A curriculum for the times: an experiment in teaching health policy to residents in family medicine Samuel E.D. Shortt, MD; P. Geoffrey Hodgetts, MD CMAJ 1997;157:1567-9 [ résumé ] From the Department of Family Medicine, Queen's University, Kingston, Ont. This article has been peer reviewed. Reprint requests to: Dr. Samuel E.D. Shortt, Queen's Health Policy Research Unit, Queen's University, 99 University Ave., Kingston ON K7L 3N6; fax 613 545-6353 © Canadian Medical Association (text and abstract/résumé) Abstract The Department of Family Medicine at Queen's University in Kingston, Ont., recently undertook a pilot project to familiarize residents in family medicine with physician-related health policy issues. The objective of the project was to ease the residents' transition into practice and to equip them to participate effectively in future policy debates. All first-year residents assigned to a 4-month clinical rotation in the Department of Family Medicine took part in the program, which consisted of 5 weekly 1-hour lecture and discussion sessions. The program was offered as one component of the 130-hour core curriculum for first-year residents. Participants evaluated the program as highly informative and extremely relevant to their career plans. The authors conclude that health policy is a subject that can be incorporated into the core curriculum of residency training programs. Résumé Le Département de médecine familiale de l'Université Queen's à Kingston (Ont.) a récemment entrepris un projet pilote destiné à familiariser les résidents en médecine familiale aux questions de politique de santé qui touchent les médecins. Le projet a pour but de faciliter la transition des résidents à leur pratique et de leur donner des moyens de participer efficacement aux débats futurs de politiques. Tous les résidents de première année assignés à un programme clinique de rotation sur 4 mois au Département de médecine familiale ont participé au projet; celui-ci se composait de 5 cours magistraux et séances de discussion d'une heure par semaine. Le programme a été offert dans le cadre du programme d'études de base de 130 heures des résidents de première année. Les participants ont évalué le programme, qu'ils ont trouvé fort informatif et très pertinent à leur plan de carrière. Les auteurs concluent que la politique de santé est un sujet qui peut être incorporé au programme d'études de base de la formation en résidence. The practice of medicine has long been recognized as inherently stressful,1 and there are some indications that it is becoming more so.2 In developed nations this new stress may well be due to contemporary changes in health policy, exemplified by increasingly common terms such as restructuring, downsizing, devolution and retrenchment. Practising physicians, often with more bewilderment than understanding, sense their professional world shifting in unanticipated directions. In Ontario, an intrusive government3 and an apparent inability to influence the administrative process4 have left physicians pessimistic about their professional future. If practising physicians find themselves puzzled and worried, how much more vulnerable must be those physicians who have yet to complete their training. Although newly graduated physicians certainly bring to the profession values and beliefs that distinguish them from their predecessors, they must also share many concerns with established physicians. They are faced with an almost daily barrage of proposals and regulations to alter licensure requirements, to reform physician payment schemes, to create a centralized medical human resources policy, to enforce evidence-based practice guidelines, and to restructure existing hospital and long-term care resources. How are postgraduate trainees prepared for this brave new world of aggressive health policy? A survey of Canadian physicians in 19925 revealed that, in reflecting on their medical education, 74% would have liked more training in medical economics. No other subject was identified by so many as lacking, yet there is little evidence that medical educators have given priority to incorporating health policy into educational programs. A review of the recent literature reveals only fragmentary efforts: a 1-day health policy symposium for Harvard medical students,6 a promising summer health policy studentship program in Washington, DC,7 a nursing program in Rhode Island with a dynamic health policy component,8 and occasional course offerings in US schools of public health.9 To our knowledge, no postgraduate training programs in family medicine in Ontario devote formal curriculum time to health policy. The pilot project Objectives The Department of Family Medicine at Queen's University, Kingston, Ont., began formal instruction in health policy for residents in fall 1995. The purpose was twofold. First, it was hoped that, by familiarizing residents with contemporary trends in policy, the program might alleviate the anxiety associated with the unfamiliar and thereby smooth the residents' passage into practice. Second, it was anticipated that teaching residents about basic health policy issues would better prepare them to play an informed role in future policy debates. Format All first-year residents in family medicine take a 4-month clinical rotation in the department's teaching facility. During the rotation residents attend 130 hours of core curriculum seminars that focus on clinical topics, medical ethics, behavioural medicine, communication skills and computers in medicine. Into this seminar series were introduced five 1-hour lecture and discussion sessions on health policy. Typically, 4 to 10 residents attended the sessions, which consisted of didactic presentations with pre-identified points for discussion. No advance preparation was required, and no assignments were given. Content The topics were chosen, first, because they were considered immediately relevant to the career concerns of residents poised to enter practice and, second, because they spoke to areas of evolving public policy. The following topics, among others, have been covered: Recent trends in Ontario health policy: an overview of the system, a survey of indicators of population health status, and measures of provider and consumer satisfaction; a discussion of the increasing awareness of high costs and the problem of resource allocation in a recessionary economy; a review of responses to the challenges of health policy, including needs-based planning, community-generated health goals, utilization review and outcomes measurement. Physician payment systems: a review of the evolution of state-sponsored health insurance in Ontario (1968 to the present); an assessment of the strengths and weaknesses of the fee-for-service system; an examination of future policy options, including reformed fee-for-service, alternative funding formats and the introduction of a two-tier system of public and private care. Physician human resources planning: an overview of the growing fears of a physician surplus in Canada; an examination of the maldistribution of physicians and the failure of attempts to change it; a consideration of constraints on policy-making and suggestions for future policy, including reductions in training slots, differential fee schedules and rural incentive programs. Quality assessment