during their training. These included “epidemiology, biostatistics, environmental health, health services administration, social and behavioral health sciences, informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, public health ethics, leadership, clinical and community preventive services, [and] public health emergency preparedness.”2,3 The IOM notes that these skills are essential to modern physicians and hold “strong
From the Center for Public Health Practice, University of Pittsburgh Graduate School of Public Health (Stebbins, Vukotich), the University of Pittsburgh Medical Scientist Training Program, University of Pittsburgh School of Medicine (Sanders), and the Offıce of Medical Education, University of Pittsburgh School of Medicine (Mahoney), Pittsburgh, Pennsylvania Address correspondence to: Samuel Stebbins, MD, MPH, Associate Director for Public Health and Medicine, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Room A733, Pittsburgh PA15261. E-mail: [email protected]. 0749-3797/$17.00 doi: 10.1016/j.amepre.2011.06.020
promise for augmenting the quality and effectiveness of clinical practice.”3 The American Association of Medical Colleges’s (AAMC) annual survey of graduating medical students tracks perception of education in the above (and many other) topics. The results indicate some areas of improvement in recent years, with upward trends in students’ rating of appropriate instruction in epidemiology (from 78% to 84% over the past 5 years) and biostatistics (from 74% to 79%).4 However, the survey also identifıes substantial unmet need. In 2010 one quarter of respondents rated public health training as inadequate, and education in occupational medicine, environmental health, and health policy were rated inadequate by 36%– 44% of graduating medical students. Nearly half reported inadequate instruction in biological, chemical, and natural disaster management, and less than half reported participating in a fıeld experience in community health.4 An important development occurred in June 2010 when the Standards for Accreditation of Medical Education Programs were revised; they now include “public health science” as a biomedical science in section ED-11. This area stipulates content that must be included in “the curriculum of a medical education program.”5 Although
© 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.
Am J Prev Med 2011;41(4S3):S237–S241 S237
S238
Stebbins et al / Am J Prev Med 2011;41(4S3):S237–S241
this change from previous publications of the Standards is substantial, details regarding implementation are left up to the individual school. At the recent (September 2010) AAMC–CDC conference, “Patients and Populations: Public Health in Medical Education,” faculty and students from around the country presented a wide variety of programs meeting this broad mandate in numerous ways. Jefferson Medical College has developed a flexible public health “college within a college” that provides breadth and depth and an option to pursue advanced degrees. At the Tufts University School of Medicine, a combined MD/MPH pathway is offered which provides both degrees in 4 years. The University of New Mexico School of Medicine now requires that all students graduate with a certifıcate in public health. The University of Wisconsin has recently changed both its vision and its name—to the University of Wisconsin School of Medicine and Public Health—to reflect greater integration between public health and medical care. Each of these (and more) programs at U.S. schools of medicine has advantages and disadvantages, though all explore ways to mend the long historical divide between the skills and constituencies of individual and population health. The University of Pittsburgh has recently developed a readily duplicated curriculum and set of activities that may be of interest to other schools looking to advance these same goals.
Background The University of Pittsburgh School of Medicine (UPSOM) fırst initiated Areas of Concentration (AOCs) in 1995. AOCs provide an opportunity for students to pursue an area of personal interest in depth during their 4 years of medical school. This is accomplished with a series of longitudinal elective experiences that supplement the required core curriculum. These para-curricular education tracks provide an opportunity for interested students to explore a potential career plan and uniquely enhance their medical education. Students who complete all components of the AOC receive offıcial recognition through a certifıcate from the School of Medicine although all students may benefıt from the AOC by selectively participating in its various components. The standard curriculum at UPSOM integrates population health and public health and prevention themes into existing courses. These courses start with Introduction to Being a Physician, a week-long course that includes an immersive experience in public and community health in two local Pittsburgh communities. Introduction to Medical Decision Making, Basic
Science of Care, and Clinical Experiences all emphasize major population and public health topics throughout their didactic material, including underserved populations, Healthy People 2020, determinants of care, healthcare fınance, public health preparedness, environmental health, effective patient education, and prevention in its myriad applications. Electives, volunteer experiences in the community, scholarly research projects, and the opportunity to obtain advanced training including an MPH degree program taught by the Graduate School of Public Health (GSPH) are available as well. Prior to the initiation of the Public Health AOC in August 2009, seven other AOCs were already in existence. These included Disabilities Medicine, Geriatric Medicine, Global Health, Medical Humanities, Neuroscience, Service Learning: Underserved Populations, and Women’s Health. This existing structure, along with support from UPSOM leadership, guidance from faculty at the University of Pittsburgh Graduate School of Public Health, and leadership from motivated students facilitated the creation and approval of the Public Health AOC.
Structure The fundamental structure of the AOC is triadic, linking UPSOM and GSPH with the Allegheny County Health Department (Figure 1). This partnership bridges the “separate worlds”6 of medicine, academic public health, and community health. In addition, the integrated curriculum connects didactic, practicebased, and research components (Figure 2). This design helps students understand the false dichotomy between medicine and public health and ensures that they learn how to integrate their individual and population health skills into a synergistic whole.
