Implementation of a competency-based medical education approach in public health and epidemiology training of medical students

Implementation of a competency-based medical education approach in public health and epidemiology... Background: There is increasing agreement among medical educators regarding the importance of improving the integration between public health and clinical education, understanding and implementation of epidemiological methods, and the ability to critically appraise medical literature. The Sackler School of Medicine at Tel-Aviv University revised its public health and preventive medicine curriculum, during 2013–2014, according to the competency-based medical education (CBME) approach in training medical students. We describe the revised curriculum, which aimed to strengthen competencies in quantitative research methods, epidemiology, public health and preventive medicine, and health service organization and delivery. Methods: We report the process undertaken to establish a relevant 6-year longitudinal curriculum and describe its contents, implementation, and continuous assessment and evaluation. Results: Central competencies included: epidemiology and statistics for appraisal of the literature and implementation of research; the application of health promotion principles and health education strategies in disease prevention; the use of an evidence-based approach in clinical and public health decision making; the examination and analysis of disease trends at the population level; and knowledge of the structure of health systems and the role of the physician in these systems. Two new courses, in health promotion, and in public health, were added to the curriculum, and the courses in statistics and epidemiology were joined. Annual evaluation of each course results in continuous revisions of the syllabi as needed, while we continue to monitor the whole curriculum. Conclusions: The described revision in a 6 year-medical school training curriculum addresses the currently identified needs in public health. Ongoing feedback from students, and re-evaluation of syllabus by courses teams are held annually. Analysis of student’s written feedbacks and courses evaluations of “before and after” the implementation of this intervention is taking place to examine the effect of the new curriculum on the perceived clinical and research capacities of our 6-year students. Background Modern preventive medicine uses proactive interven- Among the profound changes that have occurred in the tions, surgery and chronic use of preventive medications. practice of medicine in the twenty-first century are Clinical reasoning and clinical decision-making have greater sophistication, high-technological dependence, a expanded from being almost exclusively based on deter- personalized approach and extreme increases in costs. ministic pathophysiological principles to include clinical and population-based evidence [1]. Current medical practice is also multi-disciplinary, mandating coordi- * Correspondence: racheld@gertner.health.gov.il nated teamwork. The need for stronger links between Unit for Cardiovascular Epidemiology, The Gertner Institute, Chaim Sheba Medical Center, Ramat Gan, Israel medicine and public health is ongoing, and includes the Department of Epidemiology and Preventive Medicine, School of Public need for a clinical and public health workforce trained Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel to collaborate in a multi-disciplinary environment [2, 3]. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 2 of 8 Increasingly complex epidemiological research methods methods in accordance with the competency-based require physicians to acquire broad competencies in re- medical education (CBME) approach [13]. This paper search methodologies and statistics to enable their crit- presents the process and recommendations of the ical appraisal of the literature when making clinical committee, which were approved and adopted by the decisions. Physicians’ use of evidence-based medicine teaching committee of the Tel Aviv Sackler Medical (EBM) has gained importance for weighing benefits and School, and implemented during the past 4 years. harms of clinical decisions such as relating to diagnoses, disease prognosis and intervention. Training medical students in public health In parallel to the above, many changes have occurred Awareness has grown over the past 2 decades, to the im- in medical education. Medical training has shifted from portance of the public health discipline to clinicians, and frontal teaching and an observer-apprentice approach to to the need to instill medical students with competencies a task oriented approach [4]. Recommendations of the in public health [14]. The Consensus Conference on 2010 Carnegie report, which are being implemented in Undergraduate Public Health Education advocated that the US and the UK, include for example, the need to all undergraduate medical students have access to an strengthen connections between formal and experiential education in public health [3]. The Association of knowledge across the continuum of medical education American Medical Colleges and The Healthy People [4]. In addition, up-to-date teaching should emphasize Curriculum Task Force published recommendations to an evidence-based approach that empowers the medical include a population health curriculum as part of the student to actively search, rank, appraise, interpret and 4 years of medical training [3]. The IOM has since called implement the evidence that is relevant to individual for the US public health system to evolve from a patients [5]. government-centered system to involve broad partner- Preventive medicine, which is often the most cost- ships with healthcare and other organizations in com- effective medical approach, has become mandatory, to munities [15, 16]. In the working document, restrain the increasing costs of chronic disease care. For ‘Tomorrow’s Doctors’ [17–19], the UK GMC recom- many years, public health was a marginalized low profile mended that medical school education include education discipline in medical education [6]. However, there is in disease prevention, sociological and psychological as- growing concern among medical schools of gaps in pects of health and disease, population health, scientific knowledge and competence of physicians in areas such research methods and critical appraisal of the literature as clinical preventive services, quantitative methods of [18]. Medical schools in the US and the UK have been risk and outcomes assessment, the practice of commu- placing greater emphasis on the teaching of clinical pre- nity medicine, and health services organization and de- vention and health promotion [3, 19]. The need to dedi- livery [7, 8]. Consequently, several organizations cate a specific curriculum for the aspects of how the including the Association of American Medical Colleges, health system functions and what the role of the clin- the Institute of Medicine (IOM), and the United King- ician in this system was recently recognized by the dom General Medical Council (GMC) have emphasized AMA educational consortium, which published a book the importance of undergraduate medical training in the on health systems science in medical education, calling field of public health [3, 9–11]. The effect of physician’s to bring forth the “third pillar”, which was until now health care practice on patients’ health care practice was “part of the hidden curriculum in medical education”, demonstrated in the positive relationship found between intertwining with the other two (traditional) pillars: basic physicians and patients in influenza vaccination rates science and clinical science [20]. The understanding of [12]. how physicians deliver care to patients, how patients re- The Sackler School of Medicine at Tel-Aviv University ceive care, and how health systems function, are recog- was founded in 1964 with the goal of educating highly nized as a pillar which necessitate medical students professional, knowledgeable and compassionate physi- training as part of the need to align medical education cians. In accordance with the above-mentioned with the ongoing changes in health care delivery. concerns, and as part of the implementation of a revised curriculum, a committee of