Practical tips and/or guidelines
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Teaching Health Policy in Graduate Medical Education: Proposed Curricular Components

Cedric Dark[1][a], M. Tyson Pillow[1][b], Alison Haddock[1][c]

Institution: 1. Baylor College of Medicine
Corresponding Author: Dr Cedric Dark (cedric.dark@bcm.edu)
Categories: Comparative Medical Education, Curriculum Planning, Postgraduate (including Speciality Training)
Published Date: 14/11/2018

Abstract

Issue

The layers of systems affecting patient care, including that of clinic and hospital policy as well as state and federal laws, are the topic of one of the Accreditation Council for Graduate Medical Education’s six Core Competencies. Health policy, a key aspect of Systems Based Practice, often receives limited exposure in graduate medical education (GME).

Evidence

A 15-point framework for teaching health policy in undergraduate medical education was published earlier this decade. At the GME level, several programs – both institutional and specialty-specific - have described their experience teaching health policy to their own learners. We therefore expand on the previously described framework adapting it for the development of a GME curriculum focused on U.S. domestic health policy. In addition, we analyze how well the currently employed Milestones address important health policy concepts.

Implications

Review of the Milestones of across all specialties reveal that four components - health insurance, history and consequences of major health care legislation, health disparities, and U.S. healthcare system, financing, and payment – remain underrepresented in the current approach to teaching health policy in graduate medical education. We recommend a centralized approach from institutional GME programs to address shared curricular needs in health policy supplemented by tailored content designed to solidify these concepts with a specialty-specific focus.

Keywords: health policy; ethics; leadership; business of medicine; graduate medical education

Introduction

The Accreditation Council for Graduate Medical Education (ACGME) has defined Systems Based Practice (SBP) as one of six core competencies for physicians. This competency describes layers of systems affecting patient care, including that of clinic and hospital policy as well as state and federal laws, therefore necessitating that physicians understand the healthcare environment and know how to work within these complex systems to provide care for their patients (NEJM Knowledge+, 2018). Domestic health policy represents a major component of SBP.

 

Physicians must understand how health policy shapes our healthcare system to achieve true competency in this area. As defined by the World Health Organization, health policy represents the “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society” (World Health Organization, 2017) Recent health policy debates and the subsequent engagement of medical professionals in the political dialogue highlights the importance of health policy as a competency (Lancet, 2017). 

Lack of Medical Education in Health Policy

Physicians receive little education in health policy as part of their medical training (Goetz, et al, 2010; Greysen, et al, 2009). Over half of medical students are dissatisfied with the health policy education in medical school (Agrawal, et al, 2005). Therefore, we describe a framework for developing a graduate medical education (GME) curriculum focused on U.S. domestic health policy. 

 

Few publications describe existing health policy curricula at the undergraduate medical education or GME level (Bischof, et al, 1996; Short & Hodgetts, 1997; Furin, et al, 2006; Foster, et al, 2008; Strelnick, et al, 2008; Nagler, et al, 2010; Chick, et al, 2014). Despite calls for more emphasis on the “social, economic, and political aspects of health care delivery” from medical educators (Cooke, et al, 2006) and recent interest in learning health policy, leadership, and medical economics by students, perceived education in health policy remains unacceptably low (Patel, et al, 2014).

 

Graduates consistently report their education in health policy as less adequate than instruction in other subjects. In 2013, 59% of graduating medical students ranked their education in health policy as adequate (AAMC, 2013). By comparison, 94% rated education in the care of hospitalized patients as adequate (AAMC, 2013).

 

If incoming residents feel inadequately prepared to deal with the issues of health policy as they relate to daily clinical practice, how can program directors best ensure that trainees possess competency in these topics? We propose a curricular framework with 19 components to teach health policy at the GME level. 

An Existing Framework for Teaching Health Policy with Adjustments for GME

A framework with proposed components of a medical school curriculum in health policy currently exists (Patel, et al, 2011). The 15-point Patel framework contains the following components: (1) Adverse events, medical errors, and malpractice; (2) Comparative effectiveness;(3) Health care safety net; (4) Health disparities;
(5) Health information technology; (6) Health insurance;(7) History and consequences of major health care legislation; (8) Medical decision making;(9) Medical economics; (10) Models of care management and control; (11) Quality improvement;(12) Quality indicators, measures, and outcomes;(13) Patient safety; (14) Physician workforce; and (15) U.S. health care system, financing, and payment. The Patel framework can serve as the building blocks for a health policy curriculum at the GME level, with adjustments as needed for each specialty.

