Health care and population health: A team sport
The faculty at Dell Medical School at the University of Texas at Austin are enjoying a unique opportunity. Dell is the first new medical school at a tier-one university in the U.S. in 60 years, having welcomed its inaugural class in 2016. Its instructors don’t just have the chance to build a new medical school. They can build a medical school of the future.
“As you might guess, population health is right at the center of all of that,” said William Tierney, MD, professor and chair of Dell’s Department of Population Health, during a panel presentation focused on curricular innovations at the recent International Conference on Physician Health™ in Boston, moderated by Richard Hawkins, MD, AMA vice president of medical education outcomes. “There really aren’t a lot of models. There are only eight other departments of population health at academic medical centers in this country.”
But there are even more important reasons to come up with a new model.
“It has really broken my heart to see the joy leeching out of medicine,” Dr. Tierney said. “There are financial pressures, clinical pressures, information pressures, technology pressures and growing demographic pressures as my generation gets older and we have increased health inequities.
“The focus isn’t on health care. We focus on illness care. When you think about what we do day to day, we focus on diagnosing and treating chronic diseases. There’s some risk-factor reduction … but the focus is on clinical medicine. And what’s wrong with that?”
Citing a study from the University of Wisconsin, Dr. Tierney noted that, in the U.S., health care delivery only affects about 20 percent of life expectancy and quality of life. Social and economic factors—including education, employment, income, family, social support, community and safety—affect 40 percent. And behaviors—such as smoking, diet, exercise, alcohol and sexual activity—affect another 30 percent.
“Yet where has all our money gone?” he asked.
The curriculum: Different from day one
Dell is one of 32 member schools in the AMA’s Accelerating Change in Medical Education Consortium. Its vision is to incorporate value-based care, team-based care and interprofessional education into the curriculum, and to focus on the triple aim, physician leadership, community engagement and social and behavioral determinants of health, from day one.
“We’re trying to get upstream from the things we see every day in our practices, focusing on health promotion and disease prevention,” Dr. Tierney said. “I want us to see a new patient presenting with type 2 diabetes mellitus as an abject failure. Because it’s a preventable disease.”
- Year 1: Essentials. The curriculum focuses on integrating scientific principles into clinical presentations and health system contexts. It holds that team-oriented care delivery is the future of health care. Students learn in small-group, team-based environments. Large-group learning is interactive and pushes students to apply knowledge in new frameworks. Courses include Interprofessional Education and Leadership. It limits structured classroom time to less than 10 hours a week and routine feedback helps students gauge their depth of understanding of the scientific content. A pass/fail grading system encourages collaboration and learning together in the integrated curriculum.
- Year 2: Delivery. Clerkships permit students to apply the scientific principles learned during Year 1 to daily care delivery activities in the clinical setting. Students are expected to consider the scientific underpinning of clinical decision-making during the clinical activity of the clerkships, reinforcing the integration of basic science and clinical medicine begun in Year 1. Courses include Primary Care, Family and Community Medicine, Developing Outstanding Clinical Skills, Interprofessional Education and Leadership. It is composed of five block clerkships and a Primary Care, Family and Community Medicine Longitudinal clerkship, where students will have the opportunity to experience long-term relationships with a group of patients. Students see how the health care team can help a patient maintain health and manage chronic and acute disease in outpatient primary care settings.
- Year 3: Growth. A nine-month Innovation, Leadership and Discovery block gives students the opportunity to individualize experiences toward long-term goals. Students can choose to undertake an independent discovery project in one of three areas of distinction—Healthcare Innovation and Design, Population Health or Clinical/Translational Research—or to pursue one of several dual-degree programs. Students’ work contributes to the school’s pursuit of making Austin a model healthy city. Courses include Innovation, Leadership and Discovery, Primary Care, Family and Community Medicine, Developing Outstanding Clinical Skills, Interprofessional Education and Leadership.
- Year 4: Exploration. Students have the opportunity to explore personal career interests and select electives to further examine residency disciplines and pursue higher-level clinical rotations such as critical care, emergency medicine and an acting internship. Substantial time is set aside for residency interviews. A capstone experience takes place in the spring to facilitate the transition between medical school and internship. Courses include Developing Outstanding Clinical Skills, Interprofessional Education and Leadership.
Dr. Tierney noted that one of the themes of the curriculum is how population health impacts patients and communities over time.
“We should care about the upstream things that affect our patients,” he said. “We should care about the people who aren’t our patients and hopefully prevent them from becoming our patients.
“In conclusion, the past is prologue. We can do better. We can put joy back in medicine. Our first class of medical students, they’re the most excited people. They’re not burned out. So let’s not burn them out.”