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The Extent and Methods of Public Health Instruction in Family Medicine Clerkships

Jacob Prunuske, MD, MSPH; Linda Chang, PharmD, MPH, BCBH; Ranit Mishori, MD, MHS;
Alison Dobbie, MD; Christopher P. Morley, PhD, MA, CAS

Background and Objectives: The Institute of Medicine recommends integrating public health (PH) and primary care to advance community health. The status of PH integration into family medicine clerkships (FMC) is unknown. We sought to determine the extent and methods of required PH instruction in FMC.

Methods: We used the Council of Academic Family Medicine Educational Research Alliance (CERA) survey of FMC directors.

Results: From 36%–59% of FMC directors responded to individual PH questions, reporting a mean of 36.3 hours (range 1–258) of PH instruction in the clerkship. The majority of PH instructional time relates to behavioral sciences, communication, and cultural competence. Forty-nine percent of PH instructional hours are experiential. Ninety percent of respondents agree that PH training is important for medical students; 67.5% of respondents agree that PH training is appropriate for the FMC. Respondents from public schools reported more PH training than respondents from private schools (43.85 ± 9.25 hours versus 21.29 ± 3.82 hours). There was no difference between hours of instruction reported by FMC directors with shorter (≤ 4 weeks) and longer (> 4 weeks) clerkships (40.8 ± 13.7 hours versus 33.7 ± 6.4 hours). Among respondents leaving comments, 24/36 (66.7%) cited insufficient time, 6/36 (16.7%) cited lack of funding, and others identified lack of faculty or preceptor expertise and lack of student interest as barriers to PH instruction.

Conclusions: There is variability in how FMC are addressing PH instruction. Future research should qualitatively explore pedagogical methods and seek consensus on the competencies and best practices in PH instruction most suited to FMC.

(Fam Med 2014;46(7):544-8.)

Many leading causes of morbidity and mortality in the United States are affected by social determinants of health through their impact on health-related behaviors and lifestyle. Therefore, current health challenges are unlikely to be solved by clinical care alone.1 As a result, the Institute of Medicine (IOM) has called for integration of public health and primary care practice,2 recommending all medical students receive basic public health training (with a significant proportion trained at the Master’s level).3,4 This call has been echoed by a proposed framework for the knowledge, skills, and training of family physicians with respect to public health.5

Family medicine is well positioned to develop the foundation for this integration at a medical school curricular level, since family physicians often serve in leadership roles in preclinical doctoring courses, and students on family medicine clerkships are distributed widely across communities. Family medicine has also been active in the implementation of patient-centered medical home (PCMH) principles, with emphases on population management, preventive care, and attention to social determinants of health. Opportunities therefore exist to engage with systems-based quality improvement initiatives and other aspects of the PCMH, augmenting traditional focus on individual patient management with a focus on management of patient panels and populations.

There are many possible approaches to integrating public/population health (PH) competencies into medical school curricula.6-12 However, the status of PH integration into family medicine clerkships (FMCs) is unknown. Given potential and actual roles of family medicine in integrated medical/PH education, we sought (1) to determine the extent of required PH training in US allopathic medical school FMCs and (2) to explore the pedagogical nature of this training.

 

Methods

 
 

We designed a series of questions that were included in the Council of Academic Family Medicine Educational Research Alliance (CERA) survey of FMC directors (FMCDs), asking about PH instruction, specifically asking about content in the core areas described by the IOM in previous reports.2,3 The CERA survey of FMCDs was conducted between July and September 2012. It included 74 questions, with the final eight questions devoted to PH instruction. The full survey and a general CERA program description are available at http://www.stfm.org/CERA/. Potential respondents received an email invitation with a link to the survey, with nonrespondents receiving up to two follow-up invitations. Survey participation was voluntary, with no incentives tied to participation.

We restricted our analysis to individuals who answered at least one of our questions on the CERA survey.

Quantitative data were analyzed using STATA (Stata/IC 12.1 for Mac, Revision 20 Mar 2013. Copyright 1985–2011 StataCorp LP. College Station, TX). We tabulated descriptive statistics for FMCD demographic data, hours and methods of PH instruction, and evaluation of appropriate stage of training for PH instruction. We compared hours of PH instruction between public and private medical school status and between clerkship lengths (>4 weeks versus ≤4 weeks) via t test. We also performed content analysis on respondents’ narrative comments to identify emergent themes regarding barriers to PH instruction, with one author (CPM) performing open coding of all comments, followed by review and verification by three other team members (JP, LC, and RM). The American Academy of Family Physicians Institutional Review Board approved the study and The University of Minnesota Institutional Review Board determined this project exempt from review.

