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The Integration of Public Health and Prevention Into All Years of a Medical School Curriculum
The Integration of Public Health and Prevention Into All Years of a Medical School Curriculum Doug Campos-Outcalt, MD, MPA Abstract: This is one of six short papers that describe additional innovations to help integrate public health into medical education; these were featured in the “Patients and Populations: Public Health in Medical Education” conference. They represent relatively new endeavors or curricular components that had not been explored in prior publications. Although evaluation data are lacking, it was felt that sharing a description of the public health, prevention, population health, and policy (P4) curriculum at the University of Arizona College of Medicine, Phoenix (UACOM-P), would be of value to medical educators. (Am J Prev Med 2011;41(4S3):S306 –S308) © 2011 American Journal of Preventive Medicine
Objective
T
he Phoenix campus of the University of Arizona College of Medicine (UACOM-P) was founded in 2005 and accepted its fırst class in the fall of 2007. The fırst 2 years of the curriculum consist of basic science blocks organized by organ systems; biweekly clinical training in an outpatient primary care setting alternating with biweekly instruction in patient interactions and physical examination skills in a controlled teaching laboratory. The third and fourth years consist of ten required clinical clerkships and 20 weeks of clinical electives. Four longitudinal themes are integrated into all 4 years of the curriculum: biomedical informatics; social and behavioral sciences; ethics and humanities; and public health, prevention, population health, and policy (P4). Theme directors design the content, format, and delivery of their 4-year theme curriculum integrated into all basic science blocks, clinical clerkships, and other required courses.
Description The P4 content is structured around eight objectives (Table 1) that are taught in six content areas (Table 2). Evidence-based medicine content is included in both biomedical informatics and P4 themes. In the basic science blocks, P4 content is included in lectures, small group presentations in special P4 From the Department of Family and Community Medicine, University of Arizona College of Medicine, Phoenix, Arizona Address correspondence to: Doug Campos-Outcalt, MD, MPA, Associate Chair, Department of Family and Community Medicine, University of Arizona College of Medicine, 550 E Van Buren, Phoenix AZ 85004. E-mail: [email protected]. 0749-3797/$17.00 doi: 10.1016/j.amepre.2011.06.012
S306 Am J Prev Med 2011;41(4S3):S306 –S308
theme–focused cases for case-based instruction (CBIs), and all other CBI cases through explicit P4 learning objectives and content. The CBIs involve small groups of students with a faculty facilitator progressing through a clinical case, solving diagnostic problems and accomplishing specifıed learning objectives. Each basic science block includes an introductory P4 lecture on the epidemiology of the most common conditions discussed in the block as well as risks, disparities, and approaches to primary, secondary, and tertiary prevention to these conditions. This integration can save curriculum time for the basic scientists (e.g., in the gastrointestinal block, the P4 introductory session saves subsequent instructors from describing the epidemiology of obesity and diabetes.). The third-year clerkships have varied P4 theme content as part of didactic teaching with heavy emphasis on clinical prevention in family medicine, pediatrics, and internal medicine. P4 topics are also included in non– primary care clerkships such as obstetrics (periconception and prenatal care; pregnancy prevention) and surgery (pre-operative antibiotic prophylaxis; prevention of deep vein thrombosis). Intersessions (1-week curricula when the entire class returns to the main campus three times during the third and fourth year for both receptive and interactive classroom experiences) introduce additional P4, and policy content such as medical liability, the role of the medical examiner, and the importance of death records and how to complete them accurately. The fourth year includes 14 weeks of required rotations and 20 weeks of electives. Several P4 electives are available to allow students to explore P4 content in more depth. Electives for fırst- and second-year students are Issues and Trends in Public Health (a survey of national, state, and local health agencies and contemporary health and
© 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.
Campos-Outcalt / Am J Prev Med 2011;41(4S3):S306 –S308
public health issues) and Applied Public Health Practice (cases that demonstrate how local health departments address infectious diseases, chronic diseases, and environmental issues.) Clinical year electives are a 3-week intensive orientation to international health, and a rotation through the clinical and outreach departments of the local public health department. The COM-P also offers a joint MD/MPH dual degree program. Due to the P4 core content, the availability of P4 electives that provide dual MPH credit, and the overlap between a scholarly project (required of all COM-P students) and the MPH internship, the MD/MPH dual degree program can be completed in 4 or 5 years.