medical doctor faculty Examples of changes over the last decades in the members who are board certified in public health and curricula of public health training in several medical experienced in epidemiological research, was convened schools around the world in 2012–2013. The task of the committee was to evalu- Competencies in statistics and epidemiology as tools for ate and update objectives for the public health curricu- conducting and understanding quantitative medical lum for medical students; to review and revise the research current curriculum; to introduce a revised curriculum in A historical view of statistics training was that physicians public health; and to introduce appropriate teaching need to know statistics primarily if they were conducting Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 3 of 8 or going to conduct research during their medical car- curriculum. Descriptive epidemiology is taught in the eer; and when conducting research, they could generally first year, analytic epidemiology in the second year and rely on professional consultation with statisticians [21]. clinical epidemiology in the third and fourth years. Simi- Nowadays, physicians use statistics and probability larly, the basic structure of the healthcare system is methods for a wide range of activities [22]. Statistics and taught in the first year; then a project involving related competencies are used in daily clinical practice organization of community-based services in the second for understanding the validity and precision of study re- year; quality improvement and patient safety in the third sults, explaining risk to patients, comparing treatment year; and the effect of physicians’ payment systems on protocols and outcomes, interpreting the relevance and quality of patient care in the fourth year. After the implications of diagnostic test results, interacting with change in the organization of the course material into drug representatives and reading pharmaceutical litera- the longitudinal curriculum with no change in the num- ture [10]. Physicians need to be capable of interpreting ber of hours of learning, the ranking of the University of clinical epidemiology data and of understanding the lim- Toronto’s training in public health improved and be- itations of research and statistical inference. The sophis- came number one among all medical schools in Canada. ticated statistical methods that are used in an increasing number of studies necessitate good understanding of Evidence based medicine statistics to appraise the scientific literature. Surveys The early introduction of EBM in medical schools has conducted in various countries show a need for improv- been effective in changing the thought process of the ing skills of epidemiological research, statistical inference medical graduates. It was also found to increase the abil- and data analysis among physicians and medical ity for logical and critical appraisal, better suited for the students [23–26]. Almost half of UK physicians who understanding of the disease process and subsequent responded to a questionnaire felt that statistics training management [28]. In England, a six-week full time did not seem useful during their attendance at medical course linking EBM with ethics and the management of school; however, 73% felt that statistics were relevant to change in health services was introduced for third-year their subsequent careers and that teaching statistics undergraduate medical students in Imperial College should include lectures, seminars and problem-based London [29]. The students undertook projects such as practical exercises [10]. The authors recommended that hand washing in a neonatal unit to prevent infections, statistical training should start early and continue drug monitoring in the elderly to reduce the risk of falls, throughout medical school; and be presented at an and the use of peak flow meters in the management of understandable level, which is practical and integrated asthma. The course supported the notion that under- with other subject areas [10]. graduates and junior clinical students can adopt and During the 1960’s at Harvard Medical School there promote significant changes that make clinical care was a long-running required Biostatistics course. By the more evidence-based. 1970s there was an elective course, taken by a third of the class that was called, “Introduction to Biostatistics Health promotion and Epidemiology.” By the early 1980s a clinical-decision Health Promotion is a resource for theoretical know- making course was added; and today that same course ledge and practical skills in health issues, such as sexual would be called “Evidence Based Medicine” (EBM). In health, nutrition, physical activity, exercise and fitness, the last decade, Harvard Medical School implemented a weight control, and alcohol and tobacco control. In course for first-year medical and dental students entitled 2010, less than half of the schools in the UK included “Clinical Epidemiology and Population Health” [9]. The sports and exercise medicine as part of their curriculum. objectives of the course were to instill knowledge in King’s College London introduced exercise medicine, basic epidemiology and biostatistics, causal inference, which focused on the health benefits of physical activity, confounding and other issues related to research inter- the doctor’s role in assessing and prescribing physical pretation, decision making and skills for clinical and activity, and the physiological adaptations and risks of population-level interventions, health promotion and be- physical activity [30]. The intervention significantly havior change strategies, physicians’ roles in the public improved the confidence of preclinical medical students health system and population level surveillance. in their ability to counsel patients on the health benefits A few years ago, the University of Toronto initiated a of physical activity, as well as their knowledge of recom- 4 year course for undergraduate medical students, which mended physical activity guidelines [30]. Medical stu- broke down the barrier between the pre-clerkship period dents who underwent obesity intervention education and clinical clerkships [27]. Based on a longitudinal, scored higher on relevant knowledge, had more self- “spiral” curriculum, the course revisits educational con- confidence in physical activity and nutrition counseling, cepts at increasing levels of complexity across the and took more waist-hip measurements [31]. In a Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 4 of 8 community health center serving a Latino immigrant  Skills to appraise the quality of the various types of population in the United States, a 9-month pilot course epidemiologic research and to acquire tools for for medical students that combined didactic instruction comprehensive reading and understanding scientific in the social determinants of health with practical ex- literature according to EBM; perience in developing, implementing and evaluating an  Competency in efficient and precise literature intervention was shown to be feasible and effective [32]. search; Summarizing the above, the urgent need to strengthen  Competency in basic statistical skills; the education of medical students in the field of epi-  Competency in planning and conducting research, demiology and public health in an integrative manner i.e. knowledge of epidemiological methods including during the pre-clinical and clinical years, has become the various study designs, choice of an appropriate evident in many countries and action has been taken. study population, methods for data collection, Several challenges have had to be met, including the analysis and interpretation of study results; “old” perception that this topic is of little relevance to  Competency in applying health promoting principles clinical practice, low funding, low institutional priority and strategies in the selection of disease prevention and the competition with other traditional fields (e.g. measures and recommendations; anatomy, physiology, biochemistry and histology) [33].  