Participating Faculty Key faculty and students who lead the Public Health AOC bring skills from at least two or more subsets in each of the two triads indicated above. In addition, faculty who have agreed to be student mentors have backgrounds in a varied range of disciplines, to provide at least one expert in each core public health competency identifıed by the IOM.3 These include environmental health, vaccine research, health policy and fınancing, conservation medicine, outbreak modeling, informatics, communicable disease control, vector and pest control, sexually transmitted diseases, cultural competency, occupational health, tobacco and substance control, disaster preparedness and response, and community health planning and evaluation, among others. Students may thus choose from a wide variety of experts and projects as befıts the broad range of public health topics www.ajpmonline.org
Stebbins et al / Am J Prev Med 2011;41(4S3):S237–S241 Medical School
Integrated curriculum experience Public Health Department
Graduate School of Public Health
Figure 1. Public Health Area of Concentration (AOC) organization structure
available. These faculty members also participate in the interest group seminars to ensure exposure to the core public health competencies for AOC and non-AOC students.
Student Leadership Effective leadership by UPSOM students was essential to the creation of the AOC and is important to its future growth and maturation. A steering committee of medical students meets regularly with the AOC director to organize events. They serve as conduits to public health resources for other medical students, thereby helping bridge the gap between the passive many and interested few through peer-level social networking. Steering committee students gain additional experience in public health education, which helps develop the next generation of educators and leaders.
Content: General Requirements for AOC students include didactic sessions, leadership training, faculty mentorship, a scholarly project, a minimum 1-month experiential component at a health department, and self-evaluation. The summer between fırst and second year is often dedicated to a public health research project. These components progress in a logical manner so students expand their skills in sequence (Figure 3). During the fırst 2 years, students learn the theory behind public health and where medicine and public health converge and diverge. A leadership training seminar and internship allow students to integrate academic skills with real-world activities, whether through research or an applied project. In the last 2 years, students fully actualize their knowledge by participating in a 4-week clinical public health elective and completing a scholarly project with a public health focus.
Content: Specific Interest group seminars (Years 1 and 2) are a series of monthly, interactive seminars which provide informaOctober 2011
S239
tion on the theory and practice of public health. The seminars are led by a diverse group of faculty, many of whom are approved mentors for internships and scholarly projects. The seminars are held at UPSOM during the students’ lunch hour, and lunch is typically provided. This facilitates students coming to seminars and also engenders a relaxed atmosphere to spur conversation. Journal Club (Years 1 and 2) is a series of monthly discussions focused on an article of public health signifıcance. Articles are drawn from the scientifıc literature and notable periodicals. Importantly, the article’s content is matched to the basic science curriculum taught at that time to highlight for students the relationships between public health concepts and clinical issues. Because news briefs are also discussed, the journal club incorporates current events. Leadership training (Years 1 or 2) is a day-long exercise which imparts practical skills in leadership, team building, multidisciplinary problem solving, meeting planning, interagency collaboration, project management, and negotiation. Effective leadership is an essential part of being a successful physician, and the skills required can be taught in a straightforward manner. The summer internship (between Years 1 and 2) is a 10- to 12-week experience which exposes students to real-world public health practice or research. Students may work with academic, government, or private entities locally, nationally, or internationally with approval from the AOC director. The AOC helps place students and the experience is supported by the GSPH. The internship may be a stepping stone to the scholarly project and thus it is a mechanism for continued enrichment in public health. The Scholarly Project (Years 1 through 4) is required of all medical students. In the case of the AOC, it provides an opportunity to explore a public health problem in-depth, and fosters analytic thinking, development of tools for rational decision making, and high-quality oral and writ-
Didacc
Integrated educaon Praccebased
Research
Figure 2. Public Health Area of Concentration (AOC) curriculum structure
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ten communication. Faculty mentors serve as role models and resources for • Lead journal club students interested in • Aend journal club • Public health interest • Public health interest public health careers that • Public health elecve • Public health group group • Scholarly project research and/or integrate research, teach• Leadership seminar • Find internship for research pracce project • Determine scholarly ing, and clinical service. the summer • Self-evaluaon project The Public Health Clerkship (Years 3 or 4) is a 4-week fıeld-based experience, working primarily with the Allegheny County Figure 3. Public Health Area of Concentration (AOC) timeline Note: MS 1, MS 2, MS 3, and MS 4 designate first-year, second-year, third-year, and fourth-year medical Health Department, but students, respectively. including other public health agencies as appro3. The Leadership Training held its fırst session in Depriate. There is extensive exposure to environmental health cember 2010. Nine medical students attended this including food safety, water quality, solid waste, lead poison6-hour hands-on seminar and rated the training 4.4 on ing, air pollution control, and housing/vector control, as a Likert scale of 1⫽poor to 5⫽excellent. All participants well as a range of experiences including child death review, indicated yes in answer to the question Would you outbreak investigation, correctional health, and Healthy Start, among others. The fıeld work is supplemented by recommend this training to