Public Health in Medical Curriculum - Student's Toolkit by International Federation of Medical Students' Associations

Public Health in Medical Curriculum: Studentâ&#x20AC;&#x2122;s Toolkit For those passionate about advancing public health education in their medical schools

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IFMSA Imprint Executive Board Hana Lučev, Amela Hamidović, Satria Nur Sya’ban, Batool Alwahdani, Frida Vizcaíno Contributors Mahmoud Ellithy, Tarek Ezzine, Nishwa Azeem, Ilia Nadareishvili, Sanne de Wit, Elias Phiri, Rosie-James, Pablo Estrella, Ann Pongsakul, Alaa Abusufian, Wan Ting Layout Design Fahmi Kurniawan Cover unsplash.com

The International Federation of Medical Students’ Associations (IFMSA) is a non-profit, non-governmental organization representing associations of medical students worldwide. IFMSA was founded in 1951 and currently maintains 137 National Member Organizations from 127 countries across six continents, representing a network of more than 1.3 million medical students. IFMSA envisions a world in which medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally, so to shape a sustainable and healthy future. IFMSA is recognized as a nongovernmental organization within the United Nations’ system and the World Health Organization; and works in collaboration with the World Medical Association.

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Contents

About IFMSA page 4 About the SWG (team & aims) page 4 SWG Methods page 4 Introduction page 5 Methods page 7 Medical student perceptions of public health curriculum: a global survey - page 7

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Preferred public health curriculum content page 8 Preferred public health teaching methodologies page 8 How to take action! page 10 Advocacy tools page 12 Glossary of Abbreviated Terms page 13 Acknowledgements page 14

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About IFMSA The International Federation of Medical Students’ Associations (IFMSA) is a non-profit, non-governmental organization representing associations of medical students worldwide. IFMSA was founded in 1951 and currently maintains 137 National Member Organizations from 127 countries across six continents, representing a network of 1.3 million medical students. IFMSA envisions a world in which medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally, so as to shape a sustainable and healthy future. IFMSA is recognized as a non-governmental organization within the United Nations’ system and the World Health Organization; and works in collaboration with the World Medical Association.

About the Small Working Group Formed of a team of 8, the Small working Group on Public Health in Medical Curriculum was created to; • To raise medical students’ awareness on the the importance of including Public Health knowledge in the medical curriculum • To gain consensus of a preferred PH curriculum and the methodology to deliver it, based on student reflections and literature • To compile students needs and perceptions about Public Health education in medical schools around the world • To provide tools for medical students to advocate for optimal Public Health component inclusion in medical curricula

SWG Methods1 The Working Group firstly collected input from two IFMSA Regional Meetings, Americas and the Eastern Mediterranean Region in January, February and March 2018. A worldwide online survey was also distributed through the IFMSA server and on IFMSA social media channels between December and March 2018. It received a total of 327 responses from 139 countries. The respondents were in various years of their training, with the median in fourth year of medicine. A scoping literature review was then conducted. Search words included “medical school,” “curriculum,” “public health,” “guidelines,” and “standards”. Exclusion criteria was anything not mentioning medical school or public health Master’s curricula. More information about the survey results can be requested to scomed@ifmsa.org and scophd@ifmsa.org

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Introduction

Why Public Health in Medical Curriculum ? A key element of 21st century medical education is preparing students to take charge of population health, with a shift from a specialist and case-oriented model of education, toward a more generalist and community-orientated one. In this reality, importance of Public Health education of medical students is being increasingly recognized by key stakeholders. Meanwhile research on medical programmes shows that Public Health is still underrepresented in MD (undergraduate) curricula. The Lancet Commission on medical education for the 21st century criticized medical schools for not responding to community and societal needs in their curricula, stating that “fragmented, outdated, and static curricula are producing ill-equipped graduates”. (Frenk et al, 2010) Public Health is commonly defined as:

“the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO) While clinical medicine is concerned with diagnosis, treatment, and improving life quality in individual patients, public health is concerned with population health. More medical educators have begun to acknowledge the importance of public health in physicians’ training (Prescott JE, 2011). It is suggested that Public Health education will help medical students to develop a deeper understanding of the interconnected issues that influence the health of populations (School of Medicine, University of Pittsburgh, 2018). In 2007, the Institute of Medicine suggested that all medical students should receive basic PH training in population-based prevention and that a significant proportion of medical school graduates be trained in PH at a Master of

