Tyler, Ingrid V. MD, MHSc, MEd; Hau, Monica MD; Buxton, Jane A. MBBS, MHSc; Elliott, Lawrence J. MD, MSc; Harvey, Bart J. MD, PhD, MEd; Hockin, James C. MD, MSc; Mowat, David L. MBChB, MPH
The importance for all physicians to understand basic public health issues has recently been brought to light through events such as the threat of pandemic avian influenza, the emergence of West Nile virus and SARS, and the increasing burden of chronic diseases. However, the struggle to teach public health effectively and to capture the interest of medical students continues to be a challenge internationally, as recognized recently in this journal1 and elsewhere.2,3 In Canada, one outcome of inadequate public health teaching in medical schools is poor recruitment into the public health medical specialty of community medicine.4
Undergraduate medical public health courses are often used to address a wide range of the Licentiate of the Medical Council of Canada5 objectives including some public-health-oriented topics such as epidemiology, biostatistics, outbreak response, and the determinants of health, as well as other general topics such as introduction to the health care system, evidence-based medicine, ethics, cultural competencies, professionalism, and the patient–doctor relationship. Often, these courses are not integrated across the various components of the medical curriculum, which covers topics such as physiology, pathology, pharmacology, anatomy, and clinical medicine. This isolation accentuates the challenge faced by medical educators in trying to teach public health effectively within a medical culture that values acute care of individual patients and their families over population-based health protection, health promotion, and disease prevention. This disconnect between philosophies of care, combined with a frequent lack of clarity around the topics that are distinctive to public health, leaves students confused about the role of public health in medicine, and thus they struggle to understand the relevance of it in their medical education. The need for change in this area is being recognized.6,7
Our study, based on a series of medical student focus groups, seeks to understand student attitudes and perceptions of the public health education system and to identify improvements in undergraduate medical education needed to improve students’ awareness and understanding of public health. We refer to public health (PH) as the collective societal efforts to improve the health and well-being of populations. Community medicine (CM) refers to the medical specialty area, including the Royal College of Physician and Surgeons of Canada8 medical residency training program for PH physician specialists. PH practice refers to the development of public policy and the design, implementation, and evaluation of health programs that fulfill the functions of PH as it relates to the PH medical specialty of CM.
We conducted focus groups at five medical schools across Canada between February and April 2006. These schools were selected primarily on the basis of geographic location: (1) University of British Columbia Faculty of Medicine (British Columbia), (2) University of Manitoba Faculty of Medicine (Manitoba), (3) University of Toronto Faculty of Medicine (Ontario), (4) McMaster University Faculty of Health Sciences (Ontario), and (5) Université de Sherbrooke Faculty of Medicine and Health Sciences (Quebec). Each school used various teaching methods including a combination of problem-based learning, tutorial, and lecture formats in their public health curricula (personal communication from participating undergraduate course directors or their designate). On the basis of an author’s experience (I.T.), this is common in most undergraduate PH programs across Canada, as is evaluation primarily through student projects with a multiple-choice exam component often worth less than half of the final grade. All of the schools studied were associated with CM residency programs.9 Two of the schools delivered their PH curricula in preclinical years only.
We recruited medical student participants through posters and e-mails distributed two weeks in advance of a scheduled focus group, advertising an opportunity to discuss “your opinions about your public health education.” There were no specific inclusion or exclusion criteria because the widest possible range of student input was sought. Groups were limited to 12 participants and filled on a first-come, first-served basis. We established a medical student contact at each university to act as a site liaison for the study coordinators and to help with recruitment and technical arrangements. The student liaison observed and took notes but did participate in the focus group. At the conclusion of each focus group, students received textbooks10,11 as a token gift for participation. Ethics board approval was obtained from each participating university.
We administered a questionnaire to all participants at the start of each session using Group Decision Support System (GDSS) technology. This questionnaire consisted of 15 questions developed to determine basic demographic and background information about the participants, including participants’ current consideration of CM as a career choice and influences on this decision, as well as their current understanding of medical careers in PH. Our focus groups were 90 minutes long and designed to gain a better understanding of medical students’ perceptions of PH from their medical education to date and ideas to improve medical school PH education.