Competency in implementation of EBM techniques Nonetheless, recognition of the importance of this field in public health decision making, e.g. immunizations has increased dramatically [34]. and population screening; and Competency in examining and analyzing disease trends from a population perspective. Findings and insights In addition, we identified the importance of The experience of Sackler Faculty of Medicine in the adoption understanding the structure of health systems and of implementation and evaluation of competency-based medical increasing the awareness of the role of the physician education in public health in these systems as a means of better pursuing the A committee was appointed in 2012 to propose a skill of practicing and advocating health promotion competencies oriented curriculum in public health for and disease prevention in the clinic. medical students. Our form of action was multistep, much like the Situational Model [35] starting with Identifying gaps and needs to meet the required mapping the courses provided by our department (the competencies The committee performed an overview of department for Epidemiology and Preventive Medicine) all relevant education and training syllabus at the Sackler to the curriculum of the 6-year medical training. In par- School of Medicine of the Tel-Aviv University. All lec- allel, we defined the required competencies, expected tures in each course were reviewed and overlapping from a medical student and a clinician, in public health. topics given in more than one lecture were identified. We then looked into each course syllabus and pointed at This process also enabled detecting important topics gaps as well as overlaps between courses. Finally, we that were absent in the curriculum. The committee met proposed a revised curriculum in public health that in- all teachers and instructors and reviewed the courses corporates all of our conclusions and suggestions. This syllabus with them. Those with overlapping lectures was presented to the Faculty of Medicine’s Educational were asked to meet and revise their courses so that no Committee and approved by the Dean after adjustments unnecessary overlaps persisted. Two new courses were were made according to the Faculty’s constraints. We planned to fill in the gaps in important topics. The en- continuously review the courses’ evaluations students tire 6 year curriculum was presented and approved, first voluntarily and anonymously fill in the Web-based to the faculty of the School of Public Health, and then to university portal, and modify the courses accordingly. the faculty of Sackler School of Medicine (see Table 1). Implementing the competency –based medical edu- Defining the required competencies The committee cation approach The new public health curriculum in defined 3 main goals of training of medical students our medical school is based on a longitudinal approach according to their future needs and responsibilities: a) and was designed to harmonize and integrate the clinical critical appraisal of the scientific literature to inform and public health teaching to increase relevance, and to practice; b) conducting research using epidemiological address the above-mentioned competencies. The public tools and methods; and c) practicing and advocating health curriculum starts early in the first year of medical health promotion and disease prevention in the clinic. school and progresses systematically, with each year Following these goals the main competencies physicians building on competencies already gained. The goal is ef- require were defined: ficient utilization of time and avoidance of repetitions. Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 5 of 8 The limited timeframe allocated to public health training highlighting the relevance of these two disciplines to within the busy and competitive medical school curricu- the understanding and interpretation of medical data. lum is a constraint of the program. 2. Health promotion: The physician’s role (2nd year): The courses and skills provided in the longitudinal This is one of two courses initiated following the public-health curriculum as part of the 6 year medical committee’s detection of gaps in training medical training of the Sackler Medical School are the following students. Using epidemiological concepts and terms (see Fig. 1, illustrating the concept that epidemiology acquired during the first year, students are and statistics are the foundation, and are given a sub- introduced to the main concepts, principles, and stantial number of hours in the curriculum, on which methods of health promotion at the individual and medical students are gradually building their public population levels. Students practice communicating health knowledge, with the number of hours gradually and marketing healthy lifestyle to patients and gain decreasing yet the topics learned are more sophisticated, knowledge of the impact of a health promoting so that in their last year a relatively smaller, albeit very environment (e.g. media campaigns, regulatory tools important, part of the clerkships will draw on this at the local and the national levels) on adoption of a learning): healthy lifestyle. The course started as an 8-week short course but was broadened during the year 1. Epidemiology, statistics, and research methods (1st 2015–2016, to include three sessions on exercise and year): this course was re-designed to achieve a physical activity: the approach to medical examinations comprehensive and integrative understanding of key before starting a physical activity program in healthy epidemiologic and biostatistics methods. The goals and diseased patients; the responsibility of the of the course are to improve students’ abilities to physician to evaluate the level of physical activity of understand and interpret epidemiological studies their patients and to encourage them to exercise and to provide practical experience in epidemiological (Hoffman, et al. 2016); and the comprehensive physical research, study design, and key methods in biostatistics. activity prescription, which is a required responsibility Topics covered in the course include: the ability to of physicians to be provided to each of their patients integrate information and data, build statistical models, who enters an exercise program (Joy, et al. 2016). This conduct data analysis, and acquire tools for decision last session includes the students’ writing their own making in selecting diagnostic tools and treatment exercise prescription and a practical experience in protocols. Also emphasized are implementation of training according to this prescription. An additional statistical and epidemiological tools for understanding topic is a two lecture session in oral hygiene and its disease risk and prevention, etiology and prognosis, and association to systemic diseases and medications. evaluating the success and clinical relevance of 3. Selected paradigms in epidemiology and public preventive interventions. The fundamentals of health (3rd year): Following the basic course in biostatistics and epidemiology are taught together, epidemiology and biostatistics in the first year, this Table 1 The curricula before and after implementation of the revisions according to the year of medical school Year Before After Course name Total number Course name Total number of hours of hours 1 Statistics 78 Epidemiology, Statistics, and Research methods 104 2 Epidemiology 39 –– 2–– Health promotion: The physician’s role 26 3 Evidence-Based Medicine (EBM) 16 Tools for practicing evidence based medicine 16 3–– Selected paradigms in epidemiology and public health 32 3 Use of epidemiologic methods in 10 Use of epidemiologic methods in clinical decision making 12 clinical decision making 4–– E-learning course in planning and writing research proposals 4 for the M.D. thesis 5 Principles in planning and writing 6 Personal meeting with the M.D. students to critically review 30 min a research proposal their proposal for an M.D. thesis 6 Clerkship in public health and 36 Clerkship in public health and epidemiology 36 epidemiology Total Hours 185 Total Hours 230.5 Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 6 of 8 Fig. 1 Pyramid of the Public Health curriculum intensive one-week course gives an overview of the presented from body systems such as the epidemiology of specific diseases and conditions gastrointestinal and urinary tracts. The course is such as cancer, cardiovascular disease, diabetes, intended to reinforce skills covered in the first year, infectious diseases, geriatric and childhood diseases, while exploiting the advanced stage attained in the maternal and child health, and psychiatric illnesses. students’ basic medical knowledge. The course emphasizes the specific methodologies 6. E-learning course in planning and writing research used for the study of these illnesses and conditions proposals for the M.D. thesis (4th - 6th year): This and presents the specific disease registries available. electronic course is designed to provide students The second part of the course focuses on the with the necessary competencies to develop research national health system, and aims to elucidate the questions and to formulate the research role of the clinician as a public health promoter in methodology relevant to their MD thesis. The the national health system. The paradigm of course is built on the knowledge and capabilities of combining health policy with clinical decision implementing the competencies taught during making is emphasized, using relevant and timely previous years; and it is presented through a set of examples. online guided tools. 