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.

Suicidal ideation, suicide attempt, and occupations among employed adults aged 18-64years in the United States.

OBJECTIVE: Approximately 70% of all US suicides are among working-age adults. This study was to determine whether and how 12-month suicidal ideation and suicide attempt were associated with specific occupations among currently employed adults aged 18-64 in the U.S. METHODS: Data were from 184,300 currently employed adults who participated in the 2008-2013 National Surveys on Drug Use and Health (NSDUH). NSDUH provides nationally representative data on suicidal ideation and suicide attempt. Descriptive analyses and multivariable logistic regressions were conducted. RESULTS: Among currently employed adults aged 18-64 in the U.S., 3.5% had suicidal ideation in the past 12months (3.1% had suicidal ideation only, and 0.4% had suicidal ideation and attempted suicide). Compared with adults in farming, fishing, and forestry occupations (model adjusted prevalence (MAP)=1.6%), adults in the following occupations were 3.0-3.6 times more likely to have suicidal ideation in the past year (model adjusted relative risks (MARRs)=3.0-3.6): lawyers, judges, and legal support workers (MAP=4.8%), social scientists and related workers (MAP=5.4%), and media and communication workers (MAP=5.8%). CONCLUSIONS: Among employed adults aged 18-64 in the U.S., the 12-month prevalence of suicidal ideation varies by occupations. Adults in occupations that are at elevated risk for suicidal ideation may warrant focused suicide prevention.

Suicidal thoughts and behaviors among adults aged ≥18 years--United States, 2008-2009.

PROBLEM/CONDITION: Suicidal thoughts and behaviors are important public health concerns in the United States. In 2008, a total of 36,035 persons died as a result of suicide, and approximately 666,000 persons visited hospital emergency departments for nonfatal, self-inflicted injuries. State-level data on suicide-related issues are needed to help establish program priorities and to evaluate the effectiveness of suicide prevention strategies. Public health surveillance with timely and consistent exchange of data between data collectors and prevention program implementers allows prevention program practitioners to implement effective prevention and control activities. REPORTING PERIOD: January 1, 2008-December 31, 2009. DESCRIPTION OF SYSTEM: The National Survey on Drug Use and Health (NSDUH) is a national- and state-level survey of a representative sample of the civilian, noninstitutionalized U.S. population aged ≥12 years. NSDUH collects data on health-risks related to the use of illicit drugs, alcohol, and tobacco; initiation of substance use; substance use disorders and treatment; health care; and mental health. This report summarizes data on responses to questions concerning suicidal thoughts and behaviors contained in the mental health section among sampled persons aged ≥18 years in all 50 states and the District of Columbia. This report analyzes data on the prevalence of suicidal thoughts, planning, and attempts by age, sex, race/ethnicity, and state from 92,264 respondents in the 2008 and 2009 NSDUH. RESULTS: Prevalence estimates of suicidal thoughts and behaviors varied by sociodemographic factors, region, and state. During 2008-2009, an estimated 8.3 million (annual average) adults aged ≥18 years in the United States (3.7% of the adult U.S. population) reported having suicidal thoughts in the past year. The prevalence of having suicidal thoughts ranged from 2.1% in Georgia to 6.8% in Utah. An estimated 2.2 million (annual average) adults in the United States (1.0% of the adult U.S. population) reported having made suicide plans in the past year. The prevalence of reports of suicide planning ranged from 0.1% in Georgia to 2.8% in Rhode Island. An estimated 1 million (annual average) adults in the United States (0.5% of the U.S. adult population) reported making a suicide attempt in the past year. The prevalence of reports of suicide attempts ranged from 0.1% in Delaware and Georgia to 1.5% in Rhode Island. The prevalence of suicidal thoughts, suicide planning, and suicide attempts was significantly higher among young adults aged 18-29 years than it was among adults aged ≥30 years. The prevalence of suicidal thoughts was significantly higher among females than it was among males, but there was no statistically significant difference for suicide planning or suicide attempts. INTERPRETATION: The findings in this report indicate that substantial variations exist at the regional and state level in the prevalence of adults who had suicidal thoughts, made plans to attempt suicide, and attempted suicide in the past year. Geographic differences in prevalence might be attributable to selective migration, sociodemographic composition of the population, or the local social environment (e.g., social relationship indicators such as divorce rates or resources for access to health care). These findings emphasize the importance of continued surveillance to collect locally relevant data on which to base prevention and control activities. PUBLIC HEALTH ACTION: A better understanding of the patterns of the precursors to suicide is crucial to planning and evaluating a broad spectrum of suicide prevention efforts. These results can be used by state health departments and federal agencies to measure progress toward achieving national and state health objectives (e.g., those outlined in the National Strategy for Suicide Prevention). Continued surveillance is needed to design, implement, and evaluate public health policies and programs that can lead to a reduction in morbidity and mortality related to suicide-related thoughts and behaviors. Possible strategies to implement could include universal strategies (e.g., public education campaigns that focus on improving recognition of suicide risk) and indicated strategies (e.g., cognitive-behavioral therapy) that address the needs of persons exhibiting certain risk factors (e.g., persons who have made suicide attempts).

Precipitating circumstances of suicide among women of reproductive age in 16 U.S. States, 2003-2007.

Suicide is the fourth leading cause of death for women between the ages of 15 and 44 years, exceeding deaths due to homicide, HIV, cerebrovascular disease (CVD), and diabetes (CDC, 2009). Furthermore, almost half of the suicide deaths in women occur in women of reproductive age, yet little is known about the determinants of suicide in young adult and middle-age women. Data from the National Violent Death Reporting System (NVDRS) were analyzed to describe the leading circumstances associated with suicide among women aged 15-44 years. From 2003 to 2007, there were 4203 suicide deaths among women 15-44 years of age, which represents nearly half (46%) of the suicide deaths among females. Precipitating circumstances were known in 3784 cases. The most frequently cited circumstances for these suicide decedents were current mental health problem (60%), having ever been treated for a mental health problem (54%), current depressed mood (44%), and problems with a current or former intimate partner (36%). Thirty-seven percent had a history of suicide attempts. Twenty-eight percent disclosed their intent to die by suicide to another person with enough time for someone to have intervened. To prevent suicide in women of reproductive age, multiple approaches should be taken, including but not limited to appropriate and effective mental health treatment, access to support systems, familial education in recognizing the signs of suicide, and understanding the options available to get help for someone at risk.

The relative influence of different domains of social connectedness on self-directed violence in adolescence.

Previous research has linked greater social connectedness with a lowered risk of self-directed violence among adolescents. However, few studies have analyzed the comparative strength of different domains of connectedness (e.g., family, peers and school) to determine where limited resources might best be focused. Data to address that gap were taken from the Centers for Disease Control and Prevention's Student Health and Safety Survey, administered to 4,131 7th-12th graders (51.5% female; 43.8% Hispanic; 22.6% African American or Black). Logistic regressions (controlling for age, gender, race/ethnicity, family structure, academic performance, and depressive symptoms) suggest that family connectedness was a stronger predictor than connectedness to peers, school, or adults at school for non-suicidal self-harm, suicidal ideation, suicide plans, and non-fatal suicidal behavior. In some analyses, peer connectedness was unexpectedly a risk factor. Results have implications for prevention of suicide in adolescence, especially in the context of the current trend towards school-based prevention programs.