Public and Population Health in U.S. Medical Education: A Review of Guidance in Extraordinary Times.

ABSTRACT: Generations of medical educators have recommended including public and population health (PPH) content in the training of U.S. physicians. The COVID-19 pandemic, structural racism, epidemic gun violence, and the existential threats caused by climate change are currently unsubtle reminders of the essential nature of PPH in medical education and practice. To assess the state of PPH content in medical education, the authors reviewed relevant guidance, including policies, standards, and recommendations from national bodies that represent and oversee medical education for physicians with MD degrees.Findings confirm that guidance across the medical education continuum, from premedical education to continuing professional development, increasingly includes PPH elements that vary in specificity and breadth. Graduate medical education policies present the most comprehensive approach in both primary care and subspecialty fields. Behavioral, quantitative, social, and systems sciences are represented, although not uniformly, in guidance for every phase of training. Quantitative PPH skills are frequently presented in the context of research, but not in relation to the development of population health perspectives (e.g., evidence-based medicine, quality improvement, policy development). The interdependence between governmental public health and medical practice, environmental health, and the impact of structural racism and other systems of oppression on health are urgent concerns, yet are not consistently or explicitly included in curricular guidance. To prepare physicians to meet the health needs of patients and communities, educators should identify and address gaps and inconsistencies in PPH curricula and related guidance.Re-examinations of public health and health care systems in the wake of the COVID-19 pandemic support the importance of PPH in physician training and practice, as physicians can help to bridge clinical and public health systems. This review provides an inventory of existing guidance (presented in the appendices) to assist educators in establishing PPH as an essential foundation of physician training and practice.

Guiding Principles to Address the Impact of Algorithm Bias on Racial and Ethnic Disparities in Health and Health Care.

Importance: Health care algorithms are used for diagnosis, treatment, prognosis, risk stratification, and allocation of resources. Bias in the development and use of algorithms can lead to worse outcomes for racial and ethnic minoritized groups and other historically marginalized populations such as individuals with lower income. Objective: To provide a conceptual framework and guiding principles for mitigating and preventing bias in health care algorithms to promote health and health care equity. Evidence Review: The Agency for Healthcare Research and Quality and the National Institute for Minority Health and Health Disparities convened a diverse panel of experts to review evidence, hear from stakeholders, and receive community feedback. Findings: The panel developed a conceptual framework to apply guiding principles across an algorithm's life cycle, centering health and health care equity for patients and communities as the goal, within the wider context of structural racism and discrimination. Multiple stakeholders can mitigate and prevent bias at each phase of the algorithm life cycle, including problem formulation (phase 1); data selection, assessment, and management (phase 2); algorithm development, training, and validation (phase 3); deployment and integration of algorithms in intended settings (phase 4); and algorithm monitoring, maintenance, updating, or deimplementation (phase 5). Five principles should guide these efforts: (1) promote health and health care equity during all phases of the health care algorithm life cycle; (2) ensure health care algorithms and their use are transparent and explainable; (3) authentically engage patients and communities during all phases of the health care algorithm life cycle and earn trustworthiness; (4) explicitly identify health care algorithmic fairness issues and trade-offs; and (5) establish accountability for equity and fairness in outcomes from health care algorithms. Conclusions and Relevance: Multiple stakeholders must partner to create systems, processes, regulations, incentives, standards, and policies to mitigate and prevent algorithmic bias. Reforms should implement guiding principles that support promotion of health and health care equity in all phases of the algorithm life cycle as well as transparency and explainability, authentic community engagement and ethical partnerships, explicit identification of fairness issues and trade-offs, and accountability for equity and fairness.

Now Is Our Time to Act: Why Academic Medicine Must Embrace Community Collaboration as Its Fourth Mission.

