1. Teaching Population Health: An Essential Component of Context in Medical Education IAMSE June 8, 2014 Heidi Gullett, MD, MPH Assistant Professor, Department of Family Medicine and Community Health Population Health Liaison, Cuyahoga County Board of Health Amy Wilson-Delfosse, PhD Associate Professor of Pharmacology Assistant Dean for Basic Science Education

2. Disclosures No Financial Disclosures

3. Focus Session Objectives 1.Articulate the importance of teaching population health concepts in undergraduate medical education. 2.Define 2-3 essential components of population health education for medical students. 3.Describe the value of community-based learning experiences to underscore the concepts in a population health curriculum. 4.Describe 1-2 specific ways that population health could be integrated into an attendee’s curriculum.

4. Workshop Overview Workshop Participant Assessment Population Health and Professional Competencies Overview of CWRU Curriculum and Block 1 – Block 1 Goals and Philosophy – Block 1 Structure and Content – Epidemiology and Biostatistics Discussion around integration of specific population health curricular elements – Content – Teaching techniques – Faculty selection – Curricular timing – Challenges

5. Welcome! Name School Role Please tell us something fun you plan to do this summer. What do you hope to gain from this workshop? What is a specific area of interest you would like addressed in this workshop?

6. What is Population Health Institute for Healthcare Improvement (IHI) 1 – “Any group of individuals for whom consideration of health or health care at the level of the group is likely to advance health.” Dr. Kindig’s definition: 2 – “The health outcomes of a group of individuals, including distribution of such outcomes within the group.” Concerned with outcomes, as well as determinants and factors, in an effort to define the “distribution of health” Evolving definition 1 www.ihi.org 2 Kindig DA, Stoddard G. What is population health? Am J Public Health 2003; 93:366-369.

7. Tools of Population Health Epidemiology/Biostatistics Disease surveillance Data analysis Education Advocacy Policy Program design and evaluation Research Environmental Health Genetic epidemiology Process and outcome measures Quality improvement Community health and health impact assessments Bioethics

8. Teaching Population Health from Various Perspectives Context depends upon perspective Community Patient Public Health (Local, Regional, National, International) Provider Payor Government

9. Why Focus on Population Health? Competencies and Certification Exams – Liaison Committee on Medical Education (LCME) – Accreditation Council for Graduate Medical Education (ACGME) – National Board of Medical Examiners (NBME) – Specialty Boards Context for medical training and career – Rapidly changing healthcare environment – More broad understanding of determinants of health – Practical introduction to students’ new community

10. Why Focus on Population Health? Much work of population health performed by local public health Public health and clinical care most often function in isolation A move toward integration is critical to improve health – Institute of Medicine 2012 Report Primary Care and Public Health: Exploring Integration to Improve Population Health IOM Report 2012

11. LCME Competencies Population Health and Civic Professionalism – Identifies community and population-based health issues – Demonstrates skills needed to improve health and healthcare for local, national, and global communities

12. LCME Competencies Educational Program Objectives and Milestones for Graduation – Applies primary and secondary prevention strategies that improve the health of individuals and populations. – Demonstrates ability to design community-based health improvement intervention. – Integrates emerging information on individuals’ biologic and genetic risk with population-level factors when deciding upon prevention and treatment options. – Considers ethical and legal perspectives, patient advocacy, health policy, and public health concerns in clinical care.

13. ACGME Competencies Consistent with Milestone Project for all specialties Six Core Competencies – Patient Care – Medical Knowledge – Practice-based Learning and Improvement – Interpersonal and Communication Skills – Professionalism – Systems-based Practice

14. In your institutions… How do you teach these competencies? – Separate courses? – Integrated within other courses? – Other?