4. Tools for practicing Evidence Based Medicine (EBM) 7. Clerkship in public health and epidemiology (6th (3rd year): Tools and techniques are provided for year): Experiential learning in EBM in public health. practicing EBM, by means of workshops and During this 1 week interactive workshop the simulations of real life situations. At the end of the students experience the implementation of course, the student should be able to frame a clinical epidemiological tools from data collection and question in view of a specific clinical situation, analysis to public health planning and decision search the medical literature, obtain the most making. The course includes practical examples such relevant material, and critically appraise the as prevention of cervical cancer or the literature so as to achieve the best available solution implementation of various programs for secondary to the clinical question. This course reinforces the prevention of breast cancer and their impact on competencies provided in the first and second years breast cancer mortality. As in other clinical and requires the student to apply them. clerkships, the students experience the process of 5. The use of epidemiologic methods in clinical decision making. In this case it relates to decisions decision making (3rd year): This course provides the in public health. At this stage, just before epidemiological background to the major body graduation, the students have most of the medical organs and systems taught in the third and fourth knowledge they will acquire during their MD degree. years, while focusing on how epidemiology is used They have the ability to use clinical and for clinical decision-making. Specific examples are epidemiological competencies to understand the Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 7 of 8 broad range of considerations involved in health Our intended outcome is that medical school gradu- policy at the individual and population levels. ates will be curious and have the motivation and compe- tencies to obtain the evidence based information they Program evaluation The revised public health curricu- need to provide scientifically sound care to their pa- lum was implemented with first year students during tients; that they will have the skills to conduct research 2013–2016/17. We have been revising and refining the and for critically evaluating existing evidence; and that courses of the first, second and third years according to they will maximize their role in disease prevention and feedback from students and lecturers. All courses in our healthy lifestyle promotion. By having developed a longi- school have a computerized feedback system, which is tudinal exposure for students, they are reminded at all opened from the last lecture till the final exam, and is stages of their medical education about the importance filled on a voluntary anonymous basis. In addition, and relevance of the sciences as the basis of medical meetings are held with the students’ representatives to knowledge and evidence as the basis for better medical discuss their expectations and feedback, and an attempt care, prevention, and public health. to integrate necessary changes in the courses is Acknowledgements continuously performed. In the coming academic year This paper was written in memory of the late Prof. Leon (Levi) Gordis, a (2017–18) the last class from the old curriculum will distinguished epidemiologist with an international reputation, who taught in the Sackler School of Public Health and the Sackler School of Medicine graduate. At the end of this year we will conduct a sur- during his last years, and mentored faculty members of our school. vey among these students during the clerkship in public health to evaluate their perceived understanding of pub- Funding None. lic health topics and of the competencies we intended to convey in our curriculum. We will repeat this survey Disclosures among the following class – the first to experience the No financial disclosures were reported by the authors of this paper. full 6-years revised curriculum, and compare the results. Authors’ contributions In the future we intend to assess the quality of MD the- RD lead the committee and the writting of the manuscript. UG was a ses submitted at graduation, according to exposure to member of the committee and took part in writting the manuscript. LL conceived the program, nominated the committee and took part in writting the intervention, and to compare evaluations of EBM the manuscript. MS took part in writting the manuscript. SS was a member skills during clinical clerkships. We expect more MD of the committee and took part in writting the manuscript. All authors read theses to be published as papers in peer-reviewed and approved the final manuscript. international journals. Ethics approval and consent to participate Not applicable. Conclusions Competing interests Public Health topics have been taught by the Division of The authors declare that they have no competing interests. Epidemiology and Preventive Medicine ever since the Sackler School of Medicine was established. The cur- Publisher’sNote riculum evolved over the years “bottoms up” and when a Springer Nature remains neutral with regard to jurisdictional claims in decision was made to implement a Competency Ori- published maps and institutional affiliations. ented approach to the medical curriculum at large we Author details revised our curriculum. The Sackler School of Medicine 1 Unit for Cardiovascular Epidemiology, The Gertner Institute, Chaim Sheba committee re-designed a comprehensive curriculum in Medical Center, Ramat Gan, Israel. Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel epidemiology and public health, which covers the range Aviv University, Tel Aviv, Israel. Quality Unit, Rabin Medical Center, Petah of topics central for current medical students’ education 4 Tikva, Israel. Department of Medicine E, Beilinson Hospital, Rabin Medical in those fields. Among its goals, the revised curriculum Center, Petah-Tiqva, Israel. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Cancer & Radiation Epidemiology Unit, Gertner Institute, focuses on competencies required to critically appraise Chaim Sheba Medical Center, Ramat Gan, Israel. medical scientific literature. 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Am J Prev Med. 2011;41:S176–80. � Inclusion in PubMed and all major indexing services 28. Sánchez-Mendiola M, Kieffer-Escobar LF, Marín-Beltrán S, Downing SM, � Maximum visibility for your research Schwartz A. Teaching of evidence-based medicine to medical students in Mexico: a randomized controlled trial. BMC Med Educ. 2012;12:107. https:// Submit your manuscript at doi.org/10.1186/1472-6920-12-107. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Israel Journal of Health Policy Research Springer Journals

Implementation of a competency-based medical education approach in public health and epidemiology training of medical students

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Medicine & Public Health; Medicine/Public Health, general; Health Administration; Health Promotion and Disease Prevention; Social Policy
