EDITORIAL Public Health Education Reform in the Context of Health Professions Education Reform
In the context of unprecedented change in the health care delivery system in the United States and of dramatic changes in demographics and burden of disease in the United States and worldwide, it is appropriate that there is a an increased interest in the reforms that will be needed in health professions education to prepare the next generation of health professionals for this changing world. This is a time for each of the health professional schools to undergo selfexamination, to challenge many traditional assumptions, and to pilot innovations aimed at better aligning education with contemporary societal needs. Each of the health professions will identify educational issues specific to it, but there will be many issues, innovations, and pedagogies that will cross professional lines and be common to the health professions in general. These are the areas that create opportunities for the kind of interprofessional educational reform that will improve the education in each profession and at the same time better prepare health professionals to function effectively as team members in the collaborative practices and systems of the future. It is, therefore, highly desirable that the reform of health professions education be undertaken interprofessionally—across schools and with an interprofessional faculty team.
PUBLIC HEALTH AND THE INTERPROFESSIONAL APPROACH There are several reasons why schools of public health should be part of this interprofessional
S8 | Editorial
approach to health professions education reform. First, public health faculty have much to contribute to the education of all health professionals by bringing an understanding of population health and the social determinants of health. Secondly, public health students will benefit from being introduced to the culture and identity of being a health professional alongside their student colleagues in nursing, medicine, pharmacy, dentistry, and the other health professions. Third, there can be synergy between educational reforms in public health and in each of the other professions. Finally, a broader appreciation of public health by the other health professions and a greater understanding of the other health professions by public health professionals can lead to more productive professional relationships in the future. Improvements in health care delivery can be informed by public health input, and public health professionals will benefit from a greater understanding of the perspectives of their clinical colleagues. The proposition driving current reform efforts in health professions education is that insufficient attention has been given to the preparation of the health professions work force as an essential tool in achieving the goals of a reformed health and health care system: better care, better health, lower cost.1 Health professionals appropriately trained, in the right number, with the right distribution and working up to their full capabilities are essential to achieving this triple aim. To do this will require innovations in the
way in which we educate health professionals. The innovations that are needed are those that will better align education with the needs of the public, and the outcomes of the innovations should be assessed by the degree to which they lead to improvements in population and patient outcomes and in the performance of the health care system.2
AREAS OF INNOVATION There are six areas of innovation in health professions that have been identified that could improve the alignment of education and public needs.3 Each of these areas of innovation have applications in public health education, and public health faculty can be very important contributors to all of these efforts.
1. Interprofessional Education The case for Interprofessional Education (IPE) being an essential element in the alignment strategy is quite straightforward. There is a growing body of evidence that care delivered by well-functioning teams is better care, but our health professions education system keeps learners from different professions separate until the educational process is completed. Team-based competencies have not been made a core goal of health professions education. As a result, we have too many examples of poorly functioning teams because of the lack of the appropriate knowledge, attitudes, and skills. The adverse consequences of these poorly functioning teams are greater than ever in terms of poor patient outcomes
American Journal of Public Health | Supplement 1, 2015, Vol 105, No. S1
EDITORIAL
and high costs of care. Much progress has been made in defining the core competencies for interprofessional collaborative practice,4 but we have still not made “learning about, from and with”5 other professions as central to all health professions education as it needs to be. Public health needs to be a part of this effort because it brings critical population health expertise and an interprofessional perspective. In addition, public health students will benefit from better understanding the roles and skills of the other health professions if they are going to successfully interact with them in their careers. The students in the other health professions need to better appreciate how the public health perspective complements their training and experience and can help them better accomplish their goals. Some of the current IPE initiatives have included learners and faculty from public health,6 but more are needed.
2. New Models For Clinical Education The management of chronic disease over time is the predominant work of health professionals today, and the majority of this care occurs outside of the hospital. In spite of this, a large amount of health professional educations remains hospital based, and the dominant model for training is a series of “rotations” of varying lengths to provide exposure to multiple settings and specialties but with little continuity. To have health professionals who are more prepared to meet the needs of a population with an increasing burden of chronic disease, we need new models for clinical education that are more longitudinal, integrated, immersive, and community based.7 Public health
educators are well prepared to help design such experiences because their training is grounded in epidemiology, prevention, and population health and has a community, systems, and policy orientation. Well-designed longitudinal integrated educational experiences can better incorporate population health learning goals for students of all the health professions. Longitudinal experiences also make it possible to have meaningful interprofessional student engagement in quality of care and systems improvement efforts.
