As leaders in health professionals training, essential hospitals across the country are piloting innovative ways to integrate population health and health policy into undergraduate and graduate medical education.
This work is a natural fit for members of America’s Essential Hospitals: three-quarters are teaching institutions, as defined by the Accreditation Council for Graduate Medical Education, and essential hospitals train nearly three times as many physician residents as other U.S. teaching hospitals.
Population Health: A Team Sport
In addition to a robust residency program, the University of Massachusetts Medical School – Baystate, in Springfield, Mass., gives medical students an early introduction to population health through a special track called PURCH—Population-based Urban and Rural Community Health. Now in its second year, PURCH equips students to deliver patient-centered, team-based care tailored to the health disparities these communities face. Students take specialized courses in interviewing and clinical skills, and population health, and they apply their skills through real-world experiences.
“Part of the interviewing course is understanding your personal biases and understanding the social history,” says Kevin Hinchey, MD, chief education officer at Baystate Health and senior associate dean for education at UMass Baystate Medical School. To confront those biases head-on, students practiced their clinical skills with inmates at a local prison.
Hinchey says the medical students felt “a little bit of fear and hesitation” when the prisoners were brought out in shackles, but they began to relax as the prisoners shared their social history. “They just wanted to tell their story and be, in a sense, helping a generation of doctors learn something that I never, ever experienced,” Hinchey says.
Students also practiced their interviewing skills at a local homeless shelter, where they learned firsthand how social determinants affect health outcomes. Hinchey remembers one patient with diabetes who kept candy bars by his bed because he did not have access to a refrigerator and candy bars were nonperishable.
“If he eats the candy bar, he’s going to come into my office, his blood sugar’s going to be high, and I’m going to give [him] insulin,” Hinchey says. “But in the homeless shelters, the problem isn’t his diabetes. It’s that he doesn’t have a refrigerator. He doesn’t have access to good food.”
During their first year, students develop close relationships with social service organizations in the community through regular lunches and gatherings. In their second year, students deepen these relationships through a two-week population health clerkship, during which they conduct a needs assessment for a community organization. While the third year of curriculum is still under development, Hinchey says he hopes to show students that population health is a team sport, and physicians are just one player on a roster of community services.
“Students have been seduced by the medication — ‘As a physician, I can fix anything with my medicine.’ Some things can actually be prevented if we did things differently,” Hinchey says. “I can’t fix housing with my prescription pad, but I have to be aware of it. I have to be part of the team that advocates for it.”
Essential hospitals make population health a priority at all stages of medical education. At RWJBarnabas Health, in Jersey City, N.J., the “Health Care Leadership and Innovation” course pairs medical students with fourth-year residents for experiential learning and leadership development. Curriculum focuses on:
- involving patients, families, and communities in decision-making;
- team medicine;
- health care data and technology;
- social determinants of health; and
- clinical innovation programs.
Students conduct patient home assessments and ambulatory care visits, work with patient navigators, conduct community outreach, and participate in clinical simulations. Participants also get a taste of industry issues through weekly discussions on hot topics in health care and participation in hospital leadership council meetings. Throughout the course, students design and conduct their own improvement project based on their interests.
“We don’t make this busy work,” says Susan Walsh, MD, vice president of population health and program director of the internal medicine residency at RWJBarnabas Health-Jersey City Medical Center. “When they’ve come up with a solution to antibiotic use, or they come up with a solution to decrease readmissions, or they’re thinking about asthma in the home or environmental house calls, we actually have the ability…to get it put in action and do pilots around some of their performance improvement projects. It’s really moved our ability as a hospital to get closer to understanding population health principles and to get more value — efficiency plus quality — that we might not have had before.”
Integrating Advocacy into a Residency Curriculum
Focusing on population health also can help mitigate the feeling of burnout that can rear its head during residencies. As director of the University of New Mexico (UNM) Family and Community Medicine residency program, in Alburquerque, Dan Waldman, MD, often sees residents who feel discouraged by the limits of modern medicine.
“It’s not always about pills,” he says. By integrating population health efforts into the residency curriculum, he hopes to give residents an opportunity to get to the root of the health issues their patients face.
“It’s just not about doing less of things — yes, it is about spending less time typing into an [electronic medical record] — but it’s also about doing more of things that feel meaningful,” Waldman says.
Sometimes those meaningful actions include codifying population health efforts into policy. At UNM, residents in the rural family medicine program have an opportunity to engage in legislative and regulatory advocacy through a one-month rotation called “Legislative Action and Public Health.”
Karen Armitage, MD, the interim dean and director of health policy at the UNM College of Population Health, drew on her experience as chief medical officer for the New Mexico Department of Health to create this rotation 18 years ago.
“Physicians were unaware that they had a role in the public health system at all, and that many health statues, policies, and regulations were being made without any input from front-line physicians,” she remembers.
At UNM, she works to bridge that gap. Residents attend and testify at state legislative hearings, analyze proposed health policies, and build relationships with state lawmakers, other elected officials, and Department of Public Health staff.
“The resident begins to see their role in their community and in their own profession as different,” Armitage says. “They discover a whole new set of skills and a whole new set of powers that they can use to improve not just the health of their individual patients, but to improve the health of the entire population.”
For many residents, this rotation is just the beginning of a lifetime of advocacy. Around 40 to 50 percent of residents remain in New Mexico after completing their residencies, Armitage says, and it’s been rewarding to witness their continued engagement.
“Health policy is the medicine for population health ills,” she says.
Waldman says UNM leaders are constantly working to refine and improve their residency programs. “All of education is tending a garden, and if you’re not tending it, the weeds are actively growing, so you’ve got to keep doing stuff.”
In a rapidly changing health care environment, essential hospitals are tending their gardens to ensure that physicians-in-training are ready to embrace a challenging world.
The Essential Hospitals Institute in 2018 launched a Graduate Medical Education Learning Network to support the integration of population health into residency program curriculum. Tell us how we can further support you and your hospitals’ graduate medical education programs by contacting principal research associate Jennifer Stephens, MPH, at firstname.lastname@example.org.