Teaching Population Health: An Essential Component of Context in Medical Education IAMSE June 8,...
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Transcript of Teaching Population Health: An Essential Component of Context in Medical Education IAMSE June 8,...
Teaching Population Health: An Essential Component of Context
in Medical EducationIAMSE
June 8, 2014
Heidi Gullett, MD, MPHAssistant Professor, Department of Family Medicine and Community Health
Population Health Liaison, Cuyahoga County Board of Health
Amy Wilson-Delfosse, PhDAssociate Professor of Pharmacology
Assistant Dean for Basic Science Education
Disclosures• No Financial Disclosures
Focus Session Objectives
1. Articulate the importance of teaching population health concepts in undergraduate medical education.
2. Define 2-3 essential components of population health education for medical students.
3. Describe the value of community-based learning experiences to underscore the concepts in a population health curriculum.
4. Describe 1-2 specific ways that population health could be integrated into an attendee’s curriculum.
Workshop Overview• Workshop Participant Assessment• Population Health and Professional Competencies• Overview of CWRU Curriculum and Block 1
– Block 1 Goals and Philosophy– Block 1 Structure and Content – Epidemiology and Biostatistics
• Discussion around integration of specific population health curricular elements– Content– Teaching techniques– Faculty selection– Curricular timing– Challenges
Welcome!• Name• School• Role• Please tell us something fun you plan to do this
summer.• What do you hope to gain from this workshop?• What is a specific area of interest you would
like addressed in this workshop?
What is Population Health• Institute for Healthcare Improvement (IHI)1
– “Any group of individuals for whom consideration of health or health care at the level of the group is likely to advance health.”
• Dr. Kindig’s definition:2
– “The health outcomes of a group of individuals, including distribution of such outcomes within the group.”
• Concerned with outcomes, as well as determinants and factors, in an effort to define the “distribution of health”
• Evolving definition1www.ihi.org2Kindig DA, Stoddard G. What is population health? Am J Public Health 2003; 93:366-369.
Tools of Population Health• Epidemiology/Biostatistics• Disease surveillance• Data analysis• Education• Advocacy• Policy • Program design and evaluation• Research• Environmental Health• Genetic epidemiology• Process and outcome measures• Quality improvement• Community health and health impact assessments• Bioethics
Teaching Population Health from Various Perspectives
• Context depends upon perspective• Community• Patient• Public Health (Local, Regional, National,
International)• Provider • Payor• Government
Why Focus on Population Health?• Competencies and Certification Exams– Liaison Committee on Medical Education (LCME)– Accreditation Council for Graduate Medical
Education (ACGME)– National Board of Medical Examiners (NBME)– Specialty Boards
• Context for medical training and career– Rapidly changing healthcare environment– More broad understanding of determinants of health– Practical introduction to students’ new community
Why Focus on Population Health?• Much work of population health performed by local
public health• Public health and clinical care most often function in
isolation• A move toward integration is critical to improve health– Institute of Medicine 2012 Report• Primary Care and Public Health: Exploring Integration
to Improve Population Health
IOM Report 2012
LCME Competencies• Population Health and Civic
Professionalism– Identifies community and population-based
health issues– Demonstrates skills needed to improve health
and healthcare for local, national, and global communities
LCME Competencies• Educational Program Objectives and Milestones for
Graduation– Applies primary and secondary prevention strategies that
improve the health of individuals and populations.– Demonstrates ability to design community-based health
improvement intervention.– Integrates emerging information on individuals’ biologic
and genetic risk with population-level factors when deciding upon prevention and treatment options.
– Considers ethical and legal perspectives, patient advocacy, health policy, and public health concerns in clinical care.
ACGME Competencies• Consistent with Milestone Project for all
specialties• Six Core Competencies– Patient Care– Medical Knowledge– Practice-based Learning and Improvement– Interpersonal and Communication Skills– Professionalism– Systems-based Practice
In your institutions…• How do you teach these competencies?– Separate courses?– Integrated within other courses?– Other?
An Introduction to Block 1:Becoming A Doctor
• Created as part of overall curricular revision in 2004• Concentrated 5 weeks at beginning of medical school
(July-mid August)• Opportunity to create a comprehensive
understanding of population health principles• Create foundation upon which to build throughout
next 4 years– Other preclinical blocks– Tuesday seminars (Foundations of Clinical Medicine)– Core clinical rotations (including IQ+)
Population Health in the WR2 Curriculum
• “Fundamental curricular revision” in 2004• Two major goals:
1. Create opportunity for all students to conduct meaningful research culminating in required medical student thesis
2. Three areas create “backbone” of curriculum• Mastery of clinical skills• Civic professionalism
– Understanding systems and population health are critical to effective civic professionalism.