3. New Content to Complement the Biological Sciences The biological sciences are necessary but not sufficient to prepare an effective practitioner and leader in the health professions today. Both education and practice today must be informed by many other disciplines including economics, statistics, epidemiology, health policy, systems design, informatics, ethics, engineering, and business. Much more attention needs to be given to the social context of health and to the interactions between the health professions and society. Schools of public health are important resources for all the health professional schools in teaching and integrating these other disciplines. They can and should be models for cross-school interprofessional faculty efforts. These would serve as models for the future professional activities for students in public health and the other health professions.
4. New Educational Models Based on Competency Health professions education has a responsibility to society to produce health professionals who
Supplement 1, 2015, Vol 105, No. S1 | American Journal of Public Health
are competent to perform their varied functions, and the education should be accomplished in a timely and efficient manner. Historically the time for training in each profession has been determined by the number of years or months of prescribed experiences and there has been a bias toward making the experiences as similar as possible for all learners. As educators, we know that our learners arrive with a wide range of prior academic, personal, and professional experiences, and we also know that learners acquire the requisite knowledge, skills, and attitudes of their professions at different rates. We also know that within each of the professions we are preparing our learners for a wide variety of different careers. For all of these reasons the prescribed “time in place” approach to the education of health professional education makes less and less sense. A competencybased approach could be more efficient and more individualized. There is much that needs to be done across the health professions to establish the appropriate metrics for a competency-based approach. Public health has invested heavily in the development of competences for its own field. Well-functioning interprofessional faculty collaboratives (including public health) could advance this work for all the health professions. There is much that each of the health professions have to learn from each other in these efforts.8
5. New Educational Technologies The explosive growth of information relevant to the health professions, the need for distributed learning at multiple and distant sites, the goals of interprofessional education, and the necessity of life-long learning
beyond initial education for licensure and certification all call for health professions education to develop and use new tools for learning. Simulation, telemedicine, on-line asynchronous learning, avatars, and the “flipped classroom”9 will all be essential parts of the health professions education landscape of the future. These are being applied broadly across all the health professions, but there is still much to be learned about the appropriate timing and place for each of these technologies in conjunction with direct interaction with faculty, patients, families, and communities. We will need new tools to assess both individual learner and program outcomes. Each profession should not do this work alone. It can best be done by interprofessional faulty groups, including public health.
6. Develop the Next Generation of Leaders and Innovators in Health Professions Education All of the health professions have underinvested in the faculty development necessary to produce the next generation of educational scholars and innovators. To accomplish the goals of aligning health professions education with societal needs through the innovations cited earlier and to identify other innovations that will be needed in a changing and evolving health system will require time, leadership, and creativity from faculty devoted to these tasks. Every health professional school must devote itself to the task of identifying these educational innovators and leaders for the future and nurturing them. While much of this work will be school specific, there is much that each health professional school can learn from each other in
Editorial | S9
EDITORIAL
pursuit of these goals, and there also are real opportunities for interprofessional faculty development.10
CONCLUSIONS The theme of this very important supplement to the American Journal of Public Health is innovation in public health education. I have made the case that this should be thought of in the context of broader reform in health professions education. Public health faculty and students can play an important role as participants in broader health professions education reform bringing their unique knowledge, skills, and perspective, and public health education reform can be informed by and enhanced by the reform efforts in the other professions. j George E. Thibault, MD
About the Author George E. Thibault is a guest editor for this issue and is the President of the Josiah Macy Jr. Foundation, New York, NY. Correspondence should be sent to George E. Thibault, 44 East 64th Street, New York, NY 10065 (e-mail: gthibault@macyfoundation. org). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted October 20, 2014. doi:10.2105/AJPH.2014.302407
change and closer ties between classroom and practice. Health Aff (Millwood). 2013;32(11):1928---1932. 4. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. 5. World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva, Switzerland: World Health Organization; 2010. Available at: http://whqlibdoc.who. int/hq/2010/WHO_HRH_HPN_10.3_eng. pdf. Accessed on September 23, 2013. 6. Josiah Macy Jr Foundation. Conference on Interprofessional Education; April 1---3, 2012. New York, NY. Available at: http://macyfoundation.org/docs/ macy_pubs/JMF_IPE_book_web.pdf. Accessed on September 23, 2013. 7. Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;356(8):858---866. 8. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051---1056. 9. Khan S. The One World Schoolhouse: Education Reimagined. London, UK: Hodder and Stoughton Ltd.; 2012. 10. Hall LW, Zierler BK. Interprofessional education and practice guide no. 1; developing faculty to effectively facilitate interprofessional education. J Interprof Care. 2015;29(1)3---7.
Acknowledgments This editorial is based on a talk presented at the Innovations in Public Health Education Summit sponsored by the Columbia University Mailman School of Public Health on June 4, 2013.
