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.

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.

Preventive behaviors and knowledge of tick-borne illnesses: results of a survey from an endemic area.

CONTEXT: Lyme disease (LD) is the most commonly reported vector-borne illness in the United States. With physically and economically burdensome effects, it is a concern of public health officials. OBJECTIVES: To assess knowledge and preventive behaviors of individuals in the endemic area of Martha's Vineyard, Massachusetts, to better understand how sociodemographic data and knowledge correlate with preventive behaviors, and to update previous island studies. DESIGN: A 30-item paper-based anonymous survey in either English or Portuguese based on language preference. SETTING: The island of Martha's Vineyard and the ferry between island and mainland. PARTICIPANTS: A total of 946 participants were recruited at 1 of 4 island locations. The majority of participants were traveling by ferry to and from Martha's Vineyard. To reach 2 populations potentially at high risk, that is, youths and outdoor workers, 3 additional venues included the island high school, an English-as-a-Second-Language class, and a local Brazilian church. OUTCOME MEASURES: Four specific preventive behaviors as well as an overall composite prevention score. RESULTS: Participants' knowledge of tick-borne illnesses was poor, and the frequency of practicing preventive behaviors was low; the most commonly reported behavior was checking one's skin for ticks (45%). Approximately one-third of respondents (37%) stated that they did not know the late symptoms of untreated LD, nor did they know early LD treatment options (49%). The 2 high-risk groups reported little participation in preventive measures. In multivariate analyses, only 4 characteristics-older age, confidence in telling deer tick from wood tick, seeing tick-borne illness as a serious threat, and certainty in ability to identify LD symptoms-attained significance associated with preventive behavior as an overall composite score. CONCLUSIONS: Public health interventions focusing on accurately communicating risk, improving knowledge both of LD symptoms and of ticks that carry the disease, as well as teaching preventive behaviors may help reduce tick-borne illness rates.

A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager.

INTRODUCTION: The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health. METHODS: We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes. RESULTS: The following themes emerged from discussions on the DCM's role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM. CONCLUSION: The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health.

Partnering for health: collaborative leadership between a community health center and the YWCA central Massachusetts.

BACKGROUND: A collaborative partnership among community-based organizations (CBOs)-a community-health center, a YWCA, and 2 academic health centers-developed and implemented open access to physical activity for health center patients. OBJECTIVE: To describe partnership approach taken by 2 CBOs; determine staffs' views of this unique partnership, highlight aspects of the partnership that contributed to its success, identify challenges and mechanisms for overcoming them, and note lessons learned. Assess health center patients' use of YWCA facility. METHODS: Usage data were obtained from YWCA records. Staff were interviewed using primarily open-ended questions. Inductive approach was used to analyze qualitative data. RESULTS: The approach to partnership was largely organic, without formal working documents; nevertheless, the partnership reflected the organizations' missions. Over 4 years, 1134 health center patients made more than 23 000 visits to the YWCA. Responses of health center staff and provider interviewees about partnership processes sorted into the following categories: partnership description and results, partnership benefits, challenges, lessons learned, and advice to other CBOs. YWCA staff interviewee responses reflected the categories: staffing, clientele, and public face. Comments also included challenges, lessons learned, and advice to other YWCAs. CONCLUSIONS: This partnership achieved notable successes largely because (a) it formed to serve a specific purpose that met both agencies' goals, (b) leaders made sustained commitments, and (c) it managed conflict. The partnership has taken on new projects over time; new ideas for improving access and service to underserved patients continue to emerge. Interorganizational trust and allegiance have been key to addressing challenges; nevertheless, the organic nature of the partnership's origins and the challenges of success have meant that the partnership has restructured its agreement and, to avoid being overwhelmed, limited new patient use.

Weaving public health education into the fabric of a family medicine residency.

Policymakers and accrediting bodies have recognized the importance of integrating public health, population health, and prevention into graduate medical education programs. The high prevalence of chronic illness, coupled with the impact of behavioral and societal determinants of health, necessitate an urgent call for family medicine residencies to prepare future leaders to meet these challenges. The University of Massachusetts Worcester Family Medicine Residency recently developed an integrated curriculum that strives to develop a culture of incorporating fundamental public health principles into everyday practice. This public health curriculum was designed to integrate new topics within the current residency structure through longitudinal and concentrated experiences. This strategy has substantially improved public health and prevention education without substantial impact on the already strained residency curricular structure. This paper describes the integration of public health and prevention education into a family medicine residency to help residents acquire the fundamental skills necessary to improve a population's health.