 

Upon review of the Patel framework, the existing literature, and expert opinion, we feel the need to elevate four additional components as necessary for trainees in all specialties to understand health policy in the U.S. Topics within these components are partially covered in other curricula, yet certain aspects must be addressed from a health policy perspective.  

 

First, a discussion of the policy process at the federal and state levels has been excluded from the Patel framework. For physicians to understand how to change policy, it is necessary to understand the process of developing legislation through stakeholder input, the legislative process, and implementation by the executive branch of government (Greysen, et al, 2009; Heiman, et al, 2016). Second, the business aspects of medicine (e.g.physician reimbursement, practice management, organized medicine) affect a physician’s daily life and are heavily influenced by policy decisions. Other authors also recognize the importance of the business aspects of medicine (Heiman, et al, 2016; Dequesada, et al, 2015). Third, leadership principles often taught in team-based trainings (e.g.TeamSTEPPS®,LifeWings®) may not necessarily include hospital management, negotiation, or professional advocacy (Bayer, et al, 2017; Combes & Arespacochaga, 2012; Gonzalo, et al, 2017; Crosson, et al, 2011). These principles are among several skillsets today’s medical student leaders must learn. Lastly, ethical principles in health care address issues codified in laws such as HIPAA or touch upon resource allocation in health care. While not specifically mentioned as a separate component in the Patel framework, the authors indicate that faculty expertise in ethics is crucial to interdisciplinary instruction (Patel, et al, 2011). Other educators similarly address health care ethics in their curricula, therefore ethics in health care should be its own curricular component (Nagler, et al, 2010).

Mapping Milestones

Each ACGME-accredited specialty has developed a set of Milestones to assess residents in the achievement of the core competencies. We (Dark and Haddock) reviewed the list of Milestones for each of the twenty-five primary specialties (excluding transitional year) under the umbrella of the ACGME available as of September 28, 2016 (ACGME, 2016). These Milestones were evaluated to determine their alignment with the nineteen curricular components we identified as important to a health policy curriculum for GME [Table 1].

 

Table 1.  Health policy curriculum components as represented in ACGME Milestones.

 

Adverse events, medical errors, and malpractice

Business aspects of medicine

Comparative effectiveness

Ethical principles

Health care safety net

Health disparities

Health information technology

Health insurance

History and consequences of major health care legislation

Leadership principles

Medical decision making

Medical economics

Models of care management and control

Patient safety

Physician workforce

Policy process at the federal and state levels

Quality improvement

Quality indicators, measures, and outcomes

U.S. health care system, financing, and payment

Allergy & Immunology

x

 

x

 

 

 

 

 

 

 

x

 

 

x

 

 

 

 

 

Anesthesiology

x

 

x

x

 

 

 

 

 

x

x

 

 

x

 

 

x

x

 

Dermatology

x

x

x

x

x

x

 

 

 

x

x

x

 

x

 

x

x

x

x

Emergency Medicine

x

x

x

 

 

 

x

 

 

x

x

 

 

x

 

 

x

 

 

Family Medicine

x

 

x

x

 

x

x

 

 

x

x

 

 

x

 

x

x

x

 

Internal Medicine

x

 

x

x

 

x

 

 

 

x

x

 

x

x

 

 

x

 

 

Medical Genetics

 

 

x

x

 

 

x

 

 

x

x

 

 

x

 

 

x

 

 

Neurosurgery

x

x

x

x

 

x

x

x

 

 

x

x

 

x

 

 

x

 

x

Neurology

x

 

x

x

 

 

 

 

 

 

x

 

 

x

 

 

x

 

 

Nuclear Medicine

x

x

 

 

 

 

x

x

x

x

x

 

 

x

 

 

x

x

x

Obstetrics & Gynecology

x

x

x

x

 

 

 

 

 

 

x

x

 

x

 

x

x

 

 

Ophthalmology

x

 

x

 

 

 

x

 

 

x

x

 

 

x

 

 

x

 

 

Orthopedics

x

 

x

 

 

 

x

 

 

 

x

 

 

x

 

 

x

 

x

Otolaryngology

x

 

x

x

 

x

 

 

 

 

x

 

 

x

 

 

 

 

 

Pathology

x

x

x

x

 

 

x

 

 

x

x

 

 

x

 

 

x

 

x

Pediatrics

 

 

 

 

 

 

 

 

 

x

x

 

 

 

x

x

x

 

 

Plastic Surgery

x

x

x

x

 

x

 

x

 

 

x

 

 

x

 

x

 