• Leadership
Year I Year II Year III Year IV
Foundations of Medicine and Health
(20 months, including vacation)
BASIC SCIENCES
PHYSICAL DIAGNOSIS
COMMUNICATION SKILLS
COMMUNITY PATIENT CARE PRECEPTORSHIP
(CPCP)
Core Clinical Rotations
IQ+ Program
(48 weeks, flexible scheduling)
Research &
Scholarship
(16 week block +
electives, flexible
scheduling)
Advanced Clinical and Scientific
Studies
Areas of Concentration
Electives
(10 months, flexible scheduling)
Western Reserve2 Curriculum
Slide courtesy of Scott Frank, MD, MS
CWRU School of MedicineUniversity Track Basic Science Curriculum
Refle
ction
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July Year 1 March Year 2
Homeostasis
(14 wk)
Host Defense and Host Response
(14 wk)
Cognition, Sensation, and
Movement
(14 wk)
Food to Fuel
(11 wk)
(Host Defense, Microbiology,
Blood, Skin,Auto-immune)
(Endo, Repro, Development, Genetics, Mol Biol, Cancer
Biology)
(GI, Nutrition, Energy,
Metabolism, Biochemistry)
(Neuro, MindMusculoskeletal,
Cellular Neurophysiology
(CV, Pulm, Renal, Cell
Regulation, Pharmacology, Cell
physiology)
The Human Blueprint
(11 wk)
Refle
ction
, Int
egra
tion
& A
sses
smen
t
1 Week Clinical
Immersion
1 Week Clinical
Immersion
1 Week Clinical
Immersion
1 Week Clinical
Immersion
1 Week Clinical
Immersion
(Public Health, Inequities, QI/Patient
Safety/Medical Error, Bioethics, Professionalism
Epi/Biostats)
Becoming a Doctor
(5 wk)
Refle
ction
, Int
egra
tion
& A
sses
smen
t
Structure (Anatomy, Histo-Path, Radiology)
Foundations of Clinical Medicine
Slide courtesy of Scott Frank, MD, MS
CWRU School of MedicineUniversity Track Basic Science Curriculum
Refle
ction
, Int
egra
tion
& A
sses
smen
t
Refle
ction
, Int
egra
tion
& A
sses
smen
t
Refle
ction
, Int
egra
tion
& A
sses
smen
t
Refle
ction
, Int
egra
tion
& A
sses
smen
t
July Year 1 March Year 2
Homeostasis
(14 wk)
Host Defense and Host Response
(14 wk)
Cognition, Sensation, and
Movement
(14 wk)
Food to Fuel
(11 wk)
(Host Defense, Microbiology,
Blood, Skin,Auto-immune)
(Endo, Repro, Development, Genetics, Mol Biol, Cancer
Biology)
(GI, Nutrition, Energy,
Metabolism, Biochemistry)
(Neuro, MindMusculoskeletal,
Cellular Neurophysiology
(CV, Pulm, Renal, Cell
Regulation, Pharmacology, Cell
physiology)
The Human Blueprint
(11 wk)
Refle
ction
, Int
egra
tion
& A
sses
smen
t
1 Week Clinical
Immersion
1 Week Clinical
Immersion
1 Week Clinical
Immersion
1 Week Clinical
Immersion
1 Week Clinical
Immersion
(Public Health, Inequities, QI/Patient
Safety/Medical Error, Bioethics, Professionalism
Epi/Biostats)
Becoming a Doctor
(5 wk)
Refle
ction
, Int
egra
tion
& A
sses
smen
t
Structure (Anatomy, Histo-Path, Radiology)
Foundations of Clinical Medicine
Slide courtesy of Scott Frank, MD, MS
Block 1 Goals1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure, and affect the health of populations.
3. Provide a basis for understanding social, behavioral, structural, and environmental determinants of health.
4. Provide a broad understanding of health systems.5. Emphasize continuous process and system
improvement as a mechanism for limiting medical error and improving both individual and population outcomes.
Block 1 Goals1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure, and affect the health of populations.