Model approaches for advancing interprofessional prevention education.

Healthy People 2010 included an objective to "increase the proportion of … health professional training schools whose basic curriculum for healthcare providers includes the core competencies in health promotion and disease prevention." Interprofessional prevention education has been seen by the Healthy People Curriculum Task Force as a key strategy for achieving this objective and strengthening prevention content in health professions education programs. To fulfill these aims, the Association for Prevention Teaching and Research sponsored the Institute for Interprofessional Prevention Education in 2007 and in 2008. The institutes were based on the premise that if clinicians from different professions are to function effectively in teams, health professions students need to learn with, from, and about students from other professions. The institutes assembled interprofessional teams of educators from academic health centers across the country and provided instruction in approaches for improving interprofessional prevention education. Interprofessional education also plays a key role in implementation of Healthy People 2020 Education for Health framework. The delivery of preventive services provides a nearly level playing field in which multiple professions each make important contributions. Prevention education should take place during that phase of the educational continuum in which the attitudes, skills, and knowledge necessary for both effective teamwork and prevention are incorporated into the "DNA" of future health professionals. Evaluation of the teams' educational initiatives holds important lessons. These include allowing ample time for planning, obtaining student input during planning, paying explicit attention to teamwork, and taking account of cultural differences across professions.

A qualitative study of the meaning of fatherhood among young urban fathers.

OBJECTIVE: To explore the beliefs, attitudes, and needs young men have regarding their role as a father. DESIGN AND SAMPLE: Exploratory, descriptive, qualitative design. Young fathers/young expectant fathers were recruited from service sites within a city in Massachusetts. Men were considered young fathers/young expectant fathers if they were or would be <20 years old at the birth of a first child or the mother of their baby was or would be <20 years old at the baby's birth and the young man was <25 years old. MEASURES: Participants were interviewed utilizing open-ended questions, which included the following: the characteristics of good fathers, goals/needs for self and child, and whether or not they planned to raise the child as their father raised them and why. RESULTS: Responses regarding fathering clustered into the following themes: being available; providing support; and self-improvement, including completing education and becoming a positive role model. Forty-seven percent believed that being employed or finishing school would help them be better fathers; 77% reported they would not raise their child as their own father had raised them, citing physical and/or emotional abuse/abandonment. CONCLUSIONS: Young men in this study identified several challenges to being "good" fathers. These included lack of employment, education, and positive role models.

Family medicine residency characteristics associated with practice in a health professions shortage area.

BACKGROUND AND OBJECTIVES: While some family medicine residency programs are designed to train residents in community health centers (CHCs) for future careers serving underserved populations, there are few outcome studies on such programs. Our residency program provides three options for ambulatory health center training, but otherwise residents participate in the same curriculum. We analyzed relationships between ambulatory training site and likelihood of practice in health professions shortage areas (HPSAs). METHODS: We sent a mail survey to all graduates of one family medicine residency about practice locations, types, and populations; influences on practice choice; and sociodemographic characteristics. RESULTS: Training in a CHC had a statistically significant association with the likelihood of practice in an HPSA for both initial and current practice. Training in a rural residency site was associated with initial and current rural practice. Logistic regression analysis showed that physicians who completed ambulatory training in the CHC were nearly six times more likely to report having practiced initially and four times more likely to cite current practice in an HPSA. CONCLUSIONS: Outpatient CHC residency training increases the likelihood of practice in an underserved setting. This finding has policy implications for supporting workforce training in practice settings that care for underserved populations.

Community dimensions and HPSA practice location: 30 years of family medicine training.