 

x

Physical Medicine & Rehab

x

x

x

x

 

 

x

 

 

x

x

 

x

x

 

x

x

 

x

Preventive Medicine

x

 

x

x

 

x

 

 

 

 

x

 

x

 

 

x

x

 

 

Psychiatry

x

 

x

x

 

x

x

 

 

x

x

 

 

x

 

x

x

 

 

Radiation Oncology

 

 

x

x

 

 

 

 

 

 

x

 

x

 

 

 

x

x

 

Diagnostic Radiology

x

x

x

x

 

 

 

 

 

x

x

 

 

x

 

 

x

 

 

Surgery

x

 

 

 

 

 

 

 

 

 

x

 

 

 

 

 

x

 

 

Thoracic Surgery

 

x

x

x

 

x

x

x

 

 

x

 

 

x

 

x

 

 

x

Urology

x

x

x

 

 

 

x

 

 

x

x

 

 

x

x

 

x

 

x

 

 

The most common curricular components reflected in the Milestones of a majority of all training programs were medical decision-making; comparative effectiveness; quality improvement; patient safety; adverse events, medical errors, and malpractice; ethical principles in health care; and leadership principles in health care. 

 

We then surveyed a panel of physicians, nurses, and medical educators with extensive backgrounds in health policy to rank the list of components according to the greatest importance for learners. The panelists’ backgrounds include health policy fellows and fellowship directors, health care consultants, health services researchers, and government officials. The difference between these two lists highlights areas of health policy where the modern-day education of physicians may be neglectful.

 

Many components ranked most important by experts are not addressed in the Milestones of a majority of medical specialties [Table 2]. Most notably, these include health insurance (16% representation), history and consequences of major health care legislation (4% representation), health disparities (36% representation), and U.S. healthcare system, financing, and payment (36% representation). If Milestones accurately reflect residency education, it is concerning that many residents may graduate without a firm knowledge of the most important health policy topics that they will encounter throughout their career.

 

Table 2. Components of a health policy curriculum in graduate medical education as represented in current specialty milestones and ranked in order of importance by policy experts.

Health Policy Curriculum Components

ACGME Milestones

 

Delphi Panel

 

Percent of programs

Rank

Likert Score

(out of 5)

Rank

Health insurance

16

14 e

4.8

1

History and consequences of major health care legislation

4

18

4.6

2

U.S. health care system, financing, and payment

36

10 d

4.6

3a

Health disparities

36

10 d

4.6

3a

Ethical principles in health care

68

6

4.4

5

Models of care management and control

16

14 e

4.4

6 b

Health care safety net

4

18

4.4

6 b

Policy process at the federal and state levels

36

10 d

4.3

8 c

Leadership principles

56

7

4.3

8 c

Health information technology

48

8

4.2

10 d

Quality indicators, measures, and outcomes

20

13

4.2

10 d

Quality improvement

84

3 a

4.2

10 d

Medical economics

12

16

4.2

10 d

Comparative effectiveness

88

2

4.2

10 d

Adverse events, medial errors, and malpractice

84

3 a

4.2

15 f

Business aspects of medicine

44

9

4.2

15 f

Patient safety

84

3 a

4.1

17

Physician workforce

8

17

4.0

18

Medical decision-making

100

1

3.7

19

Notes: aTied for 3rd position; bTied for 6thposition; cTied for 8thposition; dTied for 10thposition; Tied for 14thposition fTied for 15thposition

Ranking for ACGME Milestones listed by frequency of representation across specialties, with highest frequency #1 and lowest #19.

Implementing a Health Policy Curriculum for GME

Creation of a health policy curriculum is likely best handled at the institutional GME level rather than at the individual departmental level to allow for pooled resources, centralized funding, and avoid redundancy. As health policy expertise is typically scattered throughout an institution, a collaborative process between GME and individual departments is key to success. One idea would be to combine asynchronous curricula – developed centrally – with individualized speakers and activities to solidify key principles across the training spectrum. 

 

At our institution, the Center for Medical Ethics and Health Policy operates a GME curriculum called the “Ethics, Professionalism and Policy Program” (EP3) which centralizes didactic and asynchronous materials for multiple clinical departments. Several EP3 modules - Care in the Social Context, Health Care Economics, Medical Error, and Confidentiality – address issues pertinent to our health policy curriculum.

 

Within our department, we subsequently create specialty-specific content focused on active learning, small groups, and case-based exercises rooted in the institution-wide EP3 curriculum.

