University of Pittsburgh

Population Medicine and Public Health

Background

Many students have entered medical school with a notion of medical practice that is based on one physician treating one patient. Expanding this frame of reference is critical during the early development of their professional persona, so that as 21st century medical practitioners they will be also prepared to understand the population, public health and preventive aspects of practice.  This will also prepare students to provide leadership and guidance beyond the walls of their individual practice, at the community, national or global levels.

Medical School Objectives Project Report on Contemporary Issues in Medicine: Medical Informatics and Population Health (1998) and the Institute of Medicine’s reports Who Will Keep the Public Healthy? (2002) and Training Physicians for Public Health Careers (2007) have provided comprehensive curriculum recommendations in these domains. Suggested topics include epidemiology; biostatistics; disease prevention/health promotion; health care organization, management, and financing; environmental and public health; social and behavioral sciences; informatics; genomics; communication; cultural competence; community-based participatory research; global health; policy and law; ethics; leadership; public health emergency preparedness; and clinical and community preventive service provision.  Many of these topics are also prioritized as part of the Health People 2020 initiative.

Implementation

The School has integrated student learning about population medicine, public health and prevention as a longitudinal curriculum theme through a program of didactic and experiential learning throughout the curriculum. 

Beginning with the major curriculum revision implemented in 1992, population medicine and public health have been addressed as a longitudinal curriculum theme that begins during the first week of medical school, during the Introduction to Being a Physician course.  Students learn from the beginning that their responsibilities include care of communities not just individual patients, that achieving better health depends on much more than a well educated physician, and that prevention is just as important and often more effective than sophisticated treatment.  The environment at Pittsburgh is terrifically well suited to help students develop in this domain.  Medical students have ready access to the resources of all six of the Schools of the Health Sciences, including the Graduate School of Public Health.  The resources of the UPMC Health System, the UPMC Health Plan, and the Allegheny County Health Department, plus community partners such as the Southwest Pennsylvania Area Health Education Center, together provide an exceptional quality and diversity of learning opportunities for our students.

Scalable Curriculum

All students learn about core topics in population medicine through required curriculum experiences in years one through three.  A subset of students with a passion for these subjects may opt to participate in Area of Concentration programs that provide opportunity for in-depth study and support for scholarly project activities in this area.  These areas of concentration include underserved medicine, women’s health, geriatrics, global health and public health.

Evidence-based Medicine and Biostatistics

In the Evidence-Based Medicine - Fundamentalscourse, biostatistics and evidence-based medicine are addressed early, throughout the Fall term of the first year. 

Prevention

Topics in prevention are addressed and re-emphasized throughout the curriculum.  For example, in the first year Clinical Experiences course, students learn firsthand about the importance of and the challenges to helping patients with prevention during their three months of clinical rotations.  In addition to one month each in primary care and rehabilitation settings, every student has a series of clinical experiences in an underserved or service learning site.  These experiences, which span the Spring term of first year through Fall second year, provide a key opportunity for students to establish a context for understanding the importance of population and public health concurrent with the didactic learning on these subjects.  Among the activities in this course is a student project on developing patient educational materials.  This project helps students develop unique insights about the challenges of communicating with patients, that barriers posed by low health literacy, and the potential power of the media in improving public health.

Topics in prevention are also addressed in an ongoing fashion through the curriculum.  For example, immunization for preventable illness is taught in the context of the Medical Microbiology course and re-emphasized during the Pediatrics, Family Medicine, Combined Ambulatory Medicine and Pediatrics (CAMPC), and Obstetrics and Gynecology clerkships.  Anticipatory guidance and preventive concepts such as the use of bicycle helmets and seatbelts and firearm safety, are initially addressed in the Clinical Experiences course but are later emphasized during the pediatrics aspects of the clerkship year.  Students have a highly effective standardized patient workshop on tobacco cessation counseling in the CAMPC clerkship, timed to occur immediately before they will be in clinical settings where they may apply these skills.

Alcohol and substance abuse counseling using a motivational interviewing approach is taught during the beginning of the Psychiatry Clerkship, so that students are prepared to apply the SBIRT (Screening, Brief Intervention, Referral to Treatment). 

Population Health Course

Medical education excels at preparing physicians to care for patients during individual interactions. During individual interactions a single patient is diagnosed and treated by a health provider. As knowledge of health determinants increases, many recognize that much of our health is determined by factors outside the ability of a physician to diagnose and treat. Accordingly medical education must increase the ability of health care providers to impact the health of whole populations of patients. Subjects that are within the broad field of population health include public health, disease prevention, health care advocacy, health policy, global health, social determinants of health, quality improvement, health insurance provision and health care systems. This second year course addresses key subjects within population health, with an emphasis on helping students understand the systems and environment that influence health and health care delivery.

The course is comprised of content units on a diverse range of subjects related to health systems science. These subjects include Public Health, Health Care Systems and Safety, and Social Medicine. For each content area, the material will address the topic to an introductory depth, with attention to tailoring the material to the experience and knowledge base of a pre-clinical, second year student. The selected topics have particular relevance at this point in the curriculum as students prepare to transition to the clinical environment.

For 2017-18, major topics are addressed including the following: basic principles of population health, the role of public health departments, the opportunity for physicians to advocate with the legislature, the role of public policy to influence health, patient safety, quality improvement, understanding health insurance and social determinants of health. The learning modalities include an introductory lecture, movie and video presentations, on-line self-study, writing exercises and small and large group interactive exercises.

Scholarly Pursuits

All UPSOM students complete a mentored scholarly project that is conducted throughout the four years of the curriculum.  Students have the option of focusing their scholarly project in any area of biomedical science, and many opt to undertake projects in community health, population medicine and public health.  Students connect with mentors within the School of Medicine and beyond, including neighboring universities, the Graduate School of Public Health, and community organizations.  Students may establish mentoring teams which include collaborations with project mentors from the Bridging the Gaps and Pittsburgh Schweitzer Fellowship programs.  Explore this link for additional information about medical student Scholarly Projects.

Our Changing Population

With UPSOM situated demographically in one of the oldest counties in America, it is easy for our students to develop an understanding of the evolving composition of our population and how health care must evolve to keep pace with these changes.  In addition to the third year Clinical Focus course on Geriatrics, students are exposed to issues in geriatrics longitudinally throughout the curriculum and may opt to participate in the Area of Concentration on Geriatric Medicine.

The other significant change is in the ethnic and cultural composition of our population. There is a growing Spanish-speaking population in Pittsburgh and across America, and virtually every language and culture has a presence in the US. Today’s physicians already need to utilize language skills and translators to care for all of their patients. To help students prepare to communicate and connect with the local and global population, the Passport to Care program provides students with elective language and cultural curriculum opportunities that reach beyond the existing curriculum. Through classroom-based and online instruction, students currently study Spanish, French and Italian, and other offerings are under development.

Elective Experiences

A broad range of electives is available to students who wish to pursue this domain in greater depth.  Many first year students connect with underserved populations through experience such as the PALS Program which pairs individual students with pregnant teenagers and through service learning at the English speaking or Spanish speaking health clinics in our community.  Students commonly volunteer in programs such as the SALUD Clinic, the Guerilla Eye Service that brings sophisticated ophthalmology services to underserved regions in Southwest Pennsylvania, and Operation Safety Net that brings medical care to the homeless of Pittsburgh.  Mini-elective courses are offered in Pandemic Preparedness and Public Health, Disaster Medicine and many other topics. The Refugee Health mini-elective illuminates the unique health challenges faced by Pittsburgh's refugee population. The Physician Advocacy mini-elective provides hands-on opportunities to develop skills in writing op-eds and in social media advocacy. 

During the clinical years, students highly value their elective experiences in a number of clinical settings that address public and community health needs.  For example, the Sexually Transmitted Diseases elective at the Allegheny County Health Department has long been valued by students as a superb clinical experience that also enlightens them about the scope of problems faced by populations they might not encounter in other settings.  Clinical rotations in women’s health, the care of HIV / AIDS patients and substance abuse patients provide students with unique perspectives on these conditions. 

Obesity

UPSOM integrates obesity and nutrition as a longitudinal curricular theme to help address the obesity epidemic.

In basic science courses, overweight and obesity content is introduced in the context of other coursework, particularly where its impact as a co-morbid condition helps students gain perspective on the impact of obesity on health.

In the Behavioral Medicine course taught during the latter half of the first year, the curriculum includes sessions on overweight and obesity. In an interactive lecture, students learn about the epidemiology and consequences of obesity. During this session, they are encouraged to think about solutions for individual patients and for populations, including changes in public policy. Subsequent course sessions address behavioral aspects of diet and nutrition; psychosocial, behavioral, and therapeutic issues in obesity; complementary and alternative approaches to weight loss; and surgical treatments. Students meet in small groups with overweight/obese patients, gaining appreciation for this condition and how it affects health, as well as practicing various interviewing approaches.  Students in this course also get a first-hand look at the challenges of weight loss, conducting a behavior modification project in their own lives; most students choose diet/exercise behaviors and find out what works and what doesn’t in weight management—an exercise that increases knowledge, skills, and empathy.

The timing of this curricular content is ideal for raising student awareness of the pervasiveness of this problem, as they begin to develop their own perspectives on clinical medicine. In this course, students also have an early exposure to the theory of and practical approaches to counseling for behavior change.  The transtheoretical “stages of change” theory underlies much of this discussion, with motivational interviewing (MI) as our main practical therapeutic technique for the course; students practice MI techniques on patients with weight problems, laying a foundation for clinical rotations to come.  The obesity theme is then contextualized in the clinical curriculum.

During the second year Digestion and Nutrition course, students learn about clinical aspects of obesity and weight management. During the third year Surgery Clerkship, fractions of the class rotate on the bariatric surgery service each month.

The importance of this topic is reinforced in all four years by including obesity counseling and therapy as explicit items in experience logs submitted during the first and second year Clinical Experience Courses, and in the clinical clerkships.

For more about how medical schools are incorporating obesity education into curricula, refer to the Association of American Medical Colleges Medical School Objectives Project Report, The Prevention and Treatment of Overweight and Obesity.

Senior Electives

Students with a particular interest in population health may choose from a diverse range of senior elective courses that provide a venue for them to experience and tightly focus on a specific topic.  Examples include a month-long rotation with Operation Safety Net , a mobile service providing medical care on the streets of Pittsburgh, and elective rotations in public health conducted in conjunction with the Graduate School of Public Health.  Students may also opt for customized rotations crafted around their individual interests in areas such as healthcare finance or patient safety.

Outcomes

Population medicine, public health and prevention have been incorporated as fundamental curriculum themes throughout the UPSOM curriculum.  The evolution of our patients, communities and populations will continue to drive innovation in this domain as we prepare for care of an aging population, diversity in our communities, evolving public health threats and a changing world in general, and healthcare finance.