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Introduction public health level, receive training in leadership, emergency preparedness, and clinical and community preventive services1,2. Why develop curricula?

public

health

The scope and needs of medicine has drastically changed over the past century. Preventable diseases now account for the majority of global mortality (Jones et al, 2012). Medical schools should be adapting their curricula to match society’s needs. If public health theory and practice is taught throughout a medical student’s career, the physicians of tomorrow will be more mindful and capable of influencing their patient’s health in a proactive manner. Targeting students at an undergraduate level will enable a change in values and best practice, as supposed to targeting professionals – whom are generally more reluctant toward learning new skill sets.Skills, and behavior that students must demonstrate by the time of graduation are classified under the headings ‘scientist and scholar’, ‘practitioner’ and ‘professional’. Public Health runs across all of these headings (Tomorrow’s Doctors, UK, 2009). Public health teaching should also be advanced further. It is suggested that larger scale practice-based teaching should be applied. Academic institution - health system/facility partnership as well as greater community involvement and community development activity enhancement is sug-

Institute of Medicine. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century (K Gebbie, LRosenstock, LM Hernandez, eds.). Washington, DC: The National Academies Press, 2003. 2 Institute of Medicine. Training Physicians for Public Health Careers (K Gebbie, L Rosenstock, LM Hernandez, eds.). Washington, DC: The National Academies Press, 2007. 1

gested. This offers a more effective approach to medical practice. This includes efficient use of applied epidemiology, diagnostic tests, weighing up the benefits, risks and costs of treatments, and understanding the natural history of patients’ diseases to help prevent disease and promote health in individual patients; having a clear understanding of their role within the wider context of health and social care. Rudolf Virchow, often credited as the founder of social medicine, stated that: “Medical instruction does not exist to provide individuals with an opportunity of learning how to make a living, but in order to make possible the protection of the health of the public.” Why you? As medical students you are the strongest proponents for adapting education to the needs of the community. Being directly exposed to the curricula in place, you have valuable insight in how it can be advanced for better outcomes. We hope that, through this toolkit, we will all be inspired and encouraged to advocate for advancing and developing public health education in our curricula. Our ultimate goal is to provide you with the necessary resources to be the change at our own institutions! “Be the change you want to see in the world” -Mahatma Gandhi

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Methods The Working Group firstly collected input from two IFMSA Regional Meetings, Americas and the Eastern Mediterranean Region in January, February and March 2018. A worldwide online survey (here) was also distributed through the IFMSA server and on IFMSA social media channels between December and March 2018. It received a total of 327 responses from 139 countries. The respondents were in var-

ious years of their training, with the median in fourth year of medicine. A scoping literature review was then conducted, using Google Scholar and Pubmed. Search words included “medical school,” “curriculum,” “public health,” “guidelines,” and “standards”. Exclusion criteria was anything not mentioning medical school or public health Master’s curricula.

Medical student perceptions of public health curriculum: a global survey

Our survey results from medical students in 139 countries indicate that overall, students do not seem to enjoy public health teaching. There is a strong division between public health and clinical medicine courses. They are often taught in separate silos. For this reason, public health is sometimes regarded as an undesirable career that is not focused on patient contact, but rather research and epidemiology only, which differs from core medical topics. The majority 246 (75%) of medical students believed that both local, national and global PH topics should be taught during medical school (Figure 1).

Figure 1: IFMSA survey of medical students worldwide, March 2018.

Figure 2: IFMSA survey of medical students worldwide, March 2018. www.ifmsa.org

Preferred public health curriculum content It is not easy to actualize one universal public health curriculum, as each country has unique health needs and systems. However, there are common underlying themes which we believe should be taught to all medical students around the world. Broadly, the goals of public health training in the 21st century, as defined by McKee 2013, are to: • Stimulate curiosity • Accepting risk and responsibility • Capable of making connections • To understand root causes of health and illness • Refocus on upstream and downstream to reach gain in population health • Advocate for health and human rights

Considering great differences not only among various countries and regions of the world, but also medical schools inside one country, development of one “standard” curriculum design or educational approach is not desirable. Instead, each medical school should work on formation of objective strategy plan on public health teaching based on their local setting and their communities’ requirements. Additionally, it must be noted that in order for students to be incentivised into improving their Public Health knowledge and actively participating in the courses, medical schools should ensure their Public Health curricula has challenging content, rather than it being oversimplified and straightforward, which is the current situation in many countries. It was suggested that medical schools should consider development of an appropriate curriculum to address their local and national health priorities. (Barss et al, 2008)

