On a Scale of Pass to Fail, Many Medical Schools Fail Students on Health Policy

We are in a time when physicians are increasingly speaking the language of health policy and public health — “value-based care,” “co-payment,” “social determinants of health,” “accountable care organization” — and are increasingly asked by patients to ensure that a particular treatment or procedure is covered by their insurance before moving forward. This dizzying list of health policy terms (and the responsibility of a physician to understand the lingo) just keeps growing. And there is no better time to introduce students to this world than in medical school, when they are primed for learning and not yet overwhelmed with patient care.

Unfortunately, most medical schools are failing to teach future doctors even the basics of health policy. This is compounded by the fact that levels of civic knowledge and public engagement are at an all-time low. If students do not possess the basics of government function, how can they or their institutions hope to engage in important discussions around healthcare over the course of their careers? If you’re thinking, “Well, I’m going to spend my time outside of clinic in the lab, this doesn’t apply to me” — think again. The National Institutes of Health invests nearly $37.3 billion annually in medical research — and that pot of money is appropriated by Congress. Congress can even earmark money within that pot for specific diseases — they included an additional $414 million for Alzheimer’s disease research last year. Health policy is as vital to lab-based research as it is to Medicaid reimbursement rates.

According to the AAMC Medical School Graduation Survey, there has been a steady rise in students who indicated they plan to participate in public health activities after graduation, from 25% in 2016 to 31.6% in 2018. There is no definition given for what “public health activities” include in this survey, but one could assume it means anything from planning to practice in a community health center and participation in loan forgiveness programs that place young doctors in underserved communities to involvement in health policy and advocacy work and efforts to improve patient lives through population health research. But in 2011, 40% of students responded in the survey that their instruction on “public health” was inadequate. [This question was removed from the survey in 2015.]

While some medical schools have altered their curriculum to offer health policy courses–some have embedded it within their curriculum and others offer a “minor” of sorts for interested students—not all students have access to this important subject matter. If a student is aware of their interest in public health, 80 medical schools offer a Master of Public Health program to medical students — but this dual degree model relies on a student having an experience that leads them to investigate and actively engage in this area of study.

These opportunities notwithstanding, it should be the responsibility of all medical schools to teach their students the basics of health policy.

The challenge of innovating medical curriculum is not new. Over 100 years ago, the (now famous) Flexner Report noted that, “it is clear that consideration for the public good has had on the whole little to do; nor is it to be expected that this situation will very readily readjust itself in response to public need.” Abraham Flexner believed that a reorganization of medical training could serve the public good. 

This is still true today. Physicians are responsible for the vast majority of medical expenditures in our health system — through prescriptions, imaging, procedures, and other clinical decision making. We are taught to diagnose and treat. And that thought process usually culminates in an exorbitant bill for the patient and the system.  Not all expensive procedures, tests, and medications are unnecessary, but some certainly are. Examining the role of physician decision making in medical expenditures has to start from an understanding of the policies driving the system.

The American Medical Association recently codified health systems science as the “third pillar” of medical education with the publication of a new textbook designed specifically for medical providers. The textbook covers many topics, ranging from patient safety and quality improvement to population health and health policy and economics. However, it is optional for schools to implement a curriculum utilizing this new book. For those students who do not attend a school with a health systems curriculum or who choose not to pursue additional studies in health policy, there can be a serious knowledge gap that can impact how they will practice medicine. [That’s the gap we’re hoping to fill with this little space on the internet.]

We should not only give students a historical understanding of Medicaid, Medicare, and private insurance, but also important topics they might encounter as they see patients — the cost of prescription drugs (i.e. Hepatitis C, gene therapy, chemotherapy), access to medication-assisted treatment for those suffering from opioid addiction, a lack of primary care providers in underserved areas, improving care transitions, outbreaks of vaccine-preventable diseases…the list of issues impacted by health policy is long and varied.

The existing literature on the issue of health policy education for medical students is limited. One survey taken of medical students in the U.K. sought to investigate medical student involvement in health policy roles; the results indicated three barriers to such participation: lack of health policy knowledge, limited awareness of opportunities, and a lack of time. These three barriers certainly have a parallel in U.S. medical education. Simply integrating health policy into medical school curriculum can circumvent these barriers — students will gain the necessary knowledge, opportunities will be presented equally to all students, and it will not be an “extra” event students have to find time to attend. Requiring students to be competent in the basics of health policy will not only help them navigate the system once they begin to practice, but it can help them communicate and better serve their patients. Medical schools must do better to support the training of young doctors in health policy.

Image from the Library of Congress.

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