References 1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759---769. 2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923---1958. 3. Thibault GE. Reforming health professions education will require culture
S10 | Editorial
American Journal of Public Health | Supplement 1, 2015, Vol 105, No. S1
In the context of unprecedented change in the health care delivery system in the United States and of dramatic changes in demographics and burden of disease in the United States and worldwide, it is appropriate that there is a an increased interest in the reforms that will be needed in health professions education to prepare the next generation of health professionals for this changing world. This is a time for each of the health professional schools to undergo selfexamination, to challenge many traditional assumptions, and to pilot innovations aimed at better aligning education with contemporary societal needs. Each of the health professions will identify educational issues specific to it, but there will be many issues, innovations, and pedagogies that will cross professional lines and be common to the health professions in general. These are the areas that create opportunities for the kind of interprofessional educational reform that will improve the education in each profession and at the same time better prepare health professionals to function effectively as team members in the collaborative practices and systems of the future. It is, therefore, highly desirable that the reform of health professions education be undertaken interprofessionally—across schools and with an interprofessional faculty team.
PUBLIC HEALTH AND THE INTERPROFESSIONAL APPROACH There are several reasons why schools of public health should be part of this interprofessional
S8 | Editorial
approach to health professions education reform. First, public health faculty have much to contribute to the education of all health professionals by bringing an understanding of population health and the social determinants of health. Secondly, public health students will benefit from being introduced to the culture and identity of being a health professional alongside their student colleagues in nursing, medicine, pharmacy, dentistry, and the other health professions. Third, there can be synergy between educational reforms in public health and in each of the other professions. Finally, a broader appreciation of public health by the other health professions and a greater understanding of the other health professions by public health professionals can lead to more productive professional relationships in the future. Improvements in health care delivery can be informed by public health input, and public health professionals will benefit from a greater understanding of the perspectives of their clinical colleagues. The proposition driving current reform efforts in health professions education is that insufficient attention has been given to the preparation of the health professions work force as an essential tool in achieving the goals of a reformed health and health care system: better care, better health, lower cost.1 Health professionals appropriately trained, in the right number, with the right distribution and working up to their full capabilities are essential to achieving this triple aim. To do this will require innovations in the
way in which we educate health professionals. The innovations that are needed are those that will better align education with the needs of the public, and the outcomes of the innovations should be assessed by the degree to which they lead to improvements in population and patient outcomes and in the performance of the health care system.2
AREAS OF INNOVATION There are six areas of innovation in health professions that have been identified that could improve the alignment of education and public needs.3 Each of these areas of innovation have applications in public health education, and public health faculty can be very important contributors to all of these efforts.
1. Interprofessional Education The case for Interprofessional Education (IPE) being an essential element in the alignment strategy is quite straightforward. There is a growing body of evidence that care delivered by well-functioning teams is better care, but our health professions education system keeps learners from different professions separate until the educational process is completed. Team-based competencies have not been made a core goal of health professions education. As a result, we have too many examples of poorly functioning teams because of the lack of the appropriate knowledge, attitudes, and skills. The adverse consequences of these poorly functioning teams are greater than ever in terms of poor patient outcomes
American Journal of Public Health | Supplement 1, 2015, Vol 105, No. S1
EDITORIAL
and high costs of care. Much progress has been made in defining the core competencies for interprofessional collaborative practice,4 but we have still not made “learning about, from and with”5 other professions as central to all health professions education as it needs to be. Public health needs to be a part of this effort because it brings critical population health expertise and an interprofessional perspective. In addition, public health students will benefit from better understanding the roles and skills of the other health professions if they are going to successfully interact with them in their careers. The students in the other health professions need to better appreciate how the public health perspective complements their training and experience and can help them better accomplish their goals. Some of the current IPE initiatives have included learners and faculty from public health,6 but more are needed.
2. New Models For Clinical Education The management of chronic disease over time is the predominant work of health professionals today, and the majority of this care occurs outside of the hospital. In spite of this, a large amount of health professional educations remains hospital based, and the dominant model for training is a series of “rotations” of varying lengths to provide exposure to multiple settings and specialties but with little continuity. To have health professionals who are more prepared to meet the needs of a population with an increasing burden of chronic disease, we need new models for clinical education that are more longitudinal, integrated, immersive, and community based.7 Public health
educators are well prepared to help design such experiences because their training is grounded in epidemiology, prevention, and population health and has a community, systems, and policy orientation. Well-designed longitudinal integrated educational experiences can better incorporate population health learning goals for students of all the health professions. Longitudinal experiences also make it possible to have meaningful interprofessional student engagement in quality of care and systems improvement efforts.
