University of Pittsburgh

Public Health Preparedness

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.

The 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; and environmental and public health; social and behavioral sciences; informatics; genomics; communication; cultural competence; community-based participatory research, global health, policy and law, and ethics; leadership; public health emergency preparedness; and clinical and community preventive service provision.  Many of these topics are also prioritized as part of the Healthy 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 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. 

The following examples illustrate how this theme is addressed in the UPSOM curriculum. 

Introduction to Being a Physician

This week-long course is the first curricular experience in medical school.  A highlight of the course is an immersive experience on public and community health.  Students learn about determinants of health including fundamental issues such as health care finance and access to care.  They then embark on a hands-on study of the health status of a local Pittsburgh community that has faced challenging economic and health circumstances in recent decades.  Students identify and propose solutions to vital determinants of and threats to good health for this community.  Themes addressed span a range of issues, including teen pregnancy; tobacco and drug abuse; access to care; and other Healthy People 2020 themes.  The reports generated by these student teams are returned to the community leaders who themselves serve as key informants for the students’ investigations.

Evidence-based Medicine and Biostatistics

In the Introduction to Medical Decision Making course, 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 specialty 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, the 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 and Combined Ambulatory Medicine and Pediatrics 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 Combined Ambulatory Medicine and Pediatrics 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 at the beginning of the Family Medicine Clerkship, so that students are prepared to apply the SBIRT (Screening, Brief Intervention, Referral to Treatment) approach during the rotation.  The importance of these measures is reinforced by teaching that refers to the evidence framework of the Association of Teachers of Preventive Medicine.  

Population Health Course

This second year course addresses key subjects within population health, with an emphasis on helping students understand the interconnected systems and environments that influence health care delivery and the health of populations. These subjects converge as part of the systems that comprise and influence the health and care of a single person.

For 2010-11, five major topics are addressed: payment systems and their origins including Medicare and Medicaid; an overview of public health; social determinants of health; global health issues with an emphasis on the global burden of disease and related financial issues; and an overview of the 2010 health care reform initiative. The selected topics have particular relevance at this point in the curriculum as students prepare to transition to the clinical environment.

The learning modalities include self-study of background materials plus various application activities. During the application activities, students engage in problem-solving exercises, identify key issues, and participate in a unique poverty simulation exercise.

The poverty simulation exercise is a large scale role-play simulation where students work in teams as “families” living under poverty conditions, and interact with agencies, businesses and organizations to accomplish activities of daily family life. Students quickly gain perspective on the challenges faced by many of their patients, and are able to describe how this brief experience provided a basis for improving their empathic connection to people who must overcome substantial barriers just to get through an ordinary week.

In the health insurance workshop, students quickly recognize the importance of understanding the ingredients of a plan and how they may need to help patients navigate the complexities of payment for medical care.

Students are asked to pause and reflect on local and global health issues in two essay assignments, and think practically about how to begin to take them on. Students have prepared thoughtful and provocative manuscripts that reveal great insight into today’s problems and even about possible solutions.

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. 

Our Changing Population

With UPSOM situated demographically in the second oldest county in America, it is easy for our students 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. Please refer to the handbook section on the Passport to Care program for additional information.

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 and Birmingham Clinics for the underserved; 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 Medical Journalism mini-elective course provides students with an opportunity to understand specifically how to affect health through mass communications.

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, directed by Dr. Bruce Dixon, 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.

Students receive more in-depth training on how to encourage behavior change effectively in their patients during the Combined Ambulatory Medicine and Pediatrics Clerkship (CAMPC). Students have opportunities to practice counseling techniques with standardized patients while in the midst of a clinical rotation where they can immediately apply what they have learned. During CAMPC, one-third of third-year students spend a week in the Weight Management and Wellness Center at Children’s Hospital, in a course segment on Preventive Cardiology and Pediatric Obesity. Students evaluate new patients for behavioral factors that contribute to obesity. They also identify and treat obesity-related illnesses in this pediatric population. This unique experience gives students the skills to recognize obesity and its consequences, and to execute practical strategies for weight loss in children. Another fraction of the class rotates on the bariatric surgery service each month as part of the third-year Surgery and Perioperative Care clerkship.

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. (Above passage reproduced with permission from the Association of American Medical Colleges.)

Public Health Preparedness

Public health threats in the 21st century include those faced by prior generations, but numerous new and emerging threats to individual and societal health have been identified. These include biological, chemical and radiological terrorism, emerging infections, food and water source contamination, impact of pharmaceutical treatments, psychosocial impact of the threat of terrorism, and other technologic threats to continuity of public and health services (e.g., computer viruses).  Successful detection and mitigation of an emerging health threat, such as an infectious outbreak or chemical weapons attack, depends on prompt (and even ultra-early) identification and response by a prepared medical community.

Medical principles related to these topics exist as core elements of typical civilian medical curricula. Relevant topics include public health, epidemiology, infectious diseases, pharmacology, toxicology, environmental and occupational medicine, genetics, patient-doctor communication, behavioral health, and informatics. The terminal goal of incorporating public health preparedness (PHP) into the medical student curriculum is to prepare graduating medical students to respond to these challenges.

Faculty continue to integrate PHP throughout the four-year medical school curriculum, with content placement as appropriate into existing courses.  Examples of the type of content integration are the mechanism of action of chemical weapons agents and antidotes within the neurosciences and cell signaling courses, and the technique of using gene mutation-counting as a means to estimate radiation exposure within the genetics curriculum. Ethics courses provide a venue to examine the dilemmas surrounding imposition of quarantine during an outbreak.  Some of the added material is covered by only a single problem or brief illustration.  At strategic points in the curriculum, students participate in focused sessions that promote assimilation of this content, including simulations and practical exercises.

An initial module on biological and chemical weapons has been a component of the required internal medicine clerkship since July 2000.  It has been educationally successful and well received.  Additional content on biological and chemical weapons agents and disaster medicine was added in 2001.

This integrative approach and the current general interest in public health preparedness bolsters support for this innovative curriculum theme.  Longitudinal integration of material on PHP was achieved by designing discrete instructional units that are directly relevant to the goals of the target course.  A second critical element was for this material to be revisited multiple times in varying contexts over time.  Thus the content is non-invasive (limited curriculum time required) yet pervasive enough that student awareness of these issues is enhanced.

The effectiveness of this aspect of the curriculum can be optimized by a flexible and dynamic approach to content, methods and timing of what and how it is presented to students. For example, in 2003, a table-top exercise on SARS was included in the first-year medical student course, Introduction to Being a Physician.  Later this was modified to present an avian influenza outbreak, in response to evolving circumstances.  Currently, outbreak and pandemic preparedness are brought to the forefront in a large scale Pandemic Simulation Exercise during the Preclerkship Course for rising third-year students. This exercise and accompanying classroom sessions help students learn about pandemic response while also developing insights and skills in team communications.

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.