All five groups were conducted by the same professional facilitator, chosen for practical and technical expertise with GDSS technology or “electronic brainstorming.”12 GDSS technology allows groups to generate a large number of ideas anonymously and provides an alternative approach to conducting traditional focus groups using tape recorders. Each participant was seated in front of a network-connected laptop computer. The facilitator introduced the topic, and then all participants typed their answers into the computer simultaneously. We did not specifically instruct students to represent their peers; therefore, it can be assumed that comments reflected their personal opinions. With the computer-assisted technology, quiet participants have equal opportunity to assert their opinions, and no participant’s ideas are in danger of being lost in the general discussion. As participants submitted their ideas, their comments were collected by the network, stored, and projected anonymously onto a large public screen. An oral discussion followed and the facilitator strived to ensure that all participants had opportunities to participate in the discussion. This dialogue typically began with the sharing and the prioritizing of the ideas projected on the public screen. The facilitator then asked probing questions to ensure a clear understanding of all the participant perspectives. This also allowed students to branch off onto topics that may be directly or indirectly linked to their previously recorded opinions. A typical session consisted of 40% computer entry and 60% discussion. During the discussion, notes were typed into the system by the facilitator as new themes or ideas emerged. The oral discussion was also recorded by a note-taker present throughout the focus group. (Discussions were not tape-recorded or transcribed on account of the extensive note-taking input by the participants directly into the GDSS.) A final transcript for each focus group included all comments that students input electronically, and the transcript was collated with the notes taken during the session.
We entered demographic and participant data from the presession survey into spreadsheet software. Double entry was used to improve accuracy. For the purposes of this analysis, McMaster’s three-year program was divided into year 1 as the preclerkship, junior level and years 2 and 3 as the clerkship, senior level because at the time the study took place, year 2 students had begun full-time clinical duties.
We independently reviewed and analyzed the final GDSS transcripts and observer notes to identify themes and recurrent issues for which recommendations could be made that are specific and relevant to students and potentially achievable within educational institutions. Following these independent analyses, we held several meetings to organize and consolidate the identified themes. We consulted the original transcripts during this process to ensure that the participants’ contributions continued to be accurately reflected throughout the analysis.
A total of 57 medical students (35 female and 22 male) participated in the focus groups. Thirty students (53%) were in their preclinical (first- and second-year medical students) years of medical school, and 40 participants (70%) stated that they had previous experience with either or both PH and CM. Analysis of the focus-group transcripts resulted in the identification of four main themes related to curriculum. Student comments illustrating each of these themes are given in List 1.
Theme 1: Poor educational experiences in PH courses
It was clear throughout the course of our focus groups that undergraduate medical students are unhappy with the state of their PH curriculum. Many found it a “waste of time” and observed that “not everybody attends the lectures.” There was an overwhelming consensus that the current curriculum has a significant negative influence in students’ perceptions of PH. Problems were identified in curriculum structure and content as well as curriculum delivery as it relates to lectures and field experiences in the preclerkship (first and second years of medical school) and electives in the clerkship (third and fourth years of medical school).
Medical students across all focus-group sites were uniformly disappointed with the quality of their PH lectures, which are primarily part of the preclerkship curriculum. Criticisms included “poorly developed/delivered/constructed,” “relevancy to medical practice not apparent,” “no exposure to what CM doctors ‘do when they go to the office,’” and “very few lectures capture your attention.” Although students often ended up learning basic PH concepts to pass their exams, they reported that these concepts seldom seemed applicable to their future medical practice.
Students had many ideas for improving the current curriculum and were excited to be given the opportunity to suggest ways in which their learning could be made more learner-centered. Suggestions ranged from the very general “make learning PH a positive experience,” “stop just defining concepts,” and “improve the PH course,” to more specific ideas such as “make lectures more interactive,” “make the connection between PH and clinical practice,” “include large group sessions on health policy and the role of the physician as advocate,” “make it an objective to understand the role of the Medical Officer of Health,” and “identify ‘What is public health’?” Some students felt that it is “better to focus efforts on more immediate goals,” and others were overwhelmed by the broad scope of PH describing it as “daunting,” “nebulous,” and “difficult to define.” Students suggested that the curriculum should “give examples of CM success stories,” “show the impact,” “give real-life examples,” and “show practical applications of PH knowledge.” Students also felt there could be more of a connection between field experiences and lecture material to help students better understand the role of medicine in PH.