 

Results

 
 

The overall response rate to the CERA survey was 65.7% (88/134). Fewer respondents answered all questions; response rates for individual PH questions ranged from 36%–59% (48–79/134). Demographic information about respondents is included in Table 1. There is wide variability in the number of instructional hours devoted to PH competencies in FMCs (Table 2). Clerkships devote most PH instructional time to behavioral sciences, communication, and cultural competence. Less time is devoted to global health, policy, advocacy, law and ethics, special population-level topics, and the PH core competencies of biostatistics and epidemiology. Multiple methods are used for PH instruction, with nearly half of the educational time being experiential (Table 2).

Table1
Table2

Ninety percent of responding clerkship directors agree PH training is important for medical students. A total of 67.5% agree, and 10.1% disagree, that PH training is appropriate for the FMC. Respondents from public medical schools report more PH training in their clerkships (43.85 ± 9.25 hours) than those from private schools (21.29 ± 3.82 hours) (P=.03), which average about 1.33 hours less instruction for each PH domain (Table 3). There was no difference between reported hours of instruction for shorter (4 weeks or less) and longer (>4 weeks) clerkships (40.8 ± 13.7 hours versus 33.7 ± 6.4 hours, P=.64). Factors influencing PH instructional time are shown in Table 4.

Table3
Table4

In narrative comments, 24/36 (66.7%) respondents cited insufficient time, and 6/36 (16.7%) cited lack of funding, as barriers to PH instruction. Others mentioned lack of faculty/preceptor expertise and lack of student interest.

 

Discussion

 
 

Clerkship directors report widely varying amounts of PH instruction during the FMC. They value PH instruction and believe it appropriate for the clerkship. Limited time is the most commonly cited barrier to PH instruction. An observed emphasis on behavioral health, communication, and cultural competency may reflect a perceived importance of these topics by medical educators related to the medical encounter. Clerkship directors reported fewer instructional hours for topics like global health, health policy, ethics, and law that may be viewed as less clinically relevant. Supporting our findings, students reported inadequate coverage of these same topics on the 2012 Medical School Graduate Questionaire,13 suggesting an area for development within clerkships.

We believe our findings provide a starting point for family medicine educators as they engage in curricular change and PH integration. Challenges include identifying the most appropriate PH competencies for the clerkship given limited time and resources, best practices in curriculum delivery, and strategies for developing sustainable community partnerships.

Our survey has several limitations: (1) Recall bias may have influenced respondents’ ability to accurately estimate instructional time and content, (2) Broad PH categories prevent assessment of curricular content; for example, 1 instructional hour of “communication” focused on public health reporting to the local health department is indistinguishable from 1 hour of patient-doctor communication, and (3) The survey is limited to the FMC and does not assess PH curricula outside the clerkship.

In conclusion, there is variability in how FMCs are addressing PH education. Additional instructional hours, innovative curricula, external funding, and non-academic partnerships may be necessary to meet current recommendations to expand, integrate, and enhance PH content in medical training.

Acknowledgments: This project was partially funded by the Society of Teachers of Family Medicine (STFM) Foundation Group Project Fund (J. Prunuske, PI) and by Health Resources and Services Administration (HRSA) AAU grant D54HP05462 (C.P. Morley, PI).

Preliminary results for this manuscript were presented at the North American Primary Care Research Group 2012 Annual Meeting in New Orleans, LA, and the 2013 STFM Conference on Medical Student Education in San Antonio, TX.

Correspnding Author: Address correspondence to Dr Prunuske, University of Minnesota Medical School, Department of Family Medicine and Community Health, 1035 University Drive, SMED #145, Duluth, MN 55812-3031. 218-726-7227. Fax: 218-726-7699. jprunusk@d.umn.edu.

 

References

 
 
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From the Department of Family Medicine and Community Health, University of Minnesota Medical School (Dr Prunuske); University of Illinois at Chicago, Rockford Family Practice Residency (Dr Chang); Department of Family Medicine, Georgetown University (Dr Mishori); Ross University School of Medicine (Dr Dobbie); and Department of Family Medicine, Department of Public Health and Preventive Medicine, and Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University (Dr Morley).


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