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Abstract

Background: There is increasing agreement among medical educators regarding the importance of improving the integration between public health and clinical education, understanding and implementation of epidemiological methods, and the ability to critically appraise medical literature. The Sackler School of Medicine at Tel-Aviv University revised its public health and preventive medicine curriculum, during 2013–2014, according to the competency-based medical education (CBME) approach in training medical students. We describe the revised curriculum, which aimed to strengthen competencies in quantitative research methods, epidemiology, public health and preventive medicine, and health service organization and delivery. Methods: We report the process undertaken to establish a relevant 6-year longitudinal curriculum and describe its contents, implementation, and continuous assessment and evaluation. Results: Central competencies included: epidemiology and statistics for appraisal of the literature and implementation of research; the application of health promotion principles and health education strategies in disease prevention; the use of an evidence-based approach in clinical and public health decision making; the examination and analysis of disease trends at the population level; and knowledge of the structure of health systems and the role of the physician in these systems. Two new courses, in health promotion, and in public health, were added to the curriculum, and the courses in statistics and epidemiology were joined. Annual evaluation of each course results in continuous revisions of the syllabi as needed, while we continue to monitor the whole curriculum. Conclusions: The described revision in a 6 year-medical school training curriculum addresses the currently identified needs in public health. Ongoing feedback from students, and re-evaluation of syllabus by courses teams are held annually. Analysis of student’s written feedbacks and courses evaluations of “before and after” the implementation of this intervention is taking place to examine the effect of the new curriculum on the perceived clinical and research capacities of our 6-year students. Background Modern preventive medicine uses proactive interven- Among the profound changes that have occurred in the tions, surgery and chronic use of preventive medications. practice of medicine in the twenty-first century are Clinical reasoning and clinical decision-making have greater sophistication, high-technological dependence, a expanded from being almost exclusively based on deter- personalized approach and extreme increases in costs. ministic pathophysiological principles to include clinical and population-based evidence [1]. Current medical practice is also multi-disciplinary, mandating coordi- * Correspondence: racheld@gertner.health.gov.il nated teamwork. The need for stronger links between Unit for Cardiovascular Epidemiology, The Gertner Institute, Chaim Sheba Medical Center, Ramat Gan, Israel medicine and public health is ongoing, and includes the Department of Epidemiology and Preventive Medicine, School of Public need for a clinical and public health workforce trained Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel to collaborate in a multi-disciplinary environment [2, 3]. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 2 of 8 Increasingly complex epidemiological research methods methods in accordance with the competency-based require physicians to acquire broad competencies in re- medical education (CBME) approach [13]. This paper search methodologies and statistics to enable their crit- presents the process and recommendations of the ical appraisal of the literature when making clinical committee, which were approved and adopted by the decisions. Physicians’ use of evidence-based medicine teaching committee of the Tel Aviv Sackler Medical (EBM) has gained importance for weighing benefits and School, and implemented during the past 4 years. harms of clinical decisions such as relating to diagnoses, disease prognosis and intervention. Training medical students in public health In parallel to the above, many changes have occurred Awareness has grown over the past 2 decades, to the im- in medical education. Medical training has shifted from portance of the public health discipline to clinicians, and frontal teaching and an observer-apprentice approach to to the need to instill medical students with competencies a task oriented approach [4]. Recommendations of the in public health [14]. The Consensus Conference on 2010 Carnegie report, which are being implemented in Undergraduate Public Health Education advocated that the US and the UK, include for example, the need to all undergraduate medical students have access to an strengthen connections between formal and experiential education in public health [3]. The Association of knowledge across the continuum of medical education American Medical Colleges and The Healthy People [4]. In addition, up-to-date teaching should emphasize Curriculum Task Force published recommendations to an evidence-based approach that empowers the medical include a population health curriculum as part of the student to actively search, rank, appraise, interpret and 4 years of medical training [3]. The IOM has since called implement the evidence that is relevant to individual for the US public health system to evolve from a patients [5]. government-centered system to involve broad partner- Preventive medicine, which is often the most cost- ships with healthcare and other organizations in com- effective medical approach, has become mandatory, to munities [15, 16]. In the working document, restrain the increasing costs of chronic disease care. For ‘Tomorrow’s Doctors’ [17–19], the UK GMC recom- many years, public health was a marginalized low profile mended that medical school education include education discipline in medical education [6]. However, there is in disease prevention, sociological and psychological as- growing concern among medical schools of gaps in pects of health and disease, population health, scientific knowledge and competence of physicians in areas such research methods and critical appraisal of the literature as clinical preventive services, quantitative methods of [18]. Medical schools in the US and the UK have been risk and outcomes assessment, the practice of commu- placing greater emphasis on the teaching of clinical pre- nity medicine, and health services organization and de- vention and health promotion [3, 19]. The need to dedi- livery [7, 8]. Consequently, several organizations cate a specific curriculum for the aspects of how the including the Association of American Medical Colleges, health system functions and what the role of the clin- the Institute of Medicine (IOM), and the United King- ician in this system was recently recognized by the dom General Medical Council (GMC) have emphasized AMA educational consortium, which published a book the importance of undergraduate medical training in the on health systems science in medical education, calling field of public health [3, 9–11]. The effect of physician’s to bring forth the “third pillar”, which was until now health care practice on patients’ health care practice was “part of the hidden curriculum in medical education”, demonstrated in the positive relationship found between intertwining with the other two (traditional) pillars: basic physicians and patients in influenza vaccination rates science and clinical science [20]. The understanding of [12]. how physicians deliver care to patients, how patients re- The Sackler School of Medicine at Tel-Aviv University ceive care, and how health systems function, are recog- was founded in 1964 with the goal of educating highly nized as a pillar which necessitate medical students professional, knowledgeable and compassionate physi- training as part of the need to align medical education cians. In accordance with the above-mentioned with the ongoing changes in health care delivery. concerns, and as part of the implementation of a revised curriculum, a committee of medical doctor faculty Examples of changes over the last decades in the members who are board certified in public health and curricula of public health training in several medical experienced