Beyond the Exam Room: A Call for Integrating Public Health Into Medical Education

Imagine a typical chronically ill patient who sees his doctor half an hour every three months. These four encounters each year—the physician's opportunity to counsel, diagnose, and treat—constitute only 0.02% of this patient's life. For all the rest—the 99.98% of the time that the patient is elsewhere, making decisions about his health in the context of his culture, family, and community—the doctor's impact on the patient's choices is minimal. Yet look at how narrowly we train doctors: four years of medical education focused almost entirely on what happens inside the exam room. Yes, those minutes are critical, but is it realistic to expect students to understand—from such a narrow perspective, in so little time—all the factors that affect their patients' lives? Have we prepared them to make sense of—much less influence—that critical 99.98%? That 99.98% belongs to community medicine, to population health, and to public health. Educators have already recognized the need to integrate more public and population health into medical education.1 In 2006, as part of an agreement between the Association of American Medical Colleges and the Centers for Disease Control and Prevention, 11 centers received funding to fully integrate population health into medical school curricula.1 More recently, the Liaison Committee on Medical Education added “public health sciences” to the requiredcurriculum (ED-11). Other U.S. institutions (e.g., the American Medical Association and the American Public Health Association2), as well as educators in Canada,3 have also advocated including more public health in training programs. These initiatives are an excellent start, yet in some ways they are not enough. Needs include addressing the differences between “public health” and “population health” (terms often used interchangeably) and ascertaining the competencies that we need to teach. Population health, often used to describe clinical preventive services measured at the level of the patient population or community, overlooks the policy, environmental, and social determinants of health that are critical components of public health. Many medical schools make a nod to concepts of epidemiology, environmental health, clinical preventive services, and community health. These are worthy topics, but for students to reach a fuller and more sophisticated understanding of the broad spectrum of public health, the curriculum must expand to include additional crucial interventions: changing social norms, creating healthy environments, developing public and private policy, and establishing laws that promote health. Take, for example, smoking—a true success story for public health. Public health policy led to higher tobacco taxes. Countermarketing campaigns helped change social norms, making smoking socially unacceptable to many. Clean indoor air laws created healthy environments and made lighting up inconvenient. Meanwhile, revised insurance policies covered nicotine replacement therapy, and solid evidence on the effectiveness of phone counseling for tobacco cessation led to the widespread creation of “quitlines,” providing management tools for clinicians and treatment options for patients. Through these interventions, the numbers of new smokers decreased, and current smokers' efforts to quit increased. Public health drove motivated individuals into the offices of prepared physicians. Patients benefited as a result of a comprehensive approach that operated within a social, legal, and policy framework. How well are we preparing tomorrow's doctors to address other high-priority health issues? Can we solve the obesity epidemic from within the exam room? Can anticipatory guidance improve the health of a child living within a food desert, in an environment where playing outside and walking to school are unsafe activities, where obesity is the norm? When we can alter public policy, social norms, and the environment, only then can we truly address the multiple factors that have created our obesogenic society. To prepare future physicians to be leaders in all aspects of health, we must give them tools that affect the underlying causes of illnesses. To do any less is to hamper their ability to improve patients' lives. Change takes time, but we cannot initiate change before we all agree on the broad scope of what public health entails. We should identify public health thinkers and innovative educators—partners from the fields of law, and public policy, from state and local health departments—with whom we can collaborate. We must also seek out model programs from within the United States and abroad. We should aim to embed and reinforce the public health model throughout the basic and clinical science years in medical school curricula, making sure students look beyond pathophysiology and traditional treatment options. Fostering a real attitudinal and philosophical paradigm shift will open up a whole realm of possibilities of causality and intervention, which will, in turn, have the greatest impact on the health of individuals and populations.

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