Public health education for medical students: rising to the professional challenge
The delivery of undergraduate medical education in public health is a worldwide challenge. The ‘what’, ‘how’, ‘when’ and ‘why’ of such education have been contested since the nineteenth century. Obstacles to facilitating learning of public health-related disciplines are philosophical and practical. The advent of evidence-based health care has reaffirmed the importance of clinical epidemiology (albeit skewing the public health model biomedically), but many people consider public health a postgraduate endeavour. In the UK, successive health service reforms and staff shortages have hampered progress.
The General Medical Council (GMC) re-emphasized public health education in Tomorrow’s Doctors. Without clear clinical relevance, however, it risks being undermined by the ‘hidden curriculum’ (i.e. the prevailing rites, conventions and assumptions that affect what students learn formally and informally from the ‘intended’ curriculum). Modernizing Medical Careers has reinforced the need to build on robust undergraduate public health education. ‘Health promotion, patient education and public health’ and ‘infection control’ have become explicit elements of education in the Foundation years. In the latest Tomorrow’s Doctors, a public health dimension permeates all three sets of proposed learning outcomes for the medical graduate: Concerns have been highlighted from various countries about the fate of public health in undergraduate curricula. While some curricula that integrate learning across basic science, behavioural science, clinical science and population health science, in a clinical context, report students’ positive perceptions of public health, some students struggle with the subject. Evidence suggests that many students’ social responsiveness declines at medical school, with few reports of their preventive medical practice improving. Negative role-modelling is a detrimental aspect of the hidden curriculum. For example, Régo and Dick found that less than half of students considered faculty to be positive about population and psychosocial issues. Evidence rarely focuses on ‘how’ students learn crucial public health concepts.
as a scholar and scientist, e.g. ‘[applying] to medical practice the principles, method and knowledge of population health and the improvement of health and healthcare’;
as a practitioner, e.g. ‘based on the available evidence’;
as a professional, e.g. the responsibility for ‘protecting and promoting the health of individual patients, their dependants and the public.’
This paper examines a national statement, first issued following a workshop in 1996 with educators from academic public health departments in UK medical schools. They agreed via small group work a minimum set of public health educational goals applicable to their very different local curricula. In 2005, a survey of medical schools found variable delivery of public health education and confirmed many challenges facing the departments. In 2008, the statement was updated following another workshop, then circulated for further comment to participants and all heads of academic departments of public health with this responsibility. Extracts are reproduced below with interleaved comments. Given the scant evidence-base, potential research questions are suggested.
In 2003, the GMC published an updated version of Tomorrow’s Doctors: recommendations on undergraduate medical education. It stated that: ‘The health and safety of the public must be an important part of the curriculum’, and that: ‘Learning opportunities must help students explore knowledge, and evaluate and integrate evidence critically’. In relation to the health of the public in the curriculum: ‘graduates must understand the issues and techniques involved in studying the effect of diseases on communities and individuals, including: This document is for people working in medical education, to suggest how the GMC recommendations can be implemented. It outlines the broad principles that should guide the development of undergraduate public health education, and explains the role of departments of public health.
assessing community needs in relation to how services are provided;
genetic, environmental and social causes of, and influences on the prevention of, illness and disease; and
the principles of promoting health and preventing disease, including surveillance and screening.’
The national statement sought to raise public health awareness amongst ‘key staff outwith public health departments’ who make, implement or influence policy in undergraduate medical education. Previous international debate about medical schools including the health of populations in their mission remains a powerful reminder of the social contract required to make the public health education of medical students ‘everyone’s business’:
How do medical educators and clinicians (from outwith public health departments) value this subject, and what is the effect of their role-modelling?
How have medical schools adapted curricula better to meet the health needs of local populations?
The importance of public health
Clinical medicine is concerned with diagnosing illness, treating disease, promoting health and relieving pain and distress in individual patients. Public health is concerned with improving the health of populations and reducing inequalities in health. It is commonly defined as:29
the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.
Public health goals can be identified in three main areas. Within ‘health services’, public health is concerned with the organization and delivery of safe, high-quality services for prevention, treatment and care. ‘Health protection’ is concerned with measures to control infectious disease risks and environmental hazards, including public health emergencies. ‘Health improvement’ is concerned with societal interventions to prevent disease and promote health that are not primarily delivered through health services. Effective medical practitioners must be concerned with contributing to each set of goals […].
This analogy between individual and population ‘diagnosis’ is an accepted way of highlighting the relationship and relevance of public health to clinical practice:
How does the ‘medical socialization’ of students shape their views about the public’s health?