 

To address issues not covered by the EP3 curriculum, we offer additional didactics and small group exercises that supplement our residents’ education in health policy. The addition of health policy education in our department has not detracted from other clinical subjects as we have shifted some of our traditional emergency medicine education to asynchronous learning when possible. When no departmental expertise is available, institutional resources or guest speakers have proved critical. A solution that leverages UME resources, GME resources, and hospital resources has helped to avoid duplicity.

Conclusion

While often excluded from the formal education of physicians, health policy is a critical subject that affects the lives and livelihoods of both patients and physicians. The implications of health care policies for society are equally important, considering that over one-sixth of the economy is devoted to health care (CMS, 2017). Teaching health policy in GME, therefore, must be a priority for all medical specialties.  

 

Expanding on an existing framework for teaching health policy to medical students, we recommend four additional components that should be incorporated into resident training. These components include: the policy process, business aspects of medicine, leadership principles, and ethical principles in health care. Where there is overlap with other educational priorities, we recommend an approach from the health policy perspective.  We prioritize these components based on the recommendation of a panel of clinicians and health policy experts. We also implore program directors and institutions to put renewed focus on the following important components - health insurance, history and consequences of major health care legislation, health disparities, and U.S. healthcare system, financing, and payment – which currently do not receive enough attention in residency curricula as reflected in our comprehensive review of the Milestones across specialties.

 

We recommend a centralized approach from institutional GME programs to address shared curricular needs in health policy. In parallel, individual specialty programs should supplement institutional efforts with tailored content designed to solidify these concepts with a specialty-specific focus. 

Take Home Messages

  • Health policy affects the lives and livelihoods of patients and doctors
  • Teaching health policy in graduate medical education should be a priority for educators
  • Physicians must understand the current U.S. health care system including its financing and payment mechanisms
  • Programs should supplement GME education about health policy with specialty-specific lessons

Notes On Contributors

Dr. Dark is the Director of Health Policy: Education in the Henry JN Taub Department of Emergency Medicine at Baylor College of Medicine (Houston, TX).

 

Dr. Haddock is the Director of Health Policy: Advocacy in the Henry JN Taub Department of Emergency Medicine at Baylor College of Medicine (Houston, TX).

 

Dr. Pillow is the Program Director and Vice-Chair of Education in the Henry JN Taub Department of Emergency Medicine at Baylor College of Medicine (Houston, TX).

Acknowledgements

None.

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Appendices

None.

Declarations

There are some conflicts of interest:
CD reports ownership in PolicyRx, LLC, an advocacy organization for evidence-based health policy. This organization has received support in the past 12 months from Community Health Choice. AH reports no conflict of interest. MTP reports no conflict of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

This work has been deemed exempt and does not constitute human subjects research by the Baylor College of Medicine Internal Review Board under US 45 CFR 46.102(d) for protocol number H-38471.

External Funding

This paper has not had any External Funding

Reviews

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Richard Hays - (15/03/2019) Panel Member Icon
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This is a well written paper that takes the position that health policy should be taught during basic medical education. While I respect this view, based on my postgraduate experience where I have observed how health policy (particularly changes in health policy) can have a powerful influence on health care delivery. However, my experiences as a dean included receiving many, many, position statements asking for more content of many important topics to be included, without much consideration of the total curriculum and assessment load. Basic medical education is already overcrowded and the main aim is preparation to begin clinical practice semi-independently. It is therefore important that papers like this go beyond the “why and what” to the “how and when”. Implementation is the real challenge. How can policy issues be integrated with learning about clinical practice? Would electives for those more interested after a more compact “core” exposure to health policy be appropriate? Some suggestions and guidance from the authors may be valuable.
Possible Conflict of Interest:

I am Editor of MedEdPublish

Ariela Marshall - (14/11/2018) Panel Member Icon
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The authors provide a comprehensive and interesting overview of the importance for providers to have knowledge in several domains of health policy but the current lack of education in these domains. Table 2 was extremely useful in demonstrating the current lack of effective teaching/curricula in many aspects of health policy. However, I found the next section of the paper (“Implementing a Health Policy Curriculum for GME”) to lack the strength of the preceding sections. The authors briefly describe the GME curriculum in policy and creation of additional didactics in health policy not covered by the broader EP3 curriculum, but did not provide information on exactly what those didactics cover, the structure of the sessions, the percentage of trainees who are interested in the sessions and/or actually attend the sessions, and trainee/teacher satisfaction with the sessions. It would be helpful to have some more granular description of the interventions made at the authors’ institution as a model for other institutions who wish to expand their own GME options for health policy education.