Integration of Health Policy into Medical School Curriculum:
Theme and Area of Concentration

Diane Rittenhouse, MD, MPH
Fall 2003

BACKGROUND INFORMATION

Introduction: Working Group on Curriculum in Health Care Systems and Health Policy

The Working Group was formed in July 2003 to coordinate the development of a comprehensive, integrated 4-year curriculum in health policy for the UCSF School of Medicine, ultimately resulting in:

· A Theme in Health Care Systems and Health Policy
· An Area of Concentration: The Health Care System and the Physician Leader.

The Working Group is chaired by Diane Rittenhouse, MD, MPH (Family & Community Medicine), and co-chaired by Josh Adler, MD (Medicine) and Jack Resneck, MD (Dermatology). Working Group membership is open, and we have enjoyed active participation by faculty in health policy and health services research across departments and disciplines. Active members include, among others: Kevin Grumbach, MD; Harold Luft, PhD; Adams Dudley, MD, MBA; Tom Bodenheimer, MD; Dana Hughes, PhD, and Bill Shore, MD. During the summer of 2003, we worked closely with two medical student curriculum ambassadors, Michael Martinez and Elizabeth Ortega-Lau, sponsored by the Dean's Office of Curricular Affairs. The Working Group has benefited greatly from the active participation of these and other interested medical students.

Working Group Progress to Date

Definition of a core curriculum in Health Care Systems and Health Policy

· Agreement on 12 major learning areas that comprise a comprehensive medical school curriculum in Health Care Systems and Health Policy, and delineation of learning objectives for each of these areas (Appendix Table 1).
· Ranking of 12 major learning areas and their subcomponents into high and low priority with respect to the curriculum.
· Prioritization of high priority learning areas and their subcomponents according to whether they should be required (Appendix Table 2) or elective (Appendix Table 3), presented early (preclinical) or late (clinical years).
· "Highest priority" learning areas include access, financing, organization, and quality.

Identification of health policy topics in the current SOM curriculum

· Exhaustive review of the current School of Medicine curriculum by searching the iLios curriculum database using approximately 180 health policy-related Medical Subject Headings. (Appendix Figures 1 and 2; Appendix Table 4)
· This search revealed that about 25 hours of lecture and small group discussion time are devoted exclusively to health policy topics. Eighteen of these hours are presented late in the third year, during the Clinical Intersessions. Six hours are presented during Year One of FPC. In addition, a popular student-initiated health policy elective was offered in the fall of 2002 and 2003.

· The current medical school curriculum devotes substantial time to topics in health care systems and health policy, but the timing and content of this material is not coordinated into a logical and cohesive theme. Although some important topics are covered well, others are repeated in a disorganized fashion or not taught at all.

GOALS

The Working Group has developed the following mission statement:

UCSF medical students will be physician-leaders at all levels of the health care system. In addition, they are and will continue to be members of families and communities, potential patients and voters. The medical school curriculum must therefore provide a strong background for all students in:

· The financing and organization of the health care system and their effects on patients, health care, physicians, and other health professionals;
· The political, economic, policy-making and cultural forces shaping the health system; and
· The key ingredients necessary to make improvements in the health system from the level of the practice organization to national health policy.

PROCEDURES

1. To develop a Theme in Health Care Systems and Health Policy

We propose the development of a formal Theme in Health Care Systems and Health Policy. Although there is substantial time in the current curriculum already devoted to health policy-related topics, these topics need to be formally coordinated with each other and better integrated with other aspects of the curriculum to maximize the use of this time. Based on feedback from the Essential Core Course Committee, we intend to identify 2 or 3 blocks where health policy could most effectively be integrated. Health policy should be taught in a variety of formats, including lecture, small group discussions, and case studies. Some basic introductory concepts should be presented very early in the curriculum; these concepts should then be reinforced by integrating material into existing case studies or small group discussions. PBL cases are particularly conducive to the integration of health systems and health policy issues. Dr. Rittenhouse is working with Carol Hodgson to identify specific PBL cases for the Working Group to begin integrating health policy topics. For example, in the PBL case of John Dugan (III block), after he has stabilized in the hospital, the utilization management department calls to transfer him to another hospital because his health plan does not have a contract with UCSF. This could lead to a discussion of the complexity of the relationships between patients, health plans and hospitals. The Working Group will work to develop background materials and discussion points for small group discussion leaders to ensure that they are prepared to lead thoughtful discussions. For topics best introduced in the clinical years, we will work closely with Drs. Josh Adler and Adams Dudley, instructors for Intersession courses on health care quality and resources, to maximize the use of this time in light of the overall health policy curriculum.

2. To develop an Area of Concentration titled: The Physician Leader and the Health Care System

We anticipate that the development of the AoC will be a collaborative effort, and have begun discussions with the leaders of the other Areas of Concentration through the AoC Meta-Group, with faculty from the UCSF/UC Berkeley Joint Medical Program, the UCSF School of Nursing Department of Social and Behavioral Sciences minor in Health Policy, the UCSF Institute for Health Policy Studies, the UC Berkeley School of Public Health Division of Health Policy and Management, and with individual students interested in health policy. We are collecting the names of students with an interest in health policy, and information about students who have recently initiated or completed projects in this area.

3. To Create a Rich Health Policy Learning Environment for UCSF Medical Students

Examples of additional ways to create an environment that increases students' awareness of current events in the health policy arena, and identifies opportunities to influence the course of these events include, for example:
· Noontime or evening panel discussions or debates on current events in health policy. These discussions would offer students exposure to some of the more "political" aspects of topics that are introduced during the core curriculum. For example, a noontime discussion of proposals to achieve universal health coverage in California could be timed to coincide with a lecture on health care financing. If there was adequate student interest, a series of these discussions could be organized into an elective course.
· Requiring each medical student to write a health policy-related editorial to a magazine, journal, newspaper, or radio station at some point during their pre-clinical years.
· Distribution of a periodic "health policy brief" that summarizes a current health policy issue at the local, state, or national level. The "brief" would be written by a faculty member with particular knowledge/expertise in the area, and would frame the topic in a balanced manner, provide talking points, references for further information and suggestions on how interested students or their friends/family members could get involved.

PLAN FOR MEASUREMENT AND DOCUMENTATION OF PROJECT EFFICACY AND OUTCOME

We recognize the importance of measuring and documenting the efficacy of our efforts and will work with the Scholarship Clinic to further develop this part of our project. We are fortunate that Diane Rittenhouse, Jack Resneck, Kevin Grumbach, Hal Luft, Tom Bodenheimer, Adams Dudley and Dana Hughes are all research faculty and have extensive experience in survey and focus group research in addition to program evaluation. We are interested in developing an evaluation methodology that will not over-burden the students since students are frequently asked to participate in surveys and focus groups.

PLAN FOR CONTINUATION OF PROJECT AT THE END OF FUNDING CYCLE:

The background work for this project began with the formation of the Working Group in July 2003. Kevin Grumbach, Chair of the Department of Family and Community Medicine, is currently using departmental funds to support 10% of Diane Rittenhouse's time to Chair the Working Group and coordinate all Working Group activities. Funding for the 2004-5 academic school year will allow her to continue her leadership, and provide much needed administrative support for the Working Group. We will continue to work to identify other sources of support for curricular development activities as we progress. The core members of the Working Group are committed to seeing the project through.

For more information, please contact:
Diane Rittenhouse, MD, MPH