3. New Content to Complement the Biological Sciences The biological sciences are necessary but not sufficient to prepare an effective practitioner and leader in the health professions today. Both education and practice today must be informed by many other disciplines including economics, statistics, epidemiology, health policy, systems design, informatics, ethics, engineering, and business. Much more attention needs to be given to the social context of health and to the interactions between the health professions and society. Schools of public health are important resources for all the health professional schools in teaching and integrating these other disciplines. They can and should be models for cross-school interprofessional faculty efforts. These would serve as models for the future professional activities for students in public health and the other health professions.
4. New Educational Models Based on Competency Health professions education has a responsibility to society to produce health professionals who
Supplement 1, 2015, Vol 105, No. S1 | American Journal of Public Health
are competent to perform their varied functions, and the education should be accomplished in a timely and efficient manner. Historically the time for training in each profession has been determined by the number of years or months of prescribed experiences and there has been a bias toward making the experiences as similar as possible for all learners. As educators, we know that our learners arrive with a wide range of prior academic, personal, and professional experiences, and we also know that learners acquire the requisite knowledge, skills, and attitudes of their professions at different rates. We also know that within each of the professions we are preparing our learners for a wide variety of different careers. For all of these reasons the prescribed “time in place” approach to the education of health professional education makes less and less sense. A competencybased approach could be more efficient and more individualized. There is much that needs to be done across the health professions to establish the appropriate metrics for a competency-based approach. Public health has invested heavily in the development of competences for its own field. Well-functioning interprofessional faculty collaboratives (including public health) could advance this work for all the health professions. There is much that each of the health professions have to learn from each other in these efforts.8
5. New Educational Technologies The explosive growth of information relevant to the health professions, the need for distributed learning at multiple and distant sites, the goals of interprofessional education, and the necessity of life-long learning
beyond initial education for licensure and certification all call for health professions education to develop and use new tools for learning. Simulation, telemedicine, on-line asynchronous learning, avatars, and the “flipped classroom”9 will all be essential parts of the health professions education landscape of the future. These are being applied broadly across all the health professions, but there is still much to be learned about the appropriate timing and place for each of these technologies in conjunction with direct interaction with faculty, patients, families, and communities. We will need new tools to assess both individual learner and program outcomes. Each profession should not do this work alone. It can best be done by interprofessional faulty groups, including public health.
6. Develop the Next Generation of Leaders and Innovators in Health Professions Education All of the health professions have underinvested in the faculty development necessary to produce the next generation of educational scholars and innovators. To accomplish the goals of aligning health professions education with societal needs through the innovations cited earlier and to identify other innovations that will be needed in a changing and evolving health system will require time, leadership, and creativity from faculty devoted to these tasks. Every health professional school must devote itself to the task of identifying these educational innovators and leaders for the future and nurturing them. While much of this work will be school specific, there is much that each health professional school can learn from each other in
Editorial | S9
EDITORIAL
pursuit of these goals, and there also are real opportunities for interprofessional faculty development.10
CONCLUSIONS The theme of this very important supplement to the American Journal of Public Health is innovation in public health education. I have made the case that this should be thought of in the context of broader reform in health professions education. Public health faculty and students can play an important role as participants in broader health professions education reform bringing their unique knowledge, skills, and perspective, and public health education reform can be informed by and enhanced by the reform efforts in the other professions. j George E. Thibault, MD
About the Author George E. Thibault is a guest editor for this issue and is the President of the Josiah Macy Jr. Foundation, New York, NY. Correspondence should be sent to George E. Thibault, 44 East 64th Street, New York, NY 10065 (e-mail: gthibault@macyfoundation. org). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted October 20, 2014. doi:10.2105/AJPH.2014.302407
change and closer ties between classroom and practice. Health Aff (Millwood). 2013;32(11):1928---1932. 4. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. 5. World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva, Switzerland: World Health Organization; 2010. Available at: http://whqlibdoc.who. int/hq/2010/WHO_HRH_HPN_10.3_eng. pdf. Accessed on September 23, 2013. 6. Josiah Macy Jr Foundation. Conference on Interprofessional Education; April 1---3, 2012. New York, NY. Available at: http://macyfoundation.org/docs/ macy_pubs/JMF_IPE_book_web.pdf. Accessed on September 23, 2013. 7. Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;356(8):858---866. 8. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051---1056. 9. Khan S. The One World Schoolhouse: Education Reimagined. London, UK: Hodder and Stoughton Ltd.; 2012. 10. Hall LW, Zierler BK. Interprofessional education and practice guide no. 1; developing faculty to effectively facilitate interprofessional education. J Interprof Care. 2015;29(1)3---7.
Acknowledgments This editorial is based on a talk presented at the Innovations in Public Health Education Summit sponsored by the Columbia University Mailman School of Public Health on June 4, 2013.
References 1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759---769. 2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923---1958. 3. Thibault GE. Reforming health professions education will require culture
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American Journal of Public Health | Supplement 1, 2015, Vol 105, No. S1