Discussion With theme content in all 4 years of the curriculum, theme directors need to constantly organize, coordinate and teach simultaneously in the fırst-, second-, and thirdyear curricula. Each theme director is allotted 20% of their time, which is supported by the medical school general education budget. Each theme director prepares an outline for their total 4-year content and presents it to the Educational Policy Committee (EPC). Theme content is mapped to Liaison Committee on Medical Education (LCME)–required competencies and content areas and approved by the EPC. Although obtaining time for themes in the basic science blocks is challenging, block directors are required to incorporate the themes, and since some of the block directors are on the EPC, there is buy-in to theme concepts and content. Theme content occupies approximately 10% of curriculum time in the fırst 2 years.
S307
Table 2. P4 content areas Public Health System and Applied Public Health Practice The difference between medicine and public health The public health method The array of tools of public health The historical effects of public health interventions and the difference they have made in mortality and morbidity statistics Basic concepts of public health law General functions and powers of local, state, and federal health agencies General roles of other local and state and federal agencies with public health functions The roles of specific federal agencies in public health Most common causes of illness, death, and disability by age, gender, and race THE ROLE OF THE PHYSICIAN IN THE PUBLIC HEALTH SYSTEM How to interact effectively with state and local health departments Reporting of infectious diseases Reporting suspicious clinical events Filling out death certificates Office infection-control practices Sources of information on public health issues Resources of local health departments available for referral Physicians’ role in emergencies and disasters Public health careers for physicians The Basic Sciences of Public Health Basic epidemiology
Table 1. P4 objectives
Biostatistics—applied and practical Applied Clinical Prevention
Describe the organization of the public health system at the local, state, and federal level. Discuss the public health interventions used to prevent disease and promote health. Utilize epidemiological tools to analyze and describe community health issues.
Evidence-based prevention recommendations; where to find and how to stay current Screening tests; how to evaluate their effectiveness Counseling to achieve lifestyle change Referral to community resources
Describe the roles of physicians and public health agencies in protecting the health of the public.
Integrating prevention into the clinical routine
Utilize a systematic approach to offer individualized, evidence-based clinical preventive services to patients.
Office systems for achieving better adherence to prevention guidelines
Describe how healthcare services are organized, financed, and administered.
Antibiotic resistance and the need for appropriate antibiotic use
Discuss potential solutions to health policy issues and how to participate in the policy-making process. Evaluate medical evidence and guidelines. P4, public health, prevention, population health, and policy
October 2011
Healthcare System and Services Healthcare disparities by race, ethnicity, gender, geography, socioeconomics (continued on next page)
S308
Campos-Outcalt / Am J Prev Med 2011;41(4S3):S306 –S308
Table 2. P4 content areas (continued) Healthcare financing Quality and safety Healthcare law Healthcare organizations Healthcare Policy Legislative process Healthcare regulation by state and federal agencies Health policy basics Role of professional societies and the public in the policy process P4, public health, prevention, population health, and policy
Once a year the four theme directors meet as a group with each block director to review the block and theme content and to plan for the next year. This allows theme directors to collaborate, co-plan sessions when possible, and effıciently use theme time while reemphasizing the theme requirements to block directors. To ensure that theme content is included in curricular blocks, theme directors can assure that all curriculum materials are turned in on time; handle communications and coordination with all invited speakers for theme sessions; and balance the proportion of theme content taught by outside experts and internal faculty including the theme director. In addition, the more theme directors can contribute to other aspects of the curriculum, such as authoring and/or reviewing CBI cases and facilitating CBI case discussions, the more their theme can be integrated into the overall block content. Thus far the P4 theme director has authored four CBI cases, with explicit P4-related topics (e.g., a food borne outbreak and a cholera outbreak in a refugee camp), and has reviewed each CBI to suggest specifıc P4-related learning objectives, when they are appropriate. These measures can help prevent incremental loss of theme content.
Another problem related to theme content has occurred that was not anticipated; the inadvertent addition of theme material. Many block directors and outside speakers will include P4 content with good intentions, but without consulting with the theme director. The theme director must review the entire content of each block to look for this material and then contact the appropriate faculty to discuss the longitudinal and comprehensive nature of theme content and how their proposed content can contribute without duplication. The total available P4 content in the curriculum allows for different levels of competency, with each level built on the foundation of the level(s) below. These levels are similar to those proposed by the IOM’s study of public health physicians.1 The basic level is provided by the core P4 curriculum to all students and provides training in competencies that the UACOM-P faculty feel all physicians should possess. An intermediate level can be achieved by students who take P4 elective courses and complete a P4-related scholarly project. An advanced level of competency is reached by those who complete the MD/MPH dual degree program. In this type of integrated model across all curricular components of a medical school, the identifıcation and institution support of a theme director is crucial for success. Publication of this article was supported by the CDC-AAMC (Association of American Medical Colleges) Cooperative Agreement number 5U36CD319276. DCO consults with the France Foundation to develop and deliver CME on immunizations. The France Foundation receives support from an array of pharmaceutic companies and other sources. This activity is not related to the content of this manuscript.
