Prevention for the 21st Century

Life expectancy at birth has increased 29 years from 47 years in 1900 to 76 years in 1996.¹ Some of this progress in health status can be attributed to advances in technical and medical sciences that have transformed how we care for the sick and have opened new possibilities to intervene effectively to treat many diseases. However, national investments in public health have played an even larger role through better housing, sanitation, and nutrition, expanded immunization, and safer workplaces.² It has been estimated that these and other public health achievements account for about 25 of the years of increased life expectancy.² Regardless of how the credit is partitioned, by any standard, this has been an amazing run.

What does the 21st century hold in store? Will life expectancy continue to increase at the same pace in the 21st century and reach 105 years by 2096? Will quality of life continue to improve? How much will it cost to sustain this trend? Recently, Surgeon General David Satcher suggested that because of successful immunization practices, future pediatrics residents would not see a child with Hemophilus influenzae meningitis during their training.³ Indeed, imagine a 21st century when a physician in training never sees a patient with metastatic cancer because the disease is uniformly detected before it spreads from its primary site of origin, or when a death from myocardial infarction before the age of 75 is considered a breakdown in health care. As researchers, health providers, and policymakers continue to search for evidenced-based, cost-effective ways to further enhance the length and quality of life, disease prevention and health promotion as the cornerstone of good medicine will inevitably receive ever-growing emphasis.

How can medical educators best prepare their students to contribute to another century of continued health improvement? The generation of students now being taught will be practicing into the middle of the next century. These student physicians will be expected to provide an expanding array of clinical preventive services and be responsible for the health and well-being of entire populations and communities. As medical educators, we must ensure that our students are able to provide individual and population-based preventive services competently, and that disease prevention and health promotion are valued and emphasized in all aspects of medical practice. This responsibility is fundamental to the educational mission of medical schools.

Are students learning about prevention currently? The Medical School Graduation Survey performed by the Association of American Medical Colleges (AAMC) indicates a steady increase in the proportion of graduates reporting that an “adequate” amount of time in the curriculum is spent on health promotion and disease prevention, from 54% in 1993 to 76% in 1997.⁴ Prevention is being taught in medical schools, in some cases very effectively. However, gaps do exist and some actions can be taken to address what is missing. David Garr points out that many medical schools indicate the desire to improve their teaching of prevention.⁵ Respondents to the Prevention Curriculum Assistance Project (PCAP) survey,⁶ sponsored by the Association of Teachers of Preventive Medicine (ATPM) and the Health Resources and Services Administration (HRSA), expressed interest in enhancing teaching about the health concerns of communities and giving students a better understanding of how our complex health care system works. These gaps fall within the content area of “population health.” The survey also points out that schools are not using particularly effective ways to evaluate their students for knowledge in and application of prevention and the population-based sciences. Prevention principles are being taught in many contexts, but most medical schools do not have curriculum-tracking systems adequate to allow them to track the delivery of education and training in disease prevention and health promotion.

One possible reason for this lack of knowledge regarding what is taught is the dynamic nature of medical education. McClary and Marantz⁷ reviewed AAMC Curriculum Directories for four academic years during the 1990s. Their review indicates that in the last decade more than 90 medical schools changed curricular structure from a “traditional” to “nontraditional” model, resulting in many significant changes in the placement and number of curricular hours devoted to health promotion and disease prevention content. A number of nontraditional curricular models included interdisciplinary courses. Some of these courses incorporated preventive medicine content, while others eliminated that content. Thus, preventive medicine and population health curricula in medical schools have become difficult to define and measure.

In 1945, the AAMC and the American Public Health Association (APHA) recommended that all medical schools have departments of preventive medicine to instruct all students in the basic disciplines of biostatistics, epidemiology, and environmental health.⁸ Since then, faculty in preventive medicine have taught these and other core skills in prevention to medical students. While departments or academic units of preventive medicine play an essential role, the teaching of prevention is not the exclusive domain of the prevention specialist. Rather, it is a shared responsibility and commitment of many different basic science and clinical disciplines, which can introduce and reinforce concepts in multiple contexts. The teaching of prevention can only be improved by taking advantage of the many opportunities for curriculum enhancement as they occur. An opportunity arises, for example, whenever a new lecture is being outlined, a case simulation is being conceptualized, or student evaluations are developed. Course directors frequently change as faculty teaching responsibilities shift. New leaders routinely should ask, “is prevention covered adequately in this course or clerkship?” Entire curricula are often being evaluated and revised—at any time about 10% of medical schools are undertaking major curricular changes.⁹ This kind of opportunity allows one to examine closely the prevention content across an entire curriculum and design a comprehensive and integrated approach. Faculty from all medical disciplines are continually striving to improve teaching methods and curriculum content. In that spirit, they must be vigilant for opportunities to incorporate prevention.

