Assessing Integration of Clinical and Public Health Skills in Preventive Medicine Residencies: Using Competency Mapping

Abstract

Objectives. We evaluated the utility of a competency mapping process for assessing the integration of clinical and public health skills in a newly developed Community Health Center (CHC) rotation at the University of Michigan School of Public Health Preventive Medicine residency.

Methods. Learning objectives for the CHC rotation were derived from the Accreditation Council for Graduate Medical Education core clinical preventive medicine competencies. CHC learning objectives were mapped to clinical preventive medicine competencies specific to the specialty of public health and general preventive medicine. Objectives were also mapped to The Council on Linkages Between Academia and Public Health Practice’s tier 2 Core Competencies for Public Health Professionals.

Results. CHC learning objectives mapped to all 4 (100%) of the public health and general preventive medicine clinical preventive medicine competencies. CHC population-level learning objectives mapped to 32 (94%) of 34 competencies for public health professionals.

Conclusions. Utilizing competency mapping to assess clinical–public health integration in a new CHC rotation proved to be feasible and useful. Clinical preventive medicine learning objectives for a CHC rotation can also address public health competencies.

The need to bridge the gap between primary care and public health has been well-identified and characterized over the last several decades. In 2005, 10 years after the American Medical Association and American Public Health Association launched the Medicine and Public Health Initiative,¹ Ronald Davis, MD, noted the need for ongoing “marriage counseling” for medicine and public health.² The revised 2010 Core Competencies for Public Health Professionals, originally developed by the Council on Linkages Between Academia and Public Health Practice (COL)³ in 2001, were followed with a 5-year strategic plan⁴ that promotes further collaboration between public health and health care professionals and organizations. Currently, the Institute of Medicine (IOM) is examining the practices by which public health and primary care can improve integration to advance population health.⁵

A practical application of public health and health care integration is currently being implemented in preventive medicine residencies (PMRs) throughout the United States, the only medical specialty to formally incorporate public health training. Preventive medicine addresses the health of individuals and populations, and encompasses 3 specialty areas that have core competencies in common: aerospace medicine, occupational medicine, and public health and general preventive medicine (PH/GPM). Of the 72 US preventive medicine residencies, PH/GPM represents the majority, comprising 41 of these residency programs (57%).⁶ The Accreditation Council for Graduate Medical Education (ACGME) defines 6 competency domains which assist residency directors across all clinical programs to assess physician competencies during resident training, consisting of patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. The Preventive Medicine Residency Review Committee (RRC) specifies core competencies within each of these domains that must be attained by all preventive medicine residents regardless of their specialty area, as well as additional specialty-specific clinical, preventive medicine, and public health competencies for ACGME-accredited PMRs.⁷

Historically, clinical rotations have not been required as a training component of PH/GPM specialty residency training, although residencies were at liberty to provide clinical experiences for residents. This changed on July 1, 2011, when the ACGME’s Preventive Medicine RRC formally instituted new residency requirements for PH/GPM specialty training, specifying a minimum of 2 months per year of direct patient care experience.⁷ These new specialty requirements could contribute significantly to promoting a public health workforce with a highly integrated clinical and public health skill set that is needed to advance population health and health equity in any health care or community setting.

Michigan, like many states, is experiencing a shortage of well-trained physicians in the public health workforce generally, and of primary care providers in areas of underserved, poor populations, specifically.⁸ Access to primary health care services is a significant concern for residents of Michigan, particularly for urban areas like Detroit.⁸ Despite the potential positive impact physicians trained in PH/GPM could have on the provision of