others? didactic material taught at the GSPH, which covers the legal 4. The Public Health Practicum (which began 2 years basis of public health, the ten essential public health services, prior to the AOC) recently completed a review of outthe organization of health departments and boards of health, comes. Ten third- and fourth-year medical students program and strategic planning, and the National Public who completed the practicum rated the experience as Health Performance Standards7 among others. Students 4.5 on a Likert scale of 1⫽poor to 5⫽excellent. These may also, with permission, elect to work with a health desame students also completed a pre/post assessment of partment or similar entity in another region, state, or counknowledge change, which showed over 14 content artry as an alternative. eas a signifıcant increase from 2.78 to 4.03 using a The self-evaluation component of the AOC allows stuLikert scale of 1⫽no knowledge to 5⫽profıcient.8 In dents to track their own success and reflect on how the addition, all students reported being “more interested” AOC affected their career plans and/or future medical in careers in public health as a result of the experience, practice. In addition, it provides essential feedback for with one having already completed an MPH degree continual program improvement. and two others planning to do so. 5. Research support has also been provided, and over Outcomes and Evaluation the fırst summer internship period, six students applied for and fıve were offered funding from GSPH Although the program is still quite young, some process to support summer research activities. Their proposand evaluation data are already available as follows: als were highly varied and included mapping the 1. Interest group seminars drew nearly one third of association of socioeconomic determinants to incifırst-year medical students (40 –50) on diverse topics dence rates of gonorrhea and chlamydia in San Franincluding the role of zinc in occupational health; the cisco; developing an Internet intervention to procontent of recently legislated health reform; flight mote the health of gay and bisexual male youth; medicine and regionalization of care; and opportucreating a cross-sectional serologic assay study of nities for academic and community-based public immunity to influenza type A—2009 pandemic health research. H1N1; evaluating and improving ob/gyn care for 2. Journal Club averaged 5–15 students per session who low–English profıciency Hispanic/Latina women at (with faculty mentorship) discussed the health of carethe Squirrel Hill Health Center; and analyzing the givers in the community; the economic, legal, social, epidemiology of acute, critical, nontraumatic brain and medical issues surrounding regulation of dietary conditions among U.S. children. salt; control of an infectious disease outbreak; and diBeyond these immediate objectives, the AOC has also saster preparedness, particularly the response to the achieved a number of broader goals, including: 2010 earthquake in Haiti. www.ajpmonline.org
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1. offering enhanced education and training in public health and leadership to interested medical students at very low cost; 2. advancing the integration of medical/public health curricula; 3. improving the visibility of public health in the medical school; 4. increasing connections among the three main partners, including opportunities for teaching, research, and practice; 5. enabling opportunities for future training innovations by uniting academic medicine and governmental public health (as endorsed by the AAMC9); 6. developing future leaders in public health and preventive medicine education through student participation on the steering committee.
Discussion The trend in medical school curricular development is clearly to expand opportunities for public health education. Different schools provide unique opportunities— including offering a combined 4-year MD/MPH program, requiring a public health certifıcate of all students, or integrating medical and public health concepts at all levels. These approaches may be appropriate for many students, but are typically highly resource-intensive and may not be the optimum choice for many schools looking to manageably increase and improve their public health programming. The AOC also has potential weaknesses. Seminars and research mentorship rely on continued participation from busy faculty members who receive little or no compensation for their participation. The faculty advisor for the AOC’s position is within the GSPH, and he receives a small amount of funding from the GSPH Dean’s Offıce for integrative projects such as the AOC. Student steering committee members may turn over at varying rates given their progression through medical school and competing responsibilities and interests. While providing exceptional opportunity, the medical–public health– health department triad can also be encumbering because it requires buy-in from partners that may or may not gain from the relationships at different times. Although the AOC has shown early success and its dissolution is not anticipated, it nonetheless must prove to be sustainable. The genesis of the Public Health Area of Concentration at UPSOM lies in a combination of student demand, faculty leadership, and the presence of adequate resources to bring it to fruition. These resources have
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little to do with money and much more to do with the priority placed on the project. The AOC is an approach that is relatively simple and builds on existing skills, interests, and resources. It is modular in that students can make use of individual components even if not offıcially enrolled in the AOC. In addition, the AOC curriculum expands important linkages among research, education, and practice, is portable to other schools looking to expand their public health offerings, and positions a school to develop further public health– oriented and population-based courses and programming. In a world where 80% (12/15) of the leading causes of disability-adjusted life-years lost in the U.S. are preventable by the application of currently understood public health practices,10 it is essential to facilitate integration of public health and medicine in medical training programs. Publication of this article was supported by the CDC-AAMC (Association of American Medical Colleges) Cooperative Agreement number 5U36CD319276. No fınancial disclosures were reported by the authors of this paper.
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