in epidemiological research, was convened schools around the world in 2012–2013. The task of the committee was to evalu- Competencies in statistics and epidemiology as tools for ate and update objectives for the public health curricu- conducting and understanding quantitative medical lum for medical students; to review and revise the research current curriculum; to introduce a revised curriculum in A historical view of statistics training was that physicians public health; and to introduce appropriate teaching need to know statistics primarily if they were conducting Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 3 of 8 or going to conduct research during their medical car- curriculum. Descriptive epidemiology is taught in the eer; and when conducting research, they could generally first year, analytic epidemiology in the second year and rely on professional consultation with statisticians [21]. clinical epidemiology in the third and fourth years. Simi- Nowadays, physicians use statistics and probability larly, the basic structure of the healthcare system is methods for a wide range of activities [22]. Statistics and taught in the first year; then a project involving related competencies are used in daily clinical practice organization of community-based services in the second for understanding the validity and precision of study re- year; quality improvement and patient safety in the third sults, explaining risk to patients, comparing treatment year; and the effect of physicians’ payment systems on protocols and outcomes, interpreting the relevance and quality of patient care in the fourth year. After the implications of diagnostic test results, interacting with change in the organization of the course material into drug representatives and reading pharmaceutical litera- the longitudinal curriculum with no change in the num- ture [10]. Physicians need to be capable of interpreting ber of hours of learning, the ranking of the University of clinical epidemiology data and of understanding the lim- Toronto’s training in public health improved and be- itations of research and statistical inference. The sophis- came number one among all medical schools in Canada. ticated statistical methods that are used in an increasing number of studies necessitate good understanding of Evidence based medicine statistics to appraise the scientific literature. Surveys The early introduction of EBM in medical schools has conducted in various countries show a need for improv- been effective in changing the thought process of the ing skills of epidemiological research, statistical inference medical graduates. It was also found to increase the abil- and data analysis among physicians and medical ity for logical and critical appraisal, better suited for the students [23–26]. Almost half of UK physicians who understanding of the disease process and subsequent responded to a questionnaire felt that statistics training management [28]. In England, a six-week full time did not seem useful during their attendance at medical course linking EBM with ethics and the management of school; however, 73% felt that statistics were relevant to change in health services was introduced for third-year their subsequent careers and that teaching statistics undergraduate medical students in Imperial College should include lectures, seminars and problem-based London [29]. The students undertook projects such as practical exercises [10]. The authors recommended that hand washing in a neonatal unit to prevent infections, statistical training should start early and continue drug monitoring in the elderly to reduce the risk of falls, throughout medical school; and be presented at an and the use of peak flow meters in the management of understandable level, which is practical and integrated asthma. The course supported the notion that under- with other subject areas [10]. graduates and junior clinical students can adopt and During the 1960’s at Harvard Medical School there promote significant changes that make clinical care was a long-running required Biostatistics course. By the more evidence-based. 1970s there was an elective course, taken by a third of the class that was called, “Introduction to Biostatistics Health promotion and Epidemiology.” By the early 1980s a clinical-decision Health Promotion is a resource for theoretical know- making course was added; and today that same course ledge and practical skills in health issues, such as sexual would be called “Evidence Based Medicine” (EBM). In health, nutrition, physical activity, exercise and fitness, the last decade, Harvard Medical School implemented a weight control, and alcohol and tobacco control. In course for first-year medical and dental students entitled 2010, less than half of the schools in the UK included “Clinical Epidemiology and Population Health” [9]. The sports and exercise medicine as part of their curriculum. objectives of the course were to instill knowledge in King’s College London introduced exercise medicine, basic epidemiology and biostatistics, causal inference, which focused on the health benefits of physical activity, confounding and other issues related to research inter- the doctor’s role in assessing and prescribing physical pretation, decision making and skills for clinical and activity, and the physiological adaptations and risks of population-level interventions, health promotion and be- physical activity [30]. The intervention significantly havior change strategies, physicians’ roles in the public improved the confidence of preclinical medical students health system and population level surveillance. in their ability to counsel patients on the health benefits A few years ago, the University of Toronto initiated a of physical activity, as well as their knowledge of recom- 4 year course for undergraduate medical students, which mended physical activity guidelines [30]. Medical stu- broke down the barrier between the pre-clerkship period dents who underwent obesity intervention education and clinical clerkships [27]. Based on a longitudinal, scored higher on relevant knowledge, had more self- “spiral” curriculum, the course revisits educational con- confidence in physical activity and nutrition counseling, cepts at increasing levels of complexity across the and took more waist-hip measurements [31]. In a Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 4 of 8 community health center serving a Latino immigrant  Skills to appraise the quality of the various types of population in the United States, a 9-month pilot course epidemiologic research and to acquire tools for for medical students that combined didactic instruction comprehensive reading and understanding scientific in the social determinants of health with practical ex- literature according to EBM; perience in developing, implementing and evaluating an  Competency in efficient and precise literature intervention was shown to be feasible and effective [32]. search; Summarizing the above, the urgent need to strengthen  Competency in basic statistical skills; the education of medical students in the field of epi-  Competency in planning and conducting research, demiology and public health in an integrative manner i.e. knowledge of epidemiological methods including during the pre-clinical and clinical years, has become the various study designs, choice of an appropriate evident in many countries and action has been taken. study population, methods for data collection, Several challenges have had to be met, including the analysis and interpretation of study results; “old” perception that this topic is of little relevance to  Competency in applying health promoting principles clinical practice, low funding, low institutional priority and strategies in the selection of disease prevention and the competition with other traditional fields (e.g. measures and recommendations; anatomy, physiology, biochemistry and histology) [33].  