15. An Introduction to Block 1: Becoming A Doctor Created as part of overall curricular revision in 2004 Concentrated 5 weeks at beginning of medical school (July-mid August) Opportunity to create a comprehensive understanding of population health principles Create foundation upon which to build throughout next 4 years – Other preclinical blocks – Tuesday seminars (Foundations of Clinical Medicine) – Core clinical rotations (including IQ+)

16. Population Health in the WR 2 Curriculum “Fundamental curricular revision” in 2004 Two major goals: 1.Create opportunity for all students to conduct meaningful research culminating in required medical student thesis 2.Three areas create “backbone” of curriculum Mastery of clinical skills Civic professionalism – Understanding systems and population health are critical to effective civic professionalism. Leadership

17. Year IYear IIYear IIIYear IV Foundations of Medicine and Health (20 months, including vacation) BASIC SCIENCES PHYSICAL DIAGNOSIS COMMUNICATION SKILLS COMMUNITY PATIENT CARE PRECEPTORSHIP (CPCP) Core Clinical Rotations IQ+ Program (48 weeks, flexible scheduling) Research & Scholarship (16 week block + electives, flexible scheduling) Advanced Clinical and Scientific Studies Areas of Concentration Electives (10 months, flexible scheduling) Western Reserve 2 Curriculum Slide courtesy of Scott Frank, MD, MS

18. CWRU School of Medicine University Track Basic Science Curriculum Reflection, Integration & Assessment July Year 1 March Year 2 Homeostasis (14 wk) Host Defense and Host Response (14 wk) Cognition, Sensation, and Movement (14 wk) Food to Fuel (11 wk) (Host Defense, Microbiology, Blood, Skin, Auto-immune) (Endo, Repro, Development, Genetics, Mol Biol, Cancer Biology) (GI, Nutrition, Energy, Metabolism, Biochemistry) (Neuro, Mind Musculoskeletal, Cellular Neurophysiology (CV, Pulm, Renal, Cell Regulation, Pharmacology, Cell physiology) The Human Blueprint (11 wk) Reflection, Integration & Assessment 1 Week Clinical Immersion (Public Health, Inequities, QI/Patient Safety/Medical Error, Bioethics, Professionalism Epi/Biostats) Becoming a Doctor (5 wk) Reflection, Integration & Assessment Structure (Anatomy, Histo-Path, Radiology) Foundations of Clinical Medicine Slide courtesy of Scott Frank, MD, MS

19. CWRU School of Medicine University Track Basic Science Curriculum Reflection, Integration & Assessment July Year 1 March Year 2 Homeostasis (14 wk) Host Defense and Host Response (14 wk) Cognition, Sensation, and Movement (14 wk) Food to Fuel (11 wk) (Host Defense, Microbiology, Blood, Skin, Auto-immune) (Endo, Repro, Development, Genetics, Mol Biol, Cancer Biology) (GI, Nutrition, Energy, Metabolism, Biochemistry) (Neuro, Mind Musculoskeletal, Cellular Neurophysiology (CV, Pulm, Renal, Cell Regulation, Pharmacology, Cell physiology) The Human Blueprint (11 wk) Reflection, Integration & Assessment 1 Week Clinical Immersion (Public Health, Inequities, QI/Patient Safety/Medical Error, Bioethics, Professionalism Epi/Biostats) Becoming a Doctor (5 wk) Reflection, Integration & Assessment Structure (Anatomy, Histo-Path, Radiology) Foundations of Clinical Medicine Slide courtesy of Scott Frank, MD, MS

20. Block 1 Goals 1.Provide a strong epidemiology and biostatistics foundation to support effective application in clinical practice and interpretation of the scientific literature. 2.Illustrate effective means to understand, measure, and affect the health of populations. 3.Provide a basis for understanding social, behavioral, structural, and environmental determinants of health. 4.Provide a broad understanding of health systems. 5.Emphasize continuous process and system improvement as a mechanism for limiting medical error and improving both individual and population outcomes.

21. Block 1 Goals 1.Provide a strong epidemiology and biostatistics foundation to support effective application in clinical practice and interpretation of the scientific literature. 2.Illustrate effective means to understand, measure, and affect the health of populations. 3.Provide a basis for understanding social, behavioral, structural, and environmental determinants of health. 4.Provide a broad understanding of health systems. 5.Emphasize continuous process and system improvement as a mechanism for limiting medical error and improving both individual and population outcomes.

22. Block 1 Goals 1.Provide a strong epidemiology and biostatistics foundation to support effective application in clinical practice and interpretation of the scientific literature. 2.Illustrate effective means to understand, measure, and affect the health of populations. 3.Provide a basis for understanding social, behavioral, structural, and environmental determinants of health. 4.Provide a broad understanding of health systems. 5.Emphasize continuous process and system improvement as a mechanism for limiting medical error and improving both individual and population outcomes.