Another important part of the preclerkship curriculum consists of the field experiences in which students are often sent to community agencies to observe PH nurses or social workers or in which they are instructed to research a PH-related area. Most students preferred this to lectures; however, they still felt that field experiences do not give a clear understanding of the role of CM specialists in the practice of PH.
Some participants suggested that a mandatory rotation in PH would help them understand PH and “gain knowledge of PH resources in the community that you can access once you are a clerk/resident/physician.” Most students, however, preferred to have the option to pursue electives in CM. In all cases, students were clear that the elective experiences offered need to be well planned and executed; “otherwise it would run the risk of further deterring medical students from pursuing CM as a career.” Electives that show students how they effect change, or that involve projects with practical applications, would give students a more personal interest in the experience, akin to their clinical rotations. As one student pointed out, “Make the experience of learning PH positive and interesting …. If it is a drag to do, then it will just turn students off.”
Some students felt that the course would be improved if it were made more challenging and implied that content should be delivered and examined with the same rigor as the other components of the medical curriculum. Many students agreed that the current system of evaluation is a factor that leads the course to be taken less seriously and not viewed as relevant to the practice of medicine.
Integration with clinical medicine.
Students also noted that their coursework in PH does not relate to the rest of the medical curriculum. Across all of the interview sites, there were students who suggested that PH material should be integrated into the core curriculum with other topics: “Add a PH lecture into every systems block,” “add a PH learning issue into each PBL case,” and “as a part of other [clinical] rotations, have a day focused on PH initiatives in that field (e.g., mental health campaigns while in psychiatry).”
Theme 2: Lack of positive exposure to CM specialists
Not enough exposure to CM specialists in the curriculum.
Most students interviewed were unable to identify a CM specialist that had taught them during medical school. The overall sense from students was that the roles of CM physicians are not what they are learning in their PH courses, and, in fact, they struggle in describing what those roles are. Not having had the opportunity to see PH medical practice “in action,” few students could describe with confidence what PH practice as a CM physician entails, including the policy and programming outcomes of PH.
Lack of positive role models.
Unfortunately, for those students who could identify PH physicians within their medical school, these individuals were rarely viewed positively. Medical students clearly need positive CM role models in their undergraduate curriculum to improve their understanding of PH practice as well as to help create a more positive attitude toward PH. It was clear that those students who have had excellent experiences with PH in the past were much more open-minded, respectful, and informed about the specialty.
Theme 3: Emphasis on statistics and epidemiology
The curricula at participating schools leave students confused about the role of CM specialists and their practice. Most schools cover PH in a general course relevant to all specialties, which does not adequately explain the application of the basic sciences (e.g., epidemiology) and administrative skills (e.g., health system delivery) in the daily practice of CM. As a result, there exists a pervasive misconception that PH is “academic and research based” and “a lot of looking at numbers,” with little appreciation for the population health outcomes achieved. The emphasis of statistics and epidemiology in the current PH education led one participant to comment that “public health should be a PhD program not a clinical program because it is a research field/data crunching.”
Theme 4: Negative attitudes toward PH topics
Many students perceive a tendency on the part of their professors and peers to dismiss PH issues as being unimportant or “fluffy,” thus imparting a hidden message that it is inferior to clinical medicine. They noted that PH is rarely mentioned outside of designated lectures or by any professor who is not currently involved in PH. This negative role modeling behavior by other specialists strongly contributes to students’ opinions about PH. If clinical teachers do not think public health outcomes are important or achievable, why should their students?
Having an understanding of the determinants of health and other population health concepts affecting individuals, knowing how to effectively collaborate with PH departments on these issues, and accessing resources for individual patients that are provided through PH programs are important educational outcomes for all physicians in training regardless of the specialty they choose. In fact, it has been found that students feel they are able to function more effectively as clinicians after taking elective PH courses or a combined MD/MPH degree.13
Unfortunately, the current Canadian undergraduate medical curricula at participating schools do not seem to adequately explain why PH knowledge is useful and valuable for all physicians, thus leaving medical students unhappy with the state of the PH portions of their medical education. Although it is perhaps inevitable that some students will dislike their PH teaching, this dislike should be on par with that of other specialties, as opposed to the almost uniform negativity that was evident throughout these focus groups, which was noted at all of the five schools included in the study despite the varied formats and teaching methods used at the different institutions.