Preferred public health teaching methodologies

Lectures, community placement and problem-based learning were proven to be most effective, according to the literature review and student survey. The WHO suggests that PH teaching is currently didactic, and that students may benefit from it becoming more engaging: “As with all elements of medical education, it is important to ensure that the curriculum is delivered using a range of educational approaches and assessments to engage students’ cognitive, affective and practical capacities as

well as cater for different learning styles and preferences. Where feasible, opportunities for experiential learning (such as placements with community groups, charities, and social care networks) can enable students to see how a variety of social situations affect the health of the people living within them. Simulating practical scenarios in the classroom can foster a sense of participation in public health activities. Examples of new technologies for public health education emerging in medical schools throughout the country include e‐modules, or real‐time exer-

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cises using social media such as Twitter debates and discussions, developing web pages or wikis, online journal clubs, videos and webinars. It was suggested that Public Health teaching though currently mostly taught through didactic teaching and lectures, should give more time to an active process, student-centered, inquiry-driven, evidence-based and problem-solving as well as addressing the needs of the community.” (WHO, 2010).

lic health information, but unfortunately only 79 (24%) benefit from this modality of education in their medical school’s curriculum. Additionally, teaching and training should provide a whole overview of the PH process from information, to capacity, to advocacy and governance as highlighted in the Global Charter for the Public’s Health. This comprehensive framework can guide PH action at national and international level and facilitate the alignment of efforts across the globe.

Figure 3: IFMSA survey of medical students worldwide, March 2018.

Figure 4: IFMSA survey of medical students worldwide, march 2018

Two important messages are conveyed in the above results. The first is that the conventional didactic lecture style education is clearly overused. While some believe this as an effective method to communicate public health education, it is not the most desired teaching method. The second message is that more interactive and socially accountable engaging methods should be used to teach PH. This is especially evident with some teaching methods, such as “Problem oriented learning” as 222 (68%) of participants viewed this as a valuable way to convey pub-

Figure 5: World Federation of Public Health Associations (WFPHA) Global Charter for Public Health framework -M. Lomazzi M, and members of the WFPHA. A Global Charter for the Public’s Health—the public health system: role, functions, competencies and education requirements. European Journal of Public Health, Vol. 26, No. 2, 210–212

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How to take action!

Call to medical students 1. Contribute to Curricula Enhancement in Medical Schools, (see our advocacy tools on the next page) 2. Engage in Public Health research through summer electives, SCOPH Public Health Exchanges by participating in collaborative research with NGOs addressing a public health issue in your community, or by conducting your own surveys & local data collections. 3. Become involved with your local student organization which dedicates itself to improving the public health of your community. Call to NGO’s and external stakeholders 1. Increase knowledge & motivation for Public Health education and research a. Collaborate with Medical Schools and Medical Students to improve medical student awareness on the importance on Public Health education for future doctors, provide practical examples on clinical practice/public health interaction in real life. b. Support public health research and projects with own resources or through contribution on grant project development and writing, in collaboration with student bodies, medical schools, etc. Mediate “public health skills enhancing activities” funding with funding agencies, schools and students. 2.

Advocate for Public Health training in medical schools a. Engage stakeholders by creating policy statements on the topic of PH in medical curriculum. There are currently very few statements on this topic at an international level.

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How to take action! Call to medical schools 1.

Increase knowledge, interest and motivation of students regarding PH a.

Use local PH case studies as teaching examples of good clinical practice

Engage students with local community health projects and institutions

Encourage and support students to attend public health conferences

Incorporate topical global health issues into the PH curriculum

Educate future doctors on healthcare disparities

Optimize the quality of Public Health teaching a. Collaborate with Public Health specialists and academicians for high quality teaching of Public Health in medical schools. b. Use the longitudinal model of teaching Public Health across most years of MD education. c.

Enable networking between Public Health professionals and medical students

d. Optimize teaching methodologies and allow for practical exposure in Public Health centers Call to Medical Education experts and Quality Assurance Agencies 1. Continuous research and development of the Public Health modules of undergraduate medical curriculum a. To form evidence on effective teaching methodologies, necessary content, good teaching delivery timing (in the context of the rest of MD programme curricula content) b. Include teaching methodologies specifically for public health topics in faculty development programs 2. Introduce and/or assure fulfillment of standards on public health education and skills delivery to the medical students by medical schools a.

