Health Policy Education for Medical Students: Time to Rethink?

Introduction

The article "Long COVID, Disability, and the Need for Timely Health Care Coverage" by Fratt and Crosson, ¹ published in this journal, is worthy of note for 2 reasons. First, it is a reminder of the long-term health and disability consequences of COVID-19 infection that need to be addressed, even as many people would prefer to stop thinking about the pandemic. It calls out the need for continued access to health care coverage for persons disabled by long COVID and proposes potential solutions.

Second, the first author of the article is a third-year medical student at the Kaiser Permanente Bernard J Tyson School of Medicine, who conceived of and drafted the article as part of a month-long elective course in health policy. The fact that she was able and interested enough to do so was likely a direct consequence of the course. As course faculty for the elective, we have given a lot of thought to the questions of whether, when, and by what means medical students should have exposure to a health policy curriculum.

Why Teach Health Policy Topics to Medical Students?

It would be hard to overestimate the role of health policy in influencing health insurance coverage, care delivery, professional licensure, research and development, and public health. Federal legislation, including the Affordable Care Act, the Employment Retirement Income Security Act, and the Health Insurance Portability and Accountability Act, have collectively impacted each of these areas over the past 4 decades. Over 100 million Americans receive coverage through government programs, including Medicare, Medicaid, and the Veterans' Health Administration. The Food and Drug Administration and the National Institutes for Health have pivotal roles in ensuring Americans’ access to safe and effective therapies. And the Centers for Disease Control and Prevention plays a substantial role in public health infrastructure, with operational policies left to states and local governments.

Despite its relevance, uptake of health policy in medical school curricula has been slow. In 1995, Clancy and 2 other medical students writing in JAMA advocated for including health policy topics in medical school education. ² Almost 2 decades later, a 2007 survey of US medical students found that less than half believed they had been adequately exposed to key health policy topics. ³ In 2010, 94% of medical school deans reported providing some health policy material in their curriculum, with the average amount of instruction of only 14 hours over the 4 years. ⁴ This is not solely an issue in the US. In 2017 Malik et al surveyed medical students in the UK, and only 47% reported any teaching in health policy. ⁵

The need to address this gap in the education of medical students is clear. The practice of medicine has become increasingly complex, clinically, structurally, and from a financing and payment perspective. By 2018, 49% of US physicians were employed by or affiliated with vertically integrated health systems, an increase of 11% in only 2 years. ⁶ The enactment of the Affordable Care Act in 2010, including the expansion of Medicaid as well as Medicare payment reforms such as global payments to Accountable Care Organizations, has increased the diversity of health care coverage and delivery system models. Graduating medical students now face decisions not only about what specialty to train in, but also what sort of practice model they foresee working in and what that means about how they will be paid. We believe it is time for all future physicians to understand the broader context in which they will be practicing medicine through exposure to a health policy curriculum beginning in medical school.

Medical schools are not only training physicians to care for patients but are also preparing many to become leaders of health systems and health care policy advisers and decision makers. Providing opportunities for in-depth exposure to health policy education for those students who exhibit an interest and passion for this subject through electives akin to clinical subspecialty electives will help sustain and deepen this interest and prepare the future leaders the profession needs.

There is more at stake than just the personal career needs of medical students. The cost of US health care—now approaching 20% of gross domestic product—is constraining resources desperately needed for other public goods such as investments in education and physical infrastructure, rebuilding the public health system, and safeguarding the environment for future generations.

It is never too early to engage physicians-in-training in thoughtful resource stewardship and cost-conscious decision making, values not always evident in institutional training settings. Cost-unconscious decision making must give way to a thoughtful consideration and avoidance of low-value care. Ethical approaches to resource stewardship should be a core teaching in every medical school curriculum and embedded in health policy curricula. Responsibility for the impact of health care spending is part of the Physician Charter—the modern equivalent of the Hippocratic oath ⁷ —and is integral to long-term affordability of health care coverage for Americans. Ethical resource stewardship is the basis of physician professionalism and is best learned early. ^8,9

How Should Health Policy Be Taught to Medical Students?

We believe there are 2 approaches for including a health policy curriculum in undergraduate medical education. First, the basics of health policy should be incorporated into the core curriculum for all medical students, with the essentials of health economics, public health, and health care policy woven into the relevant clinical teaching. For example, understanding the fundamental principles of public health goes hand in hand with—and gives meaning to—clinical infectious disease training. Lectures, reading assignments, and case-based small group discussion are all appropriate modalities. ⁴ In our experience some of this basic content "sticks" with students and some does not, likely based on individual interest, the effectiveness with which the case for relevance to clinical care delivery is made, and the competing draw of the basic sciences.