To understand the basic functioning of PH, students need to experience what CM specialists do through observation, hands-on projects, and accessible role models who can act as sources of information and inspiration. PH education needs to accurately reflect the practice of CM specialists by reducing its emphasis on the basic sciences of PH. In most of the schools studied, “public health” is currently taught as a stand-alone course, which usually includes some of these topics: evidence-based medicine, epidemiology, determinants of health, ethics, cultural competency, biostatistics, introduction to the health care system, professionalism, and the patient–doctor relationship. Unfortunately, this seems to lead to medical students’ confusion between the basic sciences necessary to practice PH and the practice of PH itself, and it may contribute to students’ lack of clarity around the role of the CM physician.
In an ideal setting, PH education would be delivered with the same relevance to medicine as other medical specialties. Instead, students felt that PH does not relate to or interact with the rest of medicine. Students in these focus groups frequently suggested integrating PH and clinical content. By embracing the students’ frequently suggested idea of incorporating PH material into the “core” medical curriculum, PH content could be highlighted for medical students while contextualizing it within the practice of medicine. Both students and faculty would be led to appreciate its broad-ranging applicability across a number of disease conditions and medical specialties while emphasizing its distinctions from and relationships to clinical epidemiology and clinical prevention. Appropriate integration could also help to diminish the perceptual divide between clinical medicine and PH practice. Integration into the clerkship years would give students the opportunity to apply the PH knowledge presented in the preclerkship years and help expose students to potential CM role models. Bellas et al14 observed that “issues of preventive medicine need to be incorporated into mainstream curriculum and taught by faculty whom the students see as credible clinicians who are key role models and opinion leaders.”
It seems intuitive that effective education in a particular area should be delivered by specialists in that field. As noted by Rego and Dick,2 “If the teaching/tutoring staff are unclear about the content and importance of PH issues because they have a specialty clinical or science background, then they are unlikely to feel comfortable with them.” The fact that many students interviewed could not reliably identify a CM specialist that had taught them during medical school is of concern. Medical students do not seem to get adequate exposure to CM specialists or PH practice to understand the role of either in the medical system. Positive CM role models could improve students understanding of PH practice, help them better appreciate how the work of public health makes a difference to individual patients as well as populations, and create a more positive attitude toward PH. Some suggested ways to increase the amount of exposure and interactions with CM specialists within the curriculum included bringing in more CM physicians to teach courses in the preclerkship and, where possible and applicable, involving CM residents in teaching PH in the undergraduate medical education curriculum. Positive role modeling could also be done by clinical specialists who are PH champions to convey the importance of PH to medicine within their field.
It should be noted that there could be potential differences in knowledge and attitudes of students at these schools compared with other medical schools not offering CM residency programs at the time of the study. More than half the participants were in their preclinical years and, therefore, may not have experienced the complete PH curriculum offered by the participating school. Unfortunately, because of the technology used, it is not possible to attribute student comments to individuals for comparison of responses between preclinical and clinical participants. Because this was not a randomly selected sample of student participants, biases may have occurred. Those who already had an interest in or awareness of PH may have been more likely to participate. Alternatively, participation may have been biased to those who have strong negative opinions toward PH. In terms of demographics, the ratio of males to females was generally reflective of current medical school enrollment in Canada, and there was wide representation of students from all years in the curriculum. Though all efforts were made to formulate independent opinions using the GDSS system and then elaborate on these thoughts with the group, participants may have had the propensity to agree with other students during the discussion. Despite its limitations, this study raises several important issues related to the teaching and learning of PH in the undergraduate medical curriculum across several Canadian medical schools, as identified by the students themselves. We hope that the findings of this study will assist those developing or revising PH curricula for medical students in Canada15 and abroad.
Overall, many students are disillusioned, disengaged, and disappointed with their undergraduate medical schools’ PH curricula. Lack of positive exposure to CM specialists, overemphasis of the basic sciences that are not specific to PH, such as statistics and epidemiology, and institutionalized negative attitudes toward PH topics inadequately prepare medical students to interact with the PH system in their future medical practice. Medical students in the schools studied would prefer a PH curriculum that is more challenging and has more applied field experiences and exposure to CM physician role models.
The Public Health Agency of Canada provided funding for this study.