23. Block 1 Goals 1.Provide a strong epidemiology and biostatistics foundation to support effective application in clinical practice and interpretation of the scientific literature. 2.Illustrate effective means to understand, measure, and affect the health of populations. 3.Provide a basis for understanding social, behavioral, structural, and environmental determinants of health. 4.Provide a broad understanding of health systems. 5.Emphasize continuous process and system improvement as a mechanism for limiting medical error and improving both individual and population outcomes.

24. Block 1 Goals 1.Provide a strong epidemiology and biostatistics foundation to support effective application in clinical practice and interpretation of the scientific literature. 2.Illustrate effective means to understand, measure, and affect the health of populations. 3.Provide a basis for understanding social, behavioral, structural, and environmental determinants of health. 4.Provide a broad understanding of health systems. 5.Emphasize continuous process and system improvement as a mechanism for limiting medical error and improving both individual and population outcomes.

25. Block 1 Goals 1.Provide a strong epidemiology and biostatistics foundation to support effective application in clinical practice and interpretation of the scientific literature. 2.Illustrate effective means to understand, measure, and affect the health of populations. 3.Provide a basis for understanding social, behavioral, structural, and environmental determinants of health. 4.Provide a broad understanding of health systems. 5.Emphasize continuous process and system improvement as a mechanism for limiting medical error and improving both individual and population outcomes.

26. Block 1 Philosophy: The Lens Create a strong foundation on which to build during the remainder of medical school. Create context for understanding health in a broad sense. – Foundation includes teaching how to measure, understand, and affect the health of populations – Foster integration of concepts learned in all activities Goal to coordinate with other faculty curricular leaders to ensure a cohesive curriculum that serves our students and community well.

27. Intentional emphasis on… Interprofessional importance, team-based practice Diverse faculty: training, expertise, specialty, experience Representation across Cleveland: local health departments and health systems Highlight tremendous community health work in our area to solidify concepts taught throughout the block

28. Block 1 Weekly Themes Problem- based Learning (IQ) Case Unnatural Causes Community Field Experiences Team-Based Learning Week 1Population HealthPandemic FluIn Sickness and in Wealth; Not Just a Paycheck Week 2Determinants of HealthToni Jackson: Determinants of Health When the Bough Breaks; Place Matters Determinants of Health/Social Work Population Health Week 3Health SystemsMr. Prince: Medical Error Collateral Damage; Becoming American Community Health Center/Safety Net Global Health System Comparisons Week 4Patient-centered careMrs. Sanchez: Diabetes Mellitus Bad SugarChronic Disease Week 5“Bringing It All Together”Jack Lee: Well Adult Care

29. Integration of Curricular Content Goal to foster reflection and integration of core concepts across the block Multiple venues to encourage connection of various learning activities with each IQ case – Google+ Field Experience reflection posts Cases are correlated with the weekly theme

30. Highlights of longitudinal curricular threads Health promotion step challenge Bioethics thread across block Google+ field experience reflection blog Online modules (IHI, APTR*) Unnatural causes: Is Inequality Making Us Sick? Epidemiology/Biostatistics *IHI = Institute for Healthcare Improvement; APTR = Association for Prevention Teaching and Research

31. Health Promotion Step Challenge Goal: To illustrate health behavior activity, continuous process improvement Foster friendly competition and camaraderie Faculty and staff participation Prizes Top PBL (IQ) group Top individuals (staff /faculty and students) Students who achieve average of 10,000 steps every day = 280,000 steps

32. 2013 IQ Winner!

33. 2013 Individual Winner!