Use national and/or global guidelines

b. Monitor & evaluate the curriculum at regular intervals (i.e. have students fill out a survey at the end of each year, so that the curriculum can be adjusted for the following students) www.ifmsa.org

Advocacy tools Use these ideas for improving PH curriculum in your medical school: Identify the problem Most schools do have existing public health modules in the curriculum, so it is paramount to first uncover/identify what is missing or what needs to be improved. Does PH need more teaching hours? More Training in community settings? A change in educational strategies used? Identifying areas to work on is the first step. This can be done through informal discussions with the staff and/or students. Research Try creating and distributing a survey similar to the one we used to write this toolkit in your local institution. Ask medical students’ perception about your PH curriculum. This can help you identify areas to work on. Use the results for awareness campaigns with your peers in your universities, as well as for a high-level evidence-based advocacy campaign with your medical school authorities. A letter to your school administration Writing a formal letter to your dean of medicine (or whoever is in charge of creating your school’s PH curriculum) is a good step. Express your concerns and motives surrounding the gap you wish to address in the curriculum. Support your letter with facts eg: based on the survey held and personal experiences. You can also add that you are willing to meet in person to discuss room for improvement. We have created a template for you to use, see here.

students. Invite experts in PH and have your professors and lecturers attend. This can help to motivate and educate medical students into taking an interest in PH and subsequently your school may decide to hold such events on a regular basis. Need help on how to turn your idea into an activity ? Checkout this IFMSA manual here! Training It is possible to become a trainer through the IFMSA. There are many courses which relate to Public Health and Medical Education Advocacy, run by SCOME or SCOPH. Attend their certified training sessions which will enable you to facilitate your workshops in your own medical school and spread your knowledge, encouraging other students to be advocates too. It is important as a medical students to know about the stakes of Public Health and Medical Education, not only for individual purposes, but most importantly to have excellent background on the matter while advocating for it. National Policies on Public Health Education Aside from medical students, other stakeholders are also working towards improving Public Health in medical curriculum.Therefore, mapping these stakeholders and making sure to include your educational policy in their National Public Health Policy would strengthen the position of all parties towards achieving successful Public Health Advocacy. You can find here a manual explaining policy making and here is a list of distinguished stakeholders for PH in medical curriculum you can consider using:

Events

1. WFPHA: World Federation for Public Health Associations

Consider holding a campaign, panel discussion or seminars relating to PH education for medical

2. ASPHER: Association of Schools of Public Health in the European Region (WORK-

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Glossary of Abbreviated Terms

ING GROUP ON UNDERGRADUATE PROGRAMMES IN PUBLIC HEALTH) 3. PHEMS: Public Health Educators in Medical Schools 4. WFME: World Federation for Medical Education’s Global Standards for Quality Improvement in Medical Education 5. WHO: Public health, environmental and social determinants of health Undertake a Public Health Exchange Interested in undertaking an actual experience that exposes you to public health settings and education in different countries? Follow this link to search IFMSA’s newest exchange portal - for SCOPH! How does it work? Please check the Regulations here. The main idea behind Public Health Exchanges is that both SCOPH and SCOPE collaborate on the content and the administration and hopefully learn from this collaboration. The Public Health Exchanges (differently from the classic SCOPE exchanges) are open to all health science students, and are based on internship forms. This means students will apply for specific projects (like it happens for SCORE exchanges). The duration of the exchange should be at least 4 weeks, and can go up to 8 weeks.

ASPHER - Association of Schools of Public Health in the European Region IFMSA - International Federation of Medical Students Associations MD - Medical Degree PH - Public Health PHEMS - Public Health Educators in Medical Schools SCOPH - Standing Committee on Public Health (a Standing Committee of IFMSA) SCOME - Standing Committee on Medical Education (a Standing Committee of IFMSA) SCORE - Standing Committee on Research Exchange (a Standing Committee of IFMSA) SCOPE - Standing Committee on Professional Exchange (a Standing Committee of IFMSA) WFME - World Federation for Medical Education WFPHA - World Federation for Public Health Associations WHO - World Health Organization

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Acknowledgements Editorial and contributors team:

Thank you to our reviewers

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medical students worldwide