|Year : 2007 | Volume
| Issue : 3 | Page : 122
Integrating Public Health and Medicine: First Steps in a New Curriculum
A Klinken Whelan, D Black
School of Public Health and Community Medicine, University of New South Wales, NSW, Australia
|Date of Submission||19-Sep-2007|
|Date of Acceptance||15-Oct-2007|
|Date of Web Publication||22-Nov-2007|
A Klinken Whelan
SPHCM, UNSW, Kensington, NSW 2052
Source of Support: None, Conflict of Interest: None
Context: Recent outbreaks of infectious diseases and humanitarian crises highlight the need for an understanding of public health issues in medical progams. However, public health teaching is perceived as peripheral in current Australian university medical programs.
Objective: To integrate public health into clinical and biomedical teaching throughout the new medicine program at the University of NSW.
Methods: The medicine program has been designed with three phases and with clinical experiences introduced early in the program. The approach is to trigger learning with scenarios and with vertical integration to reinforce lifelong learning. Public health teaching and understanding has been integrated into all the scenarios.
Discussion: As the program is only in its 4th year, there has been no summative evaluation of the impact of this approach. However, formative evaluation through Phase 1 student portfolios has demonstrated a good understanding of public health concepts in the satisfactory way students have addressed one of the eight graduate capabilities: Social and Cultural Aspects of Health and Disease. Another indicator of an appreciation of public health issues in medicine has been the choice of social and cultural topics in students' independent learning projects.
Conclusion: Summative evaluation will occur when the University's new program graduates work in the existing health care system. It is proposed that they will be followed up to see whether they apply the public health values in their practice.
Public health, integration, medical education, curriculum reform
|How to cite this article:|
Whelan A K, Black D. Integrating Public Health and Medicine: First Steps in a New Curriculum. Educ Health 2007;20:122
The importance of public health, health promotion and disease prevention has been highlighted in recent global events such as the severe acute respiratory syndrome (SARS) outbreak, the tsunami and earthquakes in South East Asia and hurricane Katrina in the USA, as well as the heightened threats of bioterrorism, influenza pandemics and climate change. Yet the teaching of public health within undergraduate medical programs has been described as ‘deeply problematic’ and regarded as peripheral or even irrelevant by medical students (Stone, 2000). Over a decade ago, Woodward (1994) posed the challenge that ‘public health has no place in undergraduate medical education.’ He argued for and against the proposition, concluding that public health could not be taken out of medical education, but questioned whether or not it was taught well.
In the United States, the Department of Health and Human Services report Healthy People 2010 encouraged a review of clinical education to become more effective in prevention education. The Healthy People 2010 report spurred the Association of Teachers of Preventive Medicine to join with the Association of Academic Health Centers to convene the Healthy People Curriculum Task Force, to develop an acceptable education framework entitled the ‘Clinical Prevention and Population Health Curriculum Framework’ (Allan et al., 2004).
While these developments are highly significant within the U.S. context of health professional education, no such consensus framework has been developed in Australia or the Asia-Pacific region. The South East Asian Public Health Institutes Network (SEAPHEIN) has focused on public health competencies in Masters of Public Health programs, but not on undergraduate or clinical education programs. In Australia, the federal Public Health Education and Research Program (PHERP) focuses on postgraduate education in public health. Medical education remains largely institution-focused with each medical school devising a separate curriculum. While curricula are accredited by the Australian Medical Council using the standards that include those for population health, there is no common national curriculum framework for public health. In recent years with an increasing number of medical schools approved, some of the newer medical schools have adopted curricula from other established schools, often without true innovation involved (Dowton, 2005).
Integration and community orientation
Attempting to change medical education to be more community-oriented has been a long struggle for many individuals and organizations, but the benefits of that struggle are seen today in medical curriculum innovations throughout the world. One of the major challenges has been the integration of public health and medicine, summarized in a Position Paper of the Network: Towards Unity for Health (Gofin et al., 2004). Integration has been described in the Australian context at the University of Sydney graduate-entry program (Trevena et al., 2005). In this paper, integration refers to educational strategies that bring together concepts of patient care and medical practice with concepts of public or population health, as well as with a broader interpretation that includes basic biomedical sciences.