3. Provide a basis for understanding social, behavioral, structural, and environmental determinants of health.
4. Provide a broad understanding of health systems.5. Emphasize continuous process and system improvement
as a mechanism for limiting medical error and improving both individual and population outcomes.
Block 1 Goals1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure, and affect the health of populations.
3. Provide a basis for understanding social, behavioral, structural, and environmental determinants of health.
4. Provide a broad understanding of health systems.5. Emphasize continuous process and system
improvement as a mechanism for limiting medical error and improving both individual and population outcomes.
Block 1 Goals1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure, and affect the health of populations.
3. Provide a basis for understanding social, behavioral, structural, and environmental determinants of health.
4. Provide a broad understanding of health systems.5. Emphasize continuous process and system
improvement as a mechanism for limiting medical error and improving both individual and population outcomes.
Block 1 Goals1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure, and affect the health of populations.
3. Provide a basis for understanding social, behavioral, structural, and environmental determinants of health.
4. Provide a broad understanding of health systems.5. Emphasize continuous process and system
improvement as a mechanism for limiting medical error and improving both individual and population outcomes.
Block 1 Goals1. Provide a strong epidemiology and biostatistics
foundation to support effective application in clinical practice and interpretation of the scientific literature.
2. Illustrate effective means to understand, measure, and affect the health of populations.
3. Provide a basis for understanding social, behavioral, structural, and environmental determinants of health.
4. Provide a broad understanding of health systems.5. Emphasize continuous process and system
improvement as a mechanism for limiting medical error and improving both individual and population outcomes.
Block 1 Philosophy: The Lens• Create a strong foundation on which to build during the
remainder of medical school.• Create context for understanding health in a broad
sense.– Foundation includes teaching how to measure,
understand, and affect the health of populations– Foster integration of concepts learned in all activities
• Goal to coordinate with other faculty curricular leaders to ensure a cohesive curriculum that serves our students and community well.
Intentional emphasis on…
• Interprofessional importance, team-based practice
• Diverse faculty: training, expertise, specialty, experience
• Representation across Cleveland: local health departments and health systems
• Highlight tremendous community health work in our area to solidify concepts taught throughout the block
Block 1 Weekly ThemesProblem-
based Learning (IQ)
CaseUnnatural
Causes
Community Field
ExperiencesTeam-Based
LearningWeek 1 Population Health Pandemic Flu In Sickness and
in Wealth; Not Just a Paycheck
Week 2 Determinants of Health Toni Jackson: Determinants of Health
When the Bough Breaks; Place Matters
Determinants of Health/Social Work
Population Health
Week 3 Health Systems Mr. Prince: Medical Error
Collateral Damage; Becoming American
Community Health Center/Safety Net
Global Health System Comparisons
Week 4 Patient-centered care Mrs. Sanchez: Diabetes Mellitus
Bad Sugar Chronic Disease
Week 5 “Bringing It All Together” Jack Lee: Well Adult Care
Integration of Curricular Content
• Goal to foster reflection and integration of core concepts across the block
• Multiple venues to encourage connection of various learning activities with each IQ case– Google+ Field Experience reflection posts
• Cases are correlated with the weekly theme
Highlights of longitudinal curricular threads
• Health promotion step challenge• Bioethics thread across block• Google+ field experience reflection blog• Online modules (IHI, APTR*)• Unnatural causes: Is Inequality Making Us
Sick?• Epidemiology/Biostatistics
*IHI = Institute for Healthcare Improvement; APTR = Association for Prevention Teaching and Research
Health Promotion Step Challenge• Goal: To illustrate health behavior activity,
continuous process improvement• Foster friendly competition and camaraderie• Faculty and staff participation• Prizes
• Top PBL (IQ) group• Top individuals (staff /faculty and students)• Students who achieve average of 10,000 steps every day