In his Leadership Plenary at the Association of American Medical Colleges (AAMC) annual meeting, "Learn Serve Lead 2020: The Virtual Experience," president and CEO David Skorton emphasized that the traditional tripartite mission of academic medicine-medical education, clinical care, and research-is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine's missions. This means going beyond "delivering care" to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed. It means appreciating community assets and creating ongoing pathways for listening to and learning from the needs, lived experiences, perspectives, and wisdom of patients, families, and communities. It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities. The authors call on academic medical institutions to do more to build a strong network of collaborators across public and population health, government, community groups, and the private sector. We in academic medicine must hold ourselves accountable for weaving community collaborations consistently throughout research, medical education, and clinical care. The authors recognize the AAMC can do better to support its member institutions in doing so and discuss new initiatives that signify a shift in emphasis through the association's new strategic plan and AAMC Center for Health Justice. The authors believe every area of academic medicine could grow and better serve communities by listening and engaging more and bringing medical care, public health, and other sectors closer together.

Evaluating the Efficacy of Medical-Legal Partnerships that Address Social Determinants of Health.

BACKGROUND: Medical-legal partnerships (MLPs) are health system-community partnerships composed of multi-disciplinary teams designed to improve patient and community health. MLPs provide legal services to address health-harming legal needs that contribute to health inequities. METHODS: A grant provided by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention established the Accelerating Health Equity, Advancing through Discovery (AHEAD) Initiative to identify, evaluate, and disseminate community-based interventions that improve health equity. Three geographically and demographically diverse institutions were chosen to strengthen the evidence-base surrounding MLP by developing standardized evaluation tools in the areas of community health, health system savings, and learner outcomes. RESULTS: The generalizable process leading to evaluation tool development is described herein, and includes the formation of multi-institutional teams, logic model development, and stakeholder interviews. CONCLUSIONS: Although MLP is presented, this process can be used by various types of community health partnerships to develop evaluation tools surrounding social determinants of health (SDOH).

Teaching Public and Population Health in Medical Education: An Evaluation Framework.

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.

Feasibility and Usability of Tele-interview for Medical Residency Interview.

Every year in the United States, medical students and residency programs dedicate millions of dollars to the residency matching process. On-site interviews for training positions involve tremendous financial investment, and time spent detracts from educational pursuits and clinical responsibilities. Students are usually required to fund their own travel and accommodations, adding additional financial burdens to an already costly medical education. Similarly, residency programs allocate considerable funds to interview-day meals, tours, staffing, and social events. With the rapid onslaught of innovations and advancements in the field of telecommunication, technology has become ubiquitous in the practice of medicine. Internet applications have aided our ability to deliver appropriate, evidence-based care at speeds previously unimagined. Wearable medical tech allows physicians to monitor patients from afar, and telemedicine has emerged as an economical means by which to provide care to all corners of the world. It is against this backdrop that we consider the integration of technology into the residency application process. This article aims to assess the implementation of technology in the form of web-based interviewing as a viable means by which to reduce the costs and productivity losses associated with traditional in-person interview days.

Holistic Admissions in Nursing: We Can Do This.

UNLABELLED: Research shows that holistic admissions review practices can increase diversity across students without decreasing the workforce preparedness and academic success of students. Therefore, many disciplines have readily adopted the widespread use of holistic admissions review. Despite its proven effectiveness in addressing student diversity, nursing has been slow to implement holistic admissions review. PURPOSE: The purpose of this study was to gain a better understanding of the barriers to implementing holistic admissions review in nursing and the feasibility of adopting holistic admissions review across nursing programs. METHODS: A biphasic qualitative research study was conducted with nursing deans from across the United States. Qualitative data collection consisted of two phases of focus group discussions conducted over a 3-month period. The qualitative data were analyzed using content analysis. The categories and subcategories identified in Phase 1 informed the discussion in Phase 2. RESULTS: One overarching category from Phase 1 was identified, which was the lack of nursing schools' knowledge regarding holistic admissions review. Four subcategories also identified in Phase 1 included the need for better dissemination of evidence, the need for additional support from university leaders and administrators, the need for legal guidance to facilitate implementation of holistic admissions review, and ensuring appropriate resources to support the holistic admissions review process. Three categories emerged in Phase 2, which included everyone's buy-in is required, the need for a model, and a need for training. CONCLUSION: The adoption of holistic admissions review in nursing may be feasible. However, certain barriers need to be overcome so that nursing schools can successfully take on this process. Therefore, five recommendations have been developed to assist nursing schools in the implementation of holistic admissions review. These recommendations include increasing knowledge and understanding of holistic admissions review among nursing deans; obtaining buy-in and support for holistic admissions review and conducting a self-assessment of current admissions practices; providing nursing administrators, faculty, and staff with diversity training; and conducting further research to identify factors most critical for success in nursing. Although the transition to a holistic admissions process requires some effort, arming ourselves with the appropriate tools will mitigate barriers during implementation.