and assurance in ambulatory care: a discussion of the debate over the state's obligation to enforce quality in health care; a review of methods to assess quality, with reference to existing programs in Ontario; an examination of future directions, including the use of practice guidelines and practice audits. Medicine and the deployment of technology: a description of the evolution of technology in medicine; critiques of technology, based on past mistakes, costs and lack of enhancement of population health; examples of unrestrained proliferation; suggestions for a program of technology assessment. The underlying themes for all of the presentations were that the areas under discussion are comparatively new on the public policy agenda, that no fixed solutions have emerged as yet and that physicians, while key players, constitute but one group among many legitimate stakeholders. The educational objective was therefore to impart a sense of the complexity of health policy issues and to point to the multiplicity of solutions offered in a pluralist society. Although 5 lecture hours could hardly do justice to such a rich field, they did suffice as a pilot project from which future expansion might proceed and which might be duplicated by other interested programs. The content was updated by the instructor as required to accommodate changes in legislation and policy. Evaluations by residents As part of regular curriculum review, each seminar was evaluated by the residents immediately after the session. The respondents completed a standard evaluation form to assess the clarity of the seminar's objectives, as well as the topic's relevance and content, on a 5-point scale. The residents were also asked to self-rate their knowledge on a scale of 1 to 10 at the beginning and the end of the session and to make note of any suggested improvements for future seminars. To date, 60 evaluations have been completed, and all have been favourable. Relevance to training was given a mean rating of 5/5 by the respondents. Knowledge of the subjects was rated at 4.7/10 before the seminars and 7.6/10 after. Additional written comments have been uniformly positive. In October 1996 the entire core seminar program was reviewed. The 27 residents who had participated in the health policy seminars up to that point rated the usefulness of these sessions at 4.7/5, the highest score achieved by any group of seminars in the series. Respondents also indicated that the time available for this subject should be increased. Although the impact of the learning experience on residents after they leave the residency program has been discussed among faculty members, we have not had the benefit of a long-term evaluation because the health policy sessions have been offered only as a brief pilot project. If the program is expanded, the participation of graduates in the policy process, such as service on District Health Council committees or on committees of professional organizations that deal with policy issues, might be one measure of long-term impact. Future directions Curriculum time permitting, the health policy course (which is now a permanent part of the curriculum) may be expanded. However, the key to success appears to be the strong consensus among residents that the material is directly relevant to their medical future. The focus on physicians was deliberately chosen to achieve this sense of relevance. This block of seminars could be the anchor for an expanded course covering both more theoretical topics, such as needs-based planning, small-area variations or outcomes measurement, and practical topics, including hospital funding, long-term care options and regional devolution. In any expanded offering, residents would be encouraged to participate in the selection of topics. The expanded course would also, ideally, be coordinated with periodic presentations on aspects of health policy by outside experts at the weekly departmental grand rounds or the monthly meetings of the hospital's Department of Family Medicine. The pilot project was not without limitations. The brief window in the curriculum into which it was squeezed did not allow time for an adequate theoretical discussion of the policy process or formal methods of policy analysis, nor did it allow for the inclusion of as many topics as would have been desirable. The format was designed to be nonthreatening to residents unfamiliar with the subject matter. As such, it may have been too undemanding in an academic sense, since no formal readings or assignments were required. This may have led to overly favourable evaluations. Lastly, because all sessions were given by a single instructor, the material was potentially subject to a systematic bias. Conclusion The seminar series at Queen's University that we have described confirms that instruction in health policy receives an enthusiastic reception from family medicine residents. This receptivity to the material might have been enhanced because the sessions were presented in a clini-cal setting by a practising family physician. Informing trainees of current policy trends may reduce some of the anxiety associated with entering practice in these politically charged times. Moreover, it may stimulate a desire to stay current with policy debates in subsequent years. Informed practitioners may have a greater chance of contributing constructively to health policy decisions and a commensurately lower likelihood of adopting a reflexive confrontational stance when dealing with government. Despite the limitations outlined earlier, it appears that by taking the initiative of incorporating health policy into the postgraduate curriculum, family medicine may provide a model for both other specialties and undergraduate training programs. It seems reasonable to conclude that if doctors are to influence the direction of future Canadian health care, they require a curriculum for the times -- one that includes a generous dose of health policy. References Shortt SED, editor. Psychiatric illness in physicians. Springfield (IL): Charles C Thomas; 1982. Sutherland VJ, Cooper CL. Job stress, satisfaction, and mental health among general practitioners before and after the introduction of a new contract. BMJ 1992;304:1545-8. Swift D, editor. National survey: the Medical Post 1995 national survey of doctors. Med Post 1995;suppl. Kravitz RL, Linn LS, Shapiro MF. Physician satisfaction under the Ontario Health Insurance Plan. Med Care 1990;28:502-12. Swift D, editor. National survey: the Medical Post 1992 national survey of Canadian doctors. Med Post 1992;suppl. Clancey TE, Fiks AG, Gelfarrd JM, Grayzel DS, Marci CD, McDonough CG, et al. A call for health policy education in the medical school curriculum. JAMA 1995;274:1084-5. Seifer S, Kahn J. Preparing future physicians as health policy leaders: the AMSA Washington Health Policy Fellowship Program. Acad Med 1994;69:410. Thomas PA, Shelton CR. Teaching students to become active in public policy. Public Health Nurs 1994;11:75-9. McFarlane DR, Gordon LJ. Teaching health policy and politics in U.S. schools of public health. J Public Health Policy 1992;13:428-34. Send a letter to the editor responding to this article Envoyez une lettre à la rédaction au sujet de cet article | CMAJ December 1, 1997 (vol 157, no 11) / JAMC le 1er décembre 1997 (vol 157, no 11) |