BACKGROUND AND OBJECTIVES: Our objective was to assess practicing family physicians' confidence and participation in a range of community-related activities. Additionally, we assessed the strength of the relationship between the physicians' reported medical school and residency training in community-related activities and their current community activities, as well as whether they were practicing in an underserved location. METHODS: All 347 graduates of the University of Massachusetts Family Medicine Residency were surveyed about practice location and type, involvement and training in community work, confidence in community-related skills, and sociodemographic characteristics. Analyses were conducted by residency graduation decade (1976-1985, 1986-1995, and 1996-2005). RESULTS: Earlier graduates (19761985) were significantly more likely to engage in an array of community-related activities, but recent graduates (1996-2005) were more likely to report having been trained in these skills. There was a significant positive association between practice in an underserved area and confidence in issues related to sociocultural aspects of care. While recent graduates were more likely to locate both initial and current practices in a Health Professions Shortage Area (HPSA), 20.6% of all graduates reported an initial practice in a HPSA. CONCLUSIONS: While family physician involvement in community-related activities increases with years out of residency, a higher proportion of recent graduates report having learned community-related skills while in medical school. Physician relocation tends to be away from HPSA toward non-HPSA sites.

The primary care physician workforce in Massachusetts: implications for the workforce in rural, small town America.

CONTEXT: Small towns across the United States struggle to maintain an adequate primary care workforce. PURPOSE: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. METHODS: A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. FINDINGS: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. CONCLUSIONS: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.

Service-learning: an integral part of undergraduate public health.

In 2003, the Institute of Medicine (IOM) described public health as "an essential part of the training of citizens," a body of knowledge needed to achieve a public health literate citizenry. To achieve that end, the IOM recommended that "all undergraduates should have access to education in public health." Service-learning, a type of experiential learning, is an effective and appropriate vehicle for teaching public health and developing public health literacy. While relatively new to public health, service-learning has its historical roots in undergraduate education and has been shown to enhance students' understanding of course relevance, change student and faculty attitudes, encourage support for community initiatives, and increase student and faculty volunteerism. Grounded in collaborative relationships, service-learning grows from authentic partnerships between communities and educational institutions. Through emphasizing reciprocal learning and reflective practice, service-learning helps students develop skills needed to be effective in working with communities and ultimately achieve social change. With public health's enduring focus on social justice, introducing undergraduate students to public health through the vehicle of service-learning as part of introductory public health core courses or public health electives will help ensure that our young people are able to contribute to developing healthy communities, thus achieving the IOM's vision.

Development of a brief questionnaire to identify families in need of legal advocacy to improve child health.

OBJECTIVE: To determine whether the medical-legal advocacy screening questionnaire (MASQ), a simple 10-item questionnaire, is able to screen families in a primary care setting for possible referral to legal services more effectively than the clinical interview alone. METHODS: Family Advocates of Central Massachusetts (FACM) is a medical-legal collaboration that assists low-income families with legal issues that affect child health. A convenience sample of parents seen at each of 5 medical practices associated with FACM was recruited to complete the MASQ prior to a routine child health care visit. Physicians blinded to the result assessed family need for referral to FACM after their usual clinical encounter. The sensitivity and specificity of both the MASQ and provider assessment were calculated. RESULTS: Two hundred fifty-five parents from 5 practices participated in the study. The MASQ identified 85 patients in need of legal services. Prior to reviewing the MASQ, the primary care providers identified 35 families in need of referral to the FACM. After completion of both the MASQ and the medical encounter, 37 families agreed to referral. The MASQ had sensitivity of 0.81 and specificity of 0.75 in predicting program referral. Provider assessment had sensitivity of 0.65 and specificity of 0.95 of predicting program referral. CONCLUSIONS: Routine use of the MASQ would likely identify more patients in pediatric practices who would accept referral to legal assistance than reliance on provider impression alone after a routine clinical encounter.

The power and the promise: working with communities to analyze data, interpret findings, and get to outcomes.

Although the intent of community-based participatory research (CBPR) is to include community voices in all phases of a research initiative, community partners appear less frequently engaged in data analysis and interpretation than in other research phases. Using 4 brief case studies, each with a different data collection methodology, we provide examples of how community members participated in data analysis, interpretation, or both, thereby strengthening community capacity and providing unique insight. The roles and skills of the community and academic partners were different from but complementary to each other. We suggest that including community partners in data analysis and interpretation, while lengthening project time, enriches insights and findings and consequently should be a focus of the next generation of CBPR initiatives.