References 1. IOM. Training physicians for public health careers. Washington DC: National Academy Press, 2007.
www.ajpmonline.org
Objective
T
he Phoenix campus of the University of Arizona College of Medicine (UACOM-P) was founded in 2005 and accepted its fırst class in the fall of 2007. The fırst 2 years of the curriculum consist of basic science blocks organized by organ systems; biweekly clinical training in an outpatient primary care setting alternating with biweekly instruction in patient interactions and physical examination skills in a controlled teaching laboratory. The third and fourth years consist of ten required clinical clerkships and 20 weeks of clinical electives. Four longitudinal themes are integrated into all 4 years of the curriculum: biomedical informatics; social and behavioral sciences; ethics and humanities; and public health, prevention, population health, and policy (P4). Theme directors design the content, format, and delivery of their 4-year theme curriculum integrated into all basic science blocks, clinical clerkships, and other required courses.
Description The P4 content is structured around eight objectives (Table 1) that are taught in six content areas (Table 2). Evidence-based medicine content is included in both biomedical informatics and P4 themes. In the basic science blocks, P4 content is included in lectures, small group presentations in special P4 From the Department of Family and Community Medicine, University of Arizona College of Medicine, Phoenix, Arizona Address correspondence to: Doug Campos-Outcalt, MD, MPA, Associate Chair, Department of Family and Community Medicine, University of Arizona College of Medicine, 550 E Van Buren, Phoenix AZ 85004. E-mail: [email protected]. 0749-3797/$17.00 doi: 10.1016/j.amepre.2011.06.012
S306 Am J Prev Med 2011;41(4S3):S306 –S308
theme–focused cases for case-based instruction (CBIs), and all other CBI cases through explicit P4 learning objectives and content. The CBIs involve small groups of students with a faculty facilitator progressing through a clinical case, solving diagnostic problems and accomplishing specifıed learning objectives. Each basic science block includes an introductory P4 lecture on the epidemiology of the most common conditions discussed in the block as well as risks, disparities, and approaches to primary, secondary, and tertiary prevention to these conditions. This integration can save curriculum time for the basic scientists (e.g., in the gastrointestinal block, the P4 introductory session saves subsequent instructors from describing the epidemiology of obesity and diabetes.). The third-year clerkships have varied P4 theme content as part of didactic teaching with heavy emphasis on clinical prevention in family medicine, pediatrics, and internal medicine. P4 topics are also included in non– primary care clerkships such as obstetrics (periconception and prenatal care; pregnancy prevention) and surgery (pre-operative antibiotic prophylaxis; prevention of deep vein thrombosis). Intersessions (1-week curricula when the entire class returns to the main campus three times during the third and fourth year for both receptive and interactive classroom experiences) introduce additional P4, and policy content such as medical liability, the role of the medical examiner, and the importance of death records and how to complete them accurately. The fourth year includes 14 weeks of required rotations and 20 weeks of electives. Several P4 electives are available to allow students to explore P4 content in more depth. Electives for fırst- and second-year students are Issues and Trends in Public Health (a survey of national, state, and local health agencies and contemporary health and
© 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.
Campos-Outcalt / Am J Prev Med 2011;41(4S3):S306 –S308
public health issues) and Applied Public Health Practice (cases that demonstrate how local health departments address infectious diseases, chronic diseases, and environmental issues.) Clinical year electives are a 3-week intensive orientation to international health, and a rotation through the clinical and outreach departments of the local public health department. The COM-P also offers a joint MD/MPH dual degree program. Due to the P4 core content, the availability of P4 electives that provide dual MPH credit, and the overlap between a scholarly project (required of all COM-P students) and the MPH internship, the MD/MPH dual degree program can be completed in 4 or 5 years.
Discussion With theme content in all 4 years of the curriculum, theme directors need to constantly organize, coordinate and teach simultaneously in the fırst-, second-, and thirdyear curricula. Each theme director is allotted 20% of their time, which is supported by the medical school general education budget. Each theme director prepares an outline for their total 4-year content and presents it to the Educational Policy Committee (EPC). Theme content is mapped to Liaison Committee on Medical Education (LCME)–required competencies and content areas and approved by the EPC. Although obtaining time for themes in the basic science blocks is challenging, block directors are required to incorporate the themes, and since some of the block directors are on the EPC, there is buy-in to theme concepts and content. Theme content occupies approximately 10% of curriculum time in the fırst 2 years.
S307
Table 2. P4 content areas Public Health System and Applied Public Health Practice The difference between medicine and public health The public health method The array of tools of public health The historical effects of public health interventions and the difference they have made in mortality and morbidity statistics Basic concepts of public health law General functions and powers of local, state, and federal health agencies General roles of other local and state and federal agencies with public health functions The roles of specific federal agencies in public health Most common causes of illness, death, and disability by age, gender, and race THE ROLE OF THE PHYSICIAN IN THE PUBLIC HEALTH SYSTEM How to interact effectively with state and local health departments Reporting of infectious diseases Reporting suspicious clinical events Filling out death certificates Office infection-control practices Sources of information on public health issues Resources of local health departments available for referral Physicians’ role in emergencies and disasters Public health careers for physicians The Basic Sciences of Public Health Basic epidemiology
Table 1. P4 objectives
Biostatistics—applied and practical Applied Clinical Prevention
Describe the organization of the public health system at the local, state, and federal level. Discuss the public health interventions used to prevent disease and promote health. Utilize epidemiological tools to analyze and describe community health issues.
Evidence-based prevention recommendations; where to find and how to stay current Screening tests; how to evaluate their effectiveness Counseling to achieve lifestyle change Referral to community resources
Describe the roles of physicians and public health agencies in protecting the health of the public.
Integrating prevention into the clinical routine
Utilize a systematic approach to offer individualized, evidence-based clinical preventive services to patients.
Office systems for achieving better adherence to prevention guidelines
Describe how healthcare services are organized, financed, and administered.
Antibiotic resistance and the need for appropriate antibiotic use
Discuss potential solutions to health policy issues and how to participate in the policy-making process. Evaluate medical evidence and guidelines. P4, public health, prevention, population health, and policy
October 2011
Healthcare System and Services Healthcare disparities by race, ethnicity, gender, geography, socioeconomics (continued on next page)
S308
Campos-Outcalt / Am J Prev Med 2011;41(4S3):S306 –S308
Table 2. P4 content areas (continued) Healthcare financing Quality and safety Healthcare law Healthcare organizations Healthcare Policy Legislative process Healthcare regulation by state and federal agencies Health policy basics Role of professional societies and the public in the policy process P4, public health, prevention, population health, and policy
Once a year the four theme directors meet as a group with each block director to review the block and theme content and to plan for the next year. This allows theme directors to collaborate, co-plan sessions when possible, and effıciently use theme time while reemphasizing the theme requirements to block directors. To ensure that theme content is included in curricular blocks, theme directors can assure that all curriculum materials are turned in on time; handle communications and coordination with all invited speakers for theme sessions; and balance the proportion of theme content taught by outside experts and internal faculty including the theme director. In addition, the more theme directors can contribute to other aspects of the curriculum, such as authoring and/or reviewing CBI cases and facilitating CBI case discussions, the more their theme can be integrated into the overall block content. Thus far the P4 theme director has authored four CBI cases, with explicit P4-related topics (e.g., a food borne outbreak and a cholera outbreak in a refugee camp), and has reviewed each CBI to suggest specifıc P4-related learning objectives, when they are appropriate. These measures can help prevent incremental loss of theme content.
Another problem related to theme content has occurred that was not anticipated; the inadvertent addition of theme material. Many block directors and outside speakers will include P4 content with good intentions, but without consulting with the theme director. The theme director must review the entire content of each block to look for this material and then contact the appropriate faculty to discuss the longitudinal and comprehensive nature of theme content and how their proposed content can contribute without duplication. The total available P4 content in the curriculum allows for different levels of competency, with each level built on the foundation of the level(s) below. These levels are similar to those proposed by the IOM’s study of public health physicians.1 The basic level is provided by the core P4 curriculum to all students and provides training in competencies that the UACOM-P faculty feel all physicians should possess. An intermediate level can be achieved by students who take P4 elective courses and complete a P4-related scholarly project. An advanced level of competency is reached by those who complete the MD/MPH dual degree program. In this type of integrated model across all curricular components of a medical school, the identifıcation and institution support of a theme director is crucial for success. Publication of this article was supported by the CDC-AAMC (Association of American Medical Colleges) Cooperative Agreement number 5U36CD319276. DCO consults with the France Foundation to develop and deliver CME on immunizations. The France Foundation receives support from an array of pharmaceutic companies and other sources. This activity is not related to the content of this manuscript.
References 1. IOM. Training physicians for public health careers. Washington DC: National Academy Press, 2007.
www.ajpmonline.org