34. Bioethics Incorporation into key elements of Block 1: Two general Bioethics introductory sessions – Week 1 Pandemic flu exercise – Week 1 Incorporation into individual v. population health didactics (theory) – Week 1 Health disparities – Week 2 Field experiences (practical application) – Weeks 2-4 IQ discussions – Weeks 2-4

35. Field Experiences Determinants of Health/Social Work Community Health Center/Safety Net Chronic Disease Neighborhood Correlations PBL (IQ) facilitators receive guide for each week with trigger questions to facilitate Google+ posts and small group discussion

36. Google+ Field experiences – Social work – Community health center/safety net providers – Chronic disease Google+ IQ group pages (“communities” – hidden and secure) for reflection blogs to facilitate integrated discussion during IQ sessions IQ student leaders asked to protect time in Friday session for discussion

37. Online modules IHI Quality Improvement – Option for certificate of completion though IHI – Free for enrolled US medical students Association for Prevention Teaching and Research (APTR) – Population Health – Public Health Learning

38. Unnatural Causes Health disparities documentary series – 4 hours, 7 episodes – Associated health policy exercises for all stakeholders regarding health equity – www.unnaturalcauses.org

39. Organization of Epi/Biostats Curriculum Total of 11 hours of class time Large-group lectures with interactive answering options Background of core concepts – Epidemiology – Biostatistics – Introduction to clinical study designs Critical evaluation of studies – Practice using “journal club” Slide courtesy of Doug Einstadter, MD, MPH

40. Epidemiology Topics Covered Introduction to Epidemiology Association and Cause Samples and populations Use and interpretation of diagnostic tests The role of screening and prevention Slide courtesy of Doug Einstadter, MD, MPH

41. Biostatistics Topics Covered Types of Data Descriptive Statistics Hypothesis testing Chance and the p-value Confidence Intervals Potential errors (Type I and II) Power Slide courtesy of Doug Einstadter, MD, MPH

42.  Study Designs Introduced: Cross-sectional studies Case-Control studies Cohort studies Randomized Controlled Trials  Journal Club(s) to practice critical review skills. Critical Evaluation Skills Slide courtesy of Doug Einstadter, MD, MPH

43. Block 1 Student Assessment Weekly during block: – Short essay questions – Multiple choice questions – IQ facilitator feedback on reflections and participation in PBL (IQ) sessions Following completion of block: – Essay questions

44. Discussion Small group discussion on the following areas of population health integration (30 min): – Content – Teaching techniques – Faculty selection – Timing in curriculum Small groups report on 1-2 ideas for population health curricular integration in your programs

45. Discussion Teaching Content – Concept of population health – Tools for understanding and applying population health principles – Epidemiology/Biostatistics – Determinants of health – Health systems Patient Protection and Affordable Care Act implications – Quality improvement – Integration with basic science concepts

46. Discussion Teaching Techniques – Problem-based learning (IQ) – Team-based learning (TBL) – Pandemic flu tabletop exercise (medium-sized group activity) – Field experiences – Google+/Social Media Tools Reflection Encouragement of participation – Online modules – Documentary series

47. Discussion Faculty Selection – Content expertise – Student exposure to interprofessional nature of population and community health – Local laboratory for understanding and applying population health principles: Future research options Cuyahoga County Board of Health population health expertise Other local health departments Better Health Greater Cleveland multi-stakeholder collaborative Health Improvement Partnership-Cuyahoga – Other considerations?

48. Discussion Timing in Curriculum – Early inclusion of principles – Relevance and variable interest among entering students – Timing of relevance evaluation – Changing content Evolving field of population health Rapidly changing health policy – New session in 2014 on Medicaid expansion and PPACA impact within Cuyahoga County

49. Discussion Challenges – Variable uptake for students from diverse backgrounds – Lack of context for some entering medical students – Timing challenges for interprofessional activities – Large number of meaningful community field experience sites are necessary

50. Block 1 in the Literature Ornt DB, Aron DC, King NB, Clementz LM, Frank SH, Wolpaw T, Wilson-Delfosse A, Wolpaw D, Allan T, Carroll M, Thompson- Shaheen K, Altose M, Horwitz R. Population Medicine in a Curricular Revision at Case Western Reserve. Academic Medicine, 2008; 83 327-331 Carney JK, Schilling LM, Frank SH, Biddinger PD, Bertsch, TF, Grace CJ, Finkelstein JA. Planning and Incorporating Public Health Preparedness Into the Medical Curriculum. American Journal of Preventive Medicine. 2011;41 (4S3):S193-S199 Frank SH. Principles for Authentic Population Health. American Journal of Preventive Medicine. 2011;41 (4S3):S152-S154

51. Thank you! Please feel free to contact me anytime! heidi.gullett@case.edu