Creating open access to exercise for low-income patients through a community collaboration for quality improvement: if you build it, they will come.

Community health centers face the need for safe, accessible, and affordable exercise for low-income patients to implement self-management strategies. This study reports on one federally qualified health center's experience developing a partnership with a local YWCA to offer open access to patients for physical activity. Over a 24-month period, 1060 adult patients made at least 1 visit to the YWCA, logging a total of 14,276 visits. Among the exercisers, 112 had diabetes and made 3225 visits. Frequent users (> or =24 visits), had an HbAlc reduction of 1% (P = .02). Community health centers can collaborate with local exercise facilities to ensure that patients have opportunities to pursue healthier lifestyles.

The body mass index of teen mothers and their toddler children.

OBJECTIVES: To evaluate: change in Body Mass Index (BMI) of adolescent mothers (14-19 years of age) from pre-pregnancy to 36 months postpartum; BMI of their children age 2 or older; relationship between maternal BMI and children's BMI. METHODS: Retrospective medical record abstraction of adolescent mothers attending a medical program in Massachusetts between 2001 and 2005 who had self-reported pre-pregnancy BMI data at first prenatal visit, at least one BMI measure 12 or more months postpartum, and who did not experience a repeat pregnancy (n = 52). Children of adolescent mothers were included if they had received their 2 (n = 41) and/or 3 (n = 28) year physical. RESULTS: Adolescent mothers: overweight increased from 25% pre-pregnancy to 33% at 24-36 months postpartum; obesity more than doubled in the same time period, from 15% to 36%. Those with BMI data available pre-pregnancy and postpartum had an increase in mean BMI from 25 pre-pregnancy to 29 at 24-36 months postpartum (P < 0.001). Two-year-old children: About 5% were at risk for overweight and 12% were overweight. Three-year-old children: About 18% were at risk for overweight and 18% were overweight. When BMI categories of children were compared to BMI categories of their mothers, there was a trend for adolescent mothers with overweight/obesity at 24-36 months postpartum to have 3-year-old children at risk for overweight or overweight (P = 0.092). CONCLUSIONS: There was a significant increase in overweight/obesity in this cohort of adolescent mothers and their children followed 36 months postpartum. The long-term sequelae of overweight/obesity indicates a need for effective interventions.

Adolescent mothers' attitudes toward contraceptive use before and after pregnancy.

STUDY OBJECTIVE: To understand attitudes and beliefs influencing use and nonuse of contraceptive methods pre- and postpartum among a group of adolescent mothers. DESIGN AND SETTING: Qualitative descriptive study utilizing focus groups conducted between May, 2005 and January, 2006 in Central Massachusetts. PARTICIPANTS: Adolescent mothers attending a federally funded multi-professional medical program. Inclusion criteria included being at least one year postpartum. Forty-six mothers were eligible; 34 were successfully contacted via telephone. Twenty-two agreed to attend; 15 adolescent mothers attended one of four groups. MAIN OUTCOME MEASURE: Emergent themes were identified concerning adolescent mothers' attitudes and beliefs regarding contraception pre and postpartum. RESULTS: Themes pertaining to nonuse of contraception prior to first pregnancy were: denial, not planning to have sex, not considering the consequences of unprotected sex, and wanting to become pregnant. Participants identified barriers to obtaining and utilizing contraception, including embarrassment discussing the topic, confidentiality, inability to obtain contraception without parental knowledge, and lack of knowledge regarding methods. Participants reported that convenience, perceived effectiveness, familiarity, and side effects were the primary reasons for selecting or changing a method of contraception postpartum and recommended several methods of promoting contraceptive use among adolescents. These included persuading health care providers to discuss the issue routinely with every adolescent patient, parental involvement, outreach by young mothers to at-risk teens, and media campaigns. CONCLUSIONS: Given the adverse consequences of adolescent pregnancy, understanding the attitudes and beliefs of postpartum adolescents regarding contraceptives is important for developing effective interventions. Focus groups conducted with adolescent mothers, a difficult population to engage, provide a venue for exploring this complex issue.