Competency in implementation of EBM techniques Nonetheless, recognition of the importance of this field in public health decision making, e.g. immunizations has increased dramatically [34]. and population screening; and Competency in examining and analyzing disease trends from a population perspective. Findings and insights In addition, we identified the importance of The experience of Sackler Faculty of Medicine in the adoption understanding the structure of health systems and of implementation and evaluation of competency-based medical increasing the awareness of the role of the physician education in public health in these systems as a means of better pursuing the A committee was appointed in 2012 to propose a skill of practicing and advocating health promotion competencies oriented curriculum in public health for and disease prevention in the clinic. medical students. Our form of action was multistep, much like the Situational Model [35] starting with Identifying gaps and needs to meet the required mapping the courses provided by our department (the competencies The committee performed an overview of department for Epidemiology and Preventive Medicine) all relevant education and training syllabus at the Sackler to the curriculum of the 6-year medical training. In par- School of Medicine of the Tel-Aviv University. All lec- allel, we defined the required competencies, expected tures in each course were reviewed and overlapping from a medical student and a clinician, in public health. topics given in more than one lecture were identified. We then looked into each course syllabus and pointed at This process also enabled detecting important topics gaps as well as overlaps between courses. Finally, we that were absent in the curriculum. The committee met proposed a revised curriculum in public health that in- all teachers and instructors and reviewed the courses corporates all of our conclusions and suggestions. This syllabus with them. Those with overlapping lectures was presented to the Faculty of Medicine’s Educational were asked to meet and revise their courses so that no Committee and approved by the Dean after adjustments unnecessary overlaps persisted. Two new courses were were made according to the Faculty’s constraints. We planned to fill in the gaps in important topics. The en- continuously review the courses’ evaluations students tire 6 year curriculum was presented and approved, first voluntarily and anonymously fill in the Web-based to the faculty of the School of Public Health, and then to university portal, and modify the courses accordingly. the faculty of Sackler School of Medicine (see Table 1). Implementing the competency –based medical edu- Defining the required competencies The committee cation approach The new public health curriculum in defined 3 main goals of training of medical students our medical school is based on a longitudinal approach according to their future needs and responsibilities: a) and was designed to harmonize and integrate the clinical critical appraisal of the scientific literature to inform and public health teaching to increase relevance, and to practice; b) conducting research using epidemiological address the above-mentioned competencies. The public tools and methods; and c) practicing and advocating health curriculum starts early in the first year of medical health promotion and disease prevention in the clinic. school and progresses systematically, with each year Following these goals the main competencies physicians building on competencies already gained. The goal is ef- require were defined: ficient utilization of time and avoidance of repetitions. Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 5 of 8 The limited timeframe allocated to public health training highlighting the relevance of these two disciplines to within the busy and competitive medical school curricu- the understanding and interpretation of medical data. lum is a constraint of the program. 2. Health promotion: The physician’s role (2nd year): The courses and skills provided in the longitudinal This is one of two courses initiated following the public-health curriculum as part of the 6 year medical committee’s detection of gaps in training medical training of the Sackler Medical School are the following students. Using epidemiological concepts and terms (see Fig. 1, illustrating the concept that epidemiology acquired during the first year, students are and statistics are the foundation, and are given a sub- introduced to the main concepts, principles, and stantial number of hours in the curriculum, on which methods of health promotion at the individual and medical students are gradually building their public population levels. Students practice communicating health knowledge, with the number of hours gradually and marketing healthy lifestyle to patients and gain decreasing yet the topics learned are more sophisticated, knowledge of the impact of a health promoting so that in their last year a relatively smaller, albeit very environment (e.g. media campaigns, regulatory tools important, part of the clerkships will draw on this at the local and the national levels) on adoption of a learning): healthy lifestyle. The course started as an 8-week short course but was broadened during the year 1. Epidemiology, statistics, and research methods (1st 2015–2016, to include three sessions on exercise and year): this course was re-designed to achieve a physical activity: the approach to medical examinations comprehensive and integrative understanding of key before starting a physical activity program in healthy epidemiologic and biostatistics methods. The goals and diseased patients; the responsibility of the of the course are to improve students’ abilities to physician to evaluate the level of physical activity of understand and interpret epidemiological studies their patients and to encourage them to exercise and to provide practical experience in epidemiological (Hoffman, et al. 2016); and the comprehensive physical research, study design, and key methods in biostatistics. activity prescription, which is a required responsibility Topics covered in the course include: the ability to of physicians to be provided to each of their patients integrate information and data, build statistical models, who enters an exercise program (Joy, et al. 2016). This conduct data analysis, and acquire tools for decision last session includes the students’ writing their own making in selecting diagnostic tools and treatment exercise prescription and a practical experience in protocols. Also emphasized are implementation of training according to this prescription. An additional statistical and epidemiological tools for understanding topic is a two lecture session in oral hygiene and its disease risk and prevention, etiology and prognosis, and association to systemic diseases and medications. evaluating the success and clinical relevance of 3. Selected paradigms in epidemiology and public preventive interventions. The fundamentals of health (3rd year): Following the basic course in biostatistics and epidemiology are taught together, epidemiology and biostatistics in the first year, this Table 1 The curricula before and after implementation of the revisions according to the year of medical school Year Before After Course name Total number Course name Total number of hours of hours 1 Statistics 78 Epidemiology, Statistics, and Research methods 104 2 Epidemiology 39 –– 2–– Health promotion: The physician’s role 26 3 Evidence-Based Medicine (EBM) 16 Tools for practicing evidence based medicine 16 3–– Selected paradigms in epidemiology and public health 32 3 Use of epidemiologic methods in 10 Use of epidemiologic methods in clinical decision making 12 clinical decision making 4–– E-learning course in planning and writing research proposals 4 for the M.D. thesis 5 Principles in planning and writing 6 Personal meeting with the M.D. students to critically review 30 min a research proposal their proposal for an M.D. thesis 6 Clerkship in public health and 36 Clerkship in public health and epidemiology 36 epidemiology Total Hours 185 Total Hours 230.5 Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 6 of 8 Fig. 1 Pyramid of the Public Health curriculum intensive one-week course gives an overview of the presented from body systems such as the epidemiology of specific diseases and conditions gastrointestinal and urinary tracts. The course is such as cancer, cardiovascular disease, diabetes, intended to reinforce skills covered in the first year, infectious diseases, geriatric and childhood diseases, while exploiting the advanced stage attained in the maternal and child health, and psychiatric illnesses. students’ basic medical knowledge. The course emphasizes the specific methodologies 6. E-learning course in planning and writing research used for the study of these illnesses and conditions proposals for the M.D. thesis (4th - 6th year): This and presents the specific disease registries available. electronic course is designed to provide students The second part of the course focuses on the with the necessary competencies to develop research national health system, and aims to elucidate the questions and to formulate the research role of the clinician as a public health promoter in methodology relevant to their MD thesis. The the national health system. The paradigm of course is built on the knowledge and capabilities of combining health policy with clinical decision implementing the competencies taught during making is emphasized, using relevant and timely previous years; and it is presented through a set of examples. online guided tools. 