Features of integration at UNSW
The new Medical program was introduced at the University of New South Wales (UNSW) in 2004 as a shift away from a traditional discipline-based curriculum. This was a major curriculum reform for the undergraduate medical program which made integration of public health, science and medicine pivotal. The reform process was driven by a new Dean and a team in a newly created Office of Medical Education, with an explicit ‘blue sky’ planning approach (McNeil et al., 2006). Underpinning the curriculum innovation was the consensus reached around “graduate capabilities” of which one of the eight directly related to public health: understanding the social and cultural aspects of health and disease. This capability is further sub-divided into Social Determinants of Health; Measuring Health Status; Health Care Systems; Improving Health through Social Approaches.
Early design groups were explicitly formed to include staff from basic sciences, medical practice, public health and social sciences as well as education experts. These groups were given very broad terms of reference in the pilot phase during 2000-2001. In most cases, this was the first time that academics from traditional disciplinary bases had come together to work on a common project. The first design group in which the authors were involved included a new professor of genetics from the Faculty of Science, a microbiologist, an immunologist, head of gastroenterology from one of UNSW’s teaching hospitals, two public health academics and a medical education academic. The curriculum design process was based on consensus from all members and, while the process was slow, it fostered ownership of the course across schools and faculties.
The New Medical Program
The program has been described in detail (McNeil et al., 2006) but it is essentially a modular, six-year undergraduate program, comprised of three phases of approximately two years in duration.
- Phase 1, commenced in 2004, consists of nine 8-week courses, utilizing a ‘scenario-based’ learning process, with early clinical experiences to reinforce learning in clinical and communication skills,
- Phase 2, ‘practice-based’ learning, consists of four clinical periods with two days per week on campus and three days per week in clinical environments, plus an Independent Learning Project,
- Phase 3, an ‘independent reflective’ learning process, consists of ten clinical rotations.
Learning and teaching are organized around four domains or courses, essentially the human life cycle (Beginnings; Growth and Development; Health Maintenance; Ageing and Endings) plus Society and the Environment. Each domain has four themes, which provide a focus for learning and teaching. Three content streams were identified for integration in the new program and are included in ALL nine courses in Phase 1:
Biomedical Science, including cellular processes in health and disease, organ system structure/function and dysfunction (i.e., the micro- and macro-biologic scientific basis of medicine),
Social Aspects, including social and behavioural determinants of health and illness,
Medical Practice, including activities directly related to the practice of medicine.
The significant feature of this design is that public health concepts are not confined to a single course or unit, which students have perceived as “soft,” in past evaluations. Students now encounter public health concepts where they relate directly to scenarios, and these are also integrated with basic sciences and medical practice elements. Data on where public health is evident in all courses is found on searching the electronic curriculum map. The integration is also driven by assessment tasks in each course, which include two focus capabilities and generic capabilities in effective communication, reflection and self-direction. These assessment tasks in the end of the Phase portfolio assessment are used as evidence to demonstrate adequate understanding of each of the eight capabilities. This includes the social and cultural capability.
Phase 1 Society and Health course
There is, in addition, one course at the end of Phase 1 that acts as a synthesis of learning, Society and Health. The overall aim of this course is to gain an understanding of the interrelationships between the health of individuals or populations and the environment in which they live. The major themes include:
- social determinants of health,
- the diversity of society focusing both on culture and genetics,
- systems that provide healthcare, and
- the relationship between health and human rights.
Particular emphasis is placed on equity of health services across social, cultural and economic differences. The themes are studied taking global, community/population and individual perspectives on health.
Student learning is triggered by scenarios that cover approximately two weeks of the eight-week course. A range of structured resources back up courses including scenario plenary, lectures, science practicals, tutorials, communication tutorials, clinical skills sessions and small scenario group sessions. In the ‘A’ year, the triggers for the three respective themes are HIV/AIDS, tuberculosis and influenza. The scenario (example in Box 1) is presented using videos in a plenary presentation that illustrates how basic science, patient management and public health are integrated into a learning activity.
This integration also occurs in all assessment activities (Toohey and Kumar, 2003).
Box 1: Second plenary scenario in Society and Health (A)
Assessment involves performance in two projects/assignments and an end of course written examination. An example of an exam question showing integration is presented in Box 2.
Box 2: Example of an exam question showing integration
The ultimate evaluation for course designers will be when medical students graduate and work in the existing healthcare system, which is much more difficult to reform. Will the values and capabilities they have been immersed in relating to public health remain useful and more importantly be practiced? We plan to answer this by following a cohort of students as they progress through the program and after graduation.
The authors gratefully acknowledge the work of numerous staff members who contributed to the design and delivery of Society and Health Phase 1, as well as others in other domains. Barbara Cameron and Eilean Watson provided input into an earlier version of the paper and Professor Patrick McNeil and Leah Bloomfield provided comments.
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