Like practitioners, educators are increasingly being held accountable for outcomes. The AAMC Medical School Objectives Project (MSOP), including the recent report that provides objectives in population health,^10,11 reinforces this trend. One important educational outcome is properly preparing our students to be “preventionists” regardless of specialty choice. In so doing, we are part of a bigger enterprise, improving the health of the public. Along with the MSOP, the AAMC and its member institutions have developed the Curriculum Management and Information Tool (CurrMIT), which will facilitate monitoring curricular structure and content, an essential step in achieving the educational objectives outlined below.¹² The joint medicine and public health initiative of the American Medical Association and the APHA reinforces the context for this notion.¹³ By taking advantage of current opportunities to enhance education and training in prevention, we will send graduates into the 21st century better prepared to keep their patients healthy and living longer and ultimately improve the health of the public.

This supplement highlights efforts being undertaken to improve undergraduate medical education by enhancing the teaching of disease prevention and health promotion. Experienced medical educators from many basic science and clinical disciplines have submitted articles. The authors were asked to address the subject of prevention from the perspectives of teaching in their respective fields. All educators can learn a great deal from the successes of these colleagues and adapt their teaching models and methods to fit local needs. Also, the supplement identifies numerous resources that teachers may find useful as tools to enhance curricula in disease prevention and health promotion.

ATPM-HRSA PARTNERSHIP

The Bureau of Health Professions of the Health Resources and Services Administration (HRSA), working in partnership with the Association of Teachers of Preventive Medicine (ATPM), has sponsored the publication of this supplement. Both HRSA and ATPM have histories of working to enhance the teaching of prevention in health professions education. These organizations have helped define the scope of prevention that educators must consider including in and integrating into medical curricula in response to the evolving needs of society and our health care system.

ATPM is the national professional association dedicated to advancing individual and community health promotion and disease prevention in the education of physicians and other health professionals. ATPM has individual members who are teachers, researchers, practitioners, administrators, residents, and students and institutional members such as departments of preventive medicine in medical schools, schools and graduate programs in public health, and various public health agencies. In keeping with its mission, ATPM collaborated with the Public Health Practice Program Office at the Centers for Disease Control and Prevention (CDC) in 1984 to produce An Inventory of Knowledge and Skills Relating to Disease Prevention and Health Promotion.¹⁴ This document summarized the input received from dozens of teachers and practitioners of clinical prevention. The Inventory was written as a guide for curriculum planners and was the subject of public discussion at the annual PREVENTION meeting in 1988 and 1989.

The Bureau of Health Professions at HRSA is the principal federal focus for health professions workforce development. Along with the CDC and the Office of Disease Prevention and Health Promotion, HRSA coordinated the “Prevention in Medical Education for the Year 2000” conference held in July 1995. ATPM and AAMC cosponsored the national conference with the purpose of identifying and developing “strategies which strengthen disease prevention and health promotion as integrated components of undergraduate medical education.” Out of this groundbreaking meeting, which was attended by deans and faculty from schools of medicine and representatives from graduate medical education programs, accrediting and examining bodies, specialty societies, managed care organizations, community health centers, and public health agencies, came a call to action and several significant recommendations (Table 1).

ATPM and HRSA have continued their relationship in order to actualize many of the recommendations of the “Year 2000” conference. In October 1997, these organizations convened a task force composed of medical educators from a broad array of basic science and clinical disciplines representing the nation's major medical teaching societies to review and update the Inventory. The membership of the multidisciplinary task force is listed in Table 2. For prevention content to be integrated throughout the entire medical curriculum, content guidelines must be relevant to teachers in diverse specialty areas. Therefore, individuals from many disciplines were invited to participate. Meeting participants not only updated the Inventory but also created a list of competencies that are essential from the perspective of each discipline and all disciplines. These “core competencies” are presented in Table 3. In a subsequent meeting held in September 1998, the task force outlined its plans for a publication/monograph to disseminate these core competencies and to illustrate model practices in medical education to ensure learners acquire these competencies. Those plans led to the publication of this supplement.

MSOP PROJECT

“Physicians must be altruistic … knowledgeable … skillful … dutiful.”¹⁰ The consensus of leaders in the medical education community is that society expects physicians to exhibit these four attributes in the practice of medicine.¹⁵ The AAMC convened a group of leaders in medical education, the Medical School Objectives Project (MSOP), to assist the AAMC in implementing the educational components of its strategic plan of 1996. The MSOP describes in broad terms the knowledge, attitudes, and skills students must master on the way to acquiring the desired attributes. Embodied in the attributes and outlined in the objectives are directives for medical educators to ensure that their students attend to the preventive and curative concerns of their patients. Future physicians are expected to understand the family, community, and cultural contexts in which their patients live. As each medical school strives to develop its own objectives, there will be an opportunity to ensure that the principles of prevention embodied in the MSOP report are translated into meaningful learning experiences for its students.