4. Tools for practicing Evidence Based Medicine (EBM) 7. Clerkship in public health and epidemiology (6th (3rd year): Tools and techniques are provided for year): Experiential learning in EBM in public health. practicing EBM, by means of workshops and During this 1 week interactive workshop the simulations of real life situations. At the end of the students experience the implementation of course, the student should be able to frame a clinical epidemiological tools from data collection and question in view of a specific clinical situation, analysis to public health planning and decision search the medical literature, obtain the most making. The course includes practical examples such relevant material, and critically appraise the as prevention of cervical cancer or the literature so as to achieve the best available solution implementation of various programs for secondary to the clinical question. This course reinforces the prevention of breast cancer and their impact on competencies provided in the first and second years breast cancer mortality. As in other clinical and requires the student to apply them. clerkships, the students experience the process of 5. The use of epidemiologic methods in clinical decision making. In this case it relates to decisions decision making (3rd year): This course provides the in public health. At this stage, just before epidemiological background to the major body graduation, the students have most of the medical organs and systems taught in the third and fourth knowledge they will acquire during their MD degree. years, while focusing on how epidemiology is used They have the ability to use clinical and for clinical decision-making. Specific examples are epidemiological competencies to understand the Dankner et al. Israel Journal of Health Policy Research (2018) 7:13 Page 7 of 8 broad range of considerations involved in health Our intended outcome is that medical school gradu- policy at the individual and population levels. ates will be curious and have the motivation and compe- tencies to obtain the evidence based information they Program evaluation The revised public health curricu- need to provide scientifically sound care to their pa- lum was implemented with first year students during tients; that they will have the skills to conduct research 2013–2016/17. We have been revising and refining the and for critically evaluating existing evidence; and that courses of the first, second and third years according to they will maximize their role in disease prevention and feedback from students and lecturers. All courses in our healthy lifestyle promotion. By having developed a longi- school have a computerized feedback system, which is tudinal exposure for students, they are reminded at all opened from the last lecture till the final exam, and is stages of their medical education about the importance filled on a voluntary anonymous basis. In addition, and relevance of the sciences as the basis of medical meetings are held with the students’ representatives to knowledge and evidence as the basis for better medical discuss their expectations and feedback, and an attempt care, prevention, and public health. to integrate necessary changes in the courses is Acknowledgements continuously performed. In the coming academic year This paper was written in memory of the late Prof. Leon (Levi) Gordis, a (2017–18) the last class from the old curriculum will distinguished epidemiologist with an international reputation, who taught in the Sackler School of Public Health and the Sackler School of Medicine graduate. At the end of this year we will conduct a sur- during his last years, and mentored faculty members of our school. vey among these students during the clerkship in public health to evaluate their perceived understanding of pub- Funding None. lic health topics and of the competencies we intended to convey in our curriculum. We will repeat this survey Disclosures among the following class – the first to experience the No financial disclosures were reported by the authors of this paper. full 6-years revised curriculum, and compare the results. Authors’ contributions In the future we intend to assess the quality of MD the- RD lead the committee and the writting of the manuscript. UG was a ses submitted at graduation, according to exposure to member of the committee and took part in writting the manuscript. LL conceived the program, nominated the committee and took part in writting the intervention, and to compare evaluations of EBM the manuscript. MS took part in writting the manuscript. SS was a member skills during clinical clerkships. We expect more MD of the committee and took part in writting the manuscript. All authors read theses to be published as papers in peer-reviewed and approved the final manuscript. international journals. Ethics approval and consent to participate Not applicable. Conclusions Competing interests Public Health topics have been taught by the Division of The authors declare that they have no competing interests. Epidemiology and Preventive Medicine ever since the Sackler School of Medicine was established. The cur- Publisher’sNote riculum evolved over the years “bottoms up” and when a Springer Nature remains neutral with regard to jurisdictional claims in decision was made to implement a Competency Ori- published maps and institutional affiliations. ented approach to the medical curriculum at large we Author details revised our curriculum. The Sackler School of Medicine 1 Unit for Cardiovascular Epidemiology, The Gertner Institute, Chaim Sheba committee re-designed a comprehensive curriculum in Medical Center, Ramat Gan, Israel. Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel epidemiology and public health, which covers the range Aviv University, Tel Aviv, Israel. Quality Unit, Rabin Medical Center, Petah of topics central for current medical students’ education 4 Tikva, Israel. Department of Medicine E, Beilinson Hospital, Rabin Medical in those fields. Among its goals, the revised curriculum Center, Petah-Tiqva, Israel. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Cancer & Radiation Epidemiology Unit, Gertner Institute, focuses on competencies required to critically appraise Chaim Sheba Medical Center, Ramat Gan, Israel. medical scientific literature. The curriculum has been implemented and fits the national system of medical Received: 19 July 2017 Accepted: 4 December 2017 education, which spans over 6 years of training. Our lon- gitudinal curriculum is based on the need for a References competency-based medical education (CBME) approach 1. Seshia SS, Young GB. The evidence-based medicine paradigm: where are we 20 years later? Part 2. Can J Neurol Sci. 2013;40(4):475–81. and an emphasis on research methods in statistics and 2. Kaprielian VS, Silberberg M, McDonald MA, Koo D, Hull SK, Murphy G, Tran epidemiology, preventive medicine and the application AN, Sheline BL, Halstater B, Martinez-Bianchi V, Weigle NJ, de Oliveira JS, of population health principles in medical education. Sangvai D, Copeland J, Tilson HH, Scutchfield FD, Michener JL. Teaching population health: a competency map approach to education. Acad Med. 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Israel Journal of Health Policy ResearchSpringer Journals

Published: Feb 20, 2018

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