We developed the Kaiser Permanente Bernard J Tyson School of Medicine elective in health policy to provide a second approach that would augment and expand on earlier didactic material and give self-selected students the time and opportunity to "dive deep." In its first year on offer, the elective was chosen by 18% of the third-year class and was broadly seen by them as meeting their personal learning objectives, despite having other options to choose from, including more directly clinically relevant choices. This is consistent with the finding by Patel et al that students who had been taught in a higher intensity health policy curriculum were 3 to 4 times more likely to feel they were appropriately trained compared with students taught in a lower intensity health policy curriculum. ³

What Content Should Health Policy Education of Medical Students Contain?

The World Health Organization defines health policy as "decisions, plans and actions that are undertaken to achieve specific health goals within a society." ⁵ On this issue, the aphorism "don't try to boil the ocean" applies. In the US, more so than in most developed countries, our health policy environment involves many diverse stakeholders, including public and private entities in insurance and care delivery, public health, and health economics as well as federal, state, and local government programs like Medicare, Medicaid, and the Veterans' Health Administration. In addition, suppliers such as the pharmaceutical and medical equipment industries play a large role in influencing the cost, quality, and access to health care. Distilling this complexity into an elective course in health policy for medical students requires prioritization and focus.

We chose to focus on 4 domains: coverage, delivery system structure, payment methodologies, and resource management. In each domain there were 4 half-day didactic presentations followed by group discussion. To elicit close attention, we put special emphasis on the policy issues most relevant to physicians. We provided particular emphasis on the Medicare program, given its potential as the basis for future health care coverage reform, and on integrated health systems like Kaiser Permanente as potential models for future care delivery reform. Our approach is similar to the Health Systems and Health Policy recommendations of the Clinical Prevention and Population Health Curriculum Framework published in 2004, ⁷ and preferences expressed by medical students in a 2005 survey conducted by Agrawal et al. ¹⁰ Feedback from our students was highly supportive of the content selected.

What Can Be Done?

Broaden the Range of Faculty Involved in Curriculum Design and Delivery

Many medical schools lack faculty members trained in health economics, health policy analysis, and practical business and organizational management. ³ But most medical schools are affiliated with or have access to university faculty in each of the policy domains who could add their expertise to the curriculum as adjunct faculty, as could leaders of health systems. This deficit may require special attention by medical school deans when evaluating the background depth of their faculty. In constructing the Kaiser Permanente Bernard J Tyson School of Medicine elective, we drew on executives and health policy leaders and researchers from Kaiser Permanente, as well as faculty from neighboring and remote universities, and from other institutions.

Invest in Additional Research

Patel et al make the case that more research is needed on how best and what to include to teach medical students. ³ Writing before the Affordable Care Act and the COVID-19 pandemic, they suggested that medical school curricula had failed to keep up with the rapidity of policy changes in the US health care system, and that a collective coordinated effort is needed to move toward regional or national curricula. Currently, medical schools are inventing their own approaches to health policy education, as we did at Kaiser Permanente Bernard J Tyson School of Medicine. A more robust and up-to-date research base on how best to design and deliver this information to students would be of benefit to all. Perhaps a multistakeholder group, including medical educators, health economists, health policymakers, and medical students convened by the Liaison Committee on Medical Education (LCME) could design and sponsor such research.

Incorporate Health Policy Education Into Accreditation and Licensing Processes

In 2015, Calvin M Kagan and Grayson W Armstrong, fourth-year medical students at Vermont and Brown University Medical Schools, called on the LCME to include health policy education in US medical school accreditation standards. ¹¹ To date that has not occurred. ¹² They also called on the National Board of Medical Examiners to include questions about health policy in physician board examinations. This has been accomplished as part of the "health systems science" body of National Board of Medical Examiners potential examination questions. ^13,14

Conclusion

The enthusiasm with which a third-year elective in health policy at the Kaiser Permanente Bernard J Tyson School of Medicine was greeted, and the level of interest and participation in the work, raises the question of when and how best to involve medical students in relevant health policy education (and for us, puts to rest the question of whether to do so). Most medical schools now incorporate some content in the curriculum, but student evaluations often reflect a desire for more. Incorporating health policy in undergraduate medical education curricula, in the accreditation standards of the LCME, and in licensing exams will better prepare physicians-in-training to practice and lead within and outside of the profession in the future by advocating for new and better policy solutions to the challenges of our incredibly complex US health care enterprise.