Report I of the MSOP has tremendous relevance to education in disease prevention and health promotion.¹⁰ Here are some specific examples for each of the attributes. Altruistic … “make decisions in the context of differing beliefs and values.” With Healthy People 2010 poised to focus on health disparities in the United States, this item is critical to fulfilling the nation's health objectives. Knowledgeable … “understand the scientific basis of medicine” and be prepared “to learn throughout their lives.” In anticipation of continued progress in applied prevention, these objectives are critical to sustain a positive trend in health improvement. Skillful … “in communication with patients and colleagues.” One of the most powerful tools in the preventionist's toolbox is the ability to engage in meaningful dialog with others about the value and importance of prevention. Dutiful … “to collaborate and use systematic approaches for promoting, maintaining and improving the health of individuals and populations.” These objectives address the need to teach students how to apply prevention in an interdisciplinary context. Teaching about prevention is not enough to accomplish this. Students must have learning experiences that show them how to apply prevention to patient care and in the community.

The MSOP has worked to develop recommendations in specific curricular areas. The MSOP Report II, published in June 1998, outlines specific objectives for Medical Informatics and Population Health.¹¹ In its section of the report, the Population Health Perspective Panel notes, “a population health perspective encompasses the ability to assess the health needs of a specific population, implement and evaluate interventions to improve the health of that population, and provide care for individual patients in the context of the culture, health status, and health needs of the populations of which that patient is a member.” The panel developed a specific list of recommendations that will lead to successful implementation of the population health objectives. These recommendations are listed in Table 4. Schools that are able to follow these recommendations can be confident that they are taking the steps necessary to assure that they teach “prevention” effectively.

CONTENT OF THE SUPPLEMENT

This supplement is divided into three sections to provide (1) an overview of the present context, so that deans and faculty can assess how prevention concepts are taught at their institutions and improve teaching of prevention through faculty development; (2) operational guidance for medical educators to teach the core competencies (contained in Table 3 of this article) as they apply in various clinical disciplines, and (3) information about key national initiatives and helpful resources for teaching and learning prevention.

The first section contains articles by Garr et al.⁵ and McClary and Marantz⁷ that examine the nature of current preventive medicine and population health teaching at schools of medicine. Blue et al.¹⁶ provide specific methods to evaluate prevention education, and Sachdeva¹⁷ presents essential elements of a faculty development program, including necessary institutional supports and mechanisms of an effective program.

The second section is composed of articles for teaching disease prevention and health promotion in schools of medicine from the perspectives of six disciplines: the behavioral sciences, family medicine, internal medicine, pediatrics, obstetrics—gynecology, and surgery. Each article includes the following elements relevant to the respective discipline: involvement in and responsibility for teaching prevention concepts; guidelines for the teaching of prevention and the relationship to the core competencies; methods of assessing current practices in the teaching of prevention; examples of “best teaching practices”; and challenges for teaching prevention and future directions to improve such teaching within the discipline. The authors employed various approaches to assess current practices. While some authors preferred literature reviews, most used electronically based communication tools such as listservs and e-mail groups.

A review of the articles reveals a number of common themes. First, most authors recommend that training and education in disease prevention and health promotion be integrated both vertically and horizontally across all four years of medical school. These authors observe that while various disciplines teach specific components of the core competencies, the absence of a unifying institutional frame-work results in teaching of prevention that is fragmented and duplicative, with underlying concepts and the importance of prevention often being lost. Second, nearly all the authors indicate that teaching in prevention occurs through diverse forms of instruction, from clinical and office settings to seminars and clinical rounds to problem-based and computer-assisted learning. Third, the authors recommend that the evaluation of prevention teaching and the measurement of prevention education outcomes need to be improved.

CONCLUSION

In the last decade, the importance of teaching preventive medicine and population-based medicine to all medical students has increased dramatically. The spotlight on generalism and on managed health care has reinforced the primacy of disease prevention and health promotion. The AAMC recommends that all medical schools teach students how to apply prevention. While increased attention has been given to prevention teaching throughout the medical disciplines, departments or academic units of preventive medicine can provide the unifying institutional framework to integrate prevention both vertically and horizontally throughout the medical education continuum. These departments have been teaching principles of prevention and population-based health for more than 50 years, including methods on how to apply prevention effectively.

Departments of preventive medicine continue to take advantage of innovative methods of teaching prevention, such as problem-based learning. The faculties within these departments have expertise in evaluation and outcomes research and are highly qualified to develop methods for measuring and evaluating performance of teaching in prevention. In these roles, departments of preventive medicine can serve as invaluable resources to schools of medicine. Furthermore, developing these departments as a pivotal element in creating a seamless and integrated approach for teaching and emphasizing disease prevention and health promotion at medical schools is a crucial step in educating physicians of the next century.