= 280,000 steps
2013 IQ Winner!
2013 Individual Winner!
Bioethics
• Incorporation into key elements of Block 1:• Two general Bioethics introductory sessions – Week 1• Pandemic flu exercise – Week 1• Incorporation into individual v. population health
didactics (theory) – Week 1• Health disparities – Week 2• Field experiences (practical application) – Weeks 2-4• IQ discussions – Weeks 2-4
Field Experiences
• Determinants of Health/Social Work• Community Health Center/Safety Net• Chronic Disease• Neighborhood Correlations • PBL (IQ) facilitators receive guide for each
week with trigger questions to facilitate Google+ posts and small group discussion
Google+• Field experiences– Social work– Community health center/safety net providers– Chronic disease
• Google+ IQ group pages (“communities” – hidden and secure) for reflection blogs to facilitate integrated discussion during IQ sessions
• IQ student leaders asked to protect time in Friday session for discussion
Online modules
• IHI Quality Improvement– Option for certificate of completion though IHI– Free for enrolled US medical students
• Association for Prevention Teaching and Research (APTR)– Population Health– Public Health Learning
Unnatural Causes
• Health disparities documentary series– 4 hours, 7 episodes– Associated health policy exercises for all
stakeholders regarding health equity– www.unnaturalcauses.org
Organization of Epi/Biostats Curriculum• Total of 11 hours of class time
• Large-group lectures with interactive answering options
• Background of core concepts– Epidemiology– Biostatistics– Introduction to clinical study designs
• Critical evaluation of studies– Practice using “journal club”
Slide courtesy of Doug Einstadter, MD, MPH
EpidemiologyTopics Covered
• Introduction to Epidemiology• Association and Cause• Samples and populations• Use and interpretation of diagnostic tests• The role of screening and prevention
Slide courtesy of Doug Einstadter, MD, MPH
BiostatisticsTopics Covered• Types of Data
• Descriptive Statistics
• Hypothesis testing
• Chance and the p-value
• Confidence Intervals
• Potential errors (Type I and II)
• Power
Slide courtesy of Doug Einstadter, MD, MPH
Study Designs Introduced:• Cross-sectional studies• Case-Control studies• Cohort studies• Randomized Controlled Trials
Journal Club(s) to practice critical review skills.
Critical Evaluation Skills
Slide courtesy of Doug Einstadter, MD, MPH
Block 1 Student Assessment
• Weekly during block:– Short essay questions– Multiple choice questions– IQ facilitator feedback on reflections and
participation in PBL (IQ) sessions• Following completion of block:– Essay questions
Discussion
• Small group discussion on the following areas of population health integration (30 min):– Content– Teaching techniques– Faculty selection– Timing in curriculum
• Small groups report on 1-2 ideas for population health curricular integration in your programs
Discussion• Teaching Content– Concept of population health– Tools for understanding and applying population
health principles– Epidemiology/Biostatistics– Determinants of health– Health systems • Patient Protection and Affordable Care Act implications
– Quality improvement– Integration with basic science concepts
Discussion
• Teaching Techniques– Problem-based learning (IQ)– Team-based learning (TBL)– Pandemic flu tabletop exercise (medium-sized group
activity)– Field experiences– Google+/Social Media Tools
• Reflection• Encouragement of participation
– Online modules– Documentary series
Discussion
• Faculty Selection– Content expertise– Student exposure to interprofessional nature of
population and community health– Local laboratory for understanding and applying
population health principles: Future research options• Cuyahoga County Board of Health population health expertise• Other local health departments• Better Health Greater Cleveland multi-stakeholder collaborative• Health Improvement Partnership-Cuyahoga
– Other considerations?
Discussion
• Timing in Curriculum– Early inclusion of principles– Relevance and variable interest among entering
students– Timing of relevance evaluation– Changing content• Evolving field of population health• Rapidly changing health policy
– New session in 2014 on Medicaid expansion and PPACA impact within Cuyahoga County
Discussion
• Challenges– Variable uptake for students from diverse
backgrounds– Lack of context for some entering medical
students– Timing challenges for interprofessional activities– Large number of meaningful community field
experience sites are necessary
Block 1 in the LiteratureOrnt DB, Aron DC, King NB, Clementz LM, Frank SH, Wolpaw T, Wilson-Delfosse A, Wolpaw D, Allan T, Carroll M, Thompson- Shaheen K, Altose M, Horwitz R. Population Medicine in a Curricular Revision at Case Western Reserve. Academic Medicine, 2008; 83 327-331
Carney JK, Schilling LM, Frank SH, Biddinger PD, Bertsch, TF, Grace CJ, Finkelstein JA. Planning and Incorporating Public Health Preparedness Into the Medical Curriculum. American Journal of Preventive Medicine. 2011;41 (4S3):S193-S199
Frank SH. Principles for Authentic Population Health. American Journal of Preventive Medicine. 2011;41 (4S3):S152-S154
Thank you!
Please feel free to contact me [email protected]