How many schools adopt interviews during the student admission process across the health professions in the United States of America?

Health profession schools use interviews during the admissions process to identify certain non-cognitive skills that are needed for success in diverse, inter-professional settings. This study aimed to assess the use of interviews during the student admissions process across health disciplines at schools in the United States of America in 2014. The type and frequency of non-cognitive skills assessed were also evaluated. Descriptive methods were used to analyze a sample of interview rubrics collected as part of a national survey on admissions in the health professions, which surveyed 228 schools of medicine, dentistry, pharmacy, nursing, and public health. Of the 228 schools, 130 used interviews. The most desirable non-cognitive skills from 34 schools were identified as follows: communication skills (30), motivation (22), readiness for the profession (17), service (12), and problem-solving (12). Ten schools reported using the multiple mini-interview format, which may indicate potential for expanding this practice. Disparities in the use of interviewing across health professions should be verified to help schools adopt interviews during student admissions processes.

Public health and community medicine instruction and physician practice location.

BACKGROUND: Experts have historically recommended better integration of public health content into medical education. Whether this adoption is associated with physician practice location has not been studied. PURPOSE: To examine the association between medical student perception of their public health and community medicine instruction and practice location in a Health Professional Shortage Area. METHODS: Descriptive analysis and a regression model assessed the significance and strength of the association between medical student perception of their public health and community medicine instruction and practice location using data from the Medical School Graduation Questionnaire 1997-2004, 2013 American Medical Association Physician Masterfile, and 2013 Health Professional Shortage Areas. RESULTS: A higher proportion of medical students with an intent to practice in underserved areas reported inadequate instruction in public health and community medicine than those without such intentions. Students reporting adequate public health and community medicine instruction are slightly more likely to practice in a Health Professional Shortage Area, controlling for their intent to practice in underserved areas. CONCLUSIONS: Findings suggest an association between perceptions of public health and community medicine instruction and practice location. Improved public health and community medicine instruction may support medical students' preparation and ability to integrate public health skills into practices in underserved settings. More research is needed to ascertain factors enabling better incorporation of public health and community medicine in medical education.

A novel approach to incorporating evidence-based medicine into an emergency medicine clerkship.

OBJECTIVES: Despite the growing emphasis of evidence-based medicine (EBM) in the medical school curriculum, and the recognition of EBM's role in the practice of emergency medicine (EM), there are no current guidelines on how to teach EBM to fourth-year medical students during their EM rotations. The goal was to create a unique EM clerkship curriculum that teaches students to incorporate EBM into their clinical decision-making and complies with the core curriculum recommendations of the Clerkship Directors in Emergency Medicine (CDEM). PROJECT DESCRIPTION: Prior to a scheduled, case-based small group discussion, students are provided with a clinically relevant question to investigate. Case discussions are led by EM faculty with each case highlighting a core EM topic developed by CDEM. During the case discussion, the assigned clinical question is addressed and a plan of care is presented based on the tenets of EBM. Faculty members function as moderators for these discussions and provide individual feedback regarding search strategies, appraisal of the literature findings, and applicability to the patient population. This multifaceted approach to EBM through the incorporation of individual student literature searches, clinical vignettes, small group discussion with consensus building, and faculty moderation with timely feedback is an innovative educational technique. Future educational research must explore the efficacy of this curriculum and whether or not the model produces greater long-term understanding of EBM by students and if similar curricula can be executed at other institutions. CONCLUSIONS: The authors have developed a novel fourth-year EM clerkship curriculum that integrates EBM through the use of a highly interactive, faculty-led, small group-learning environment that encourages students to develop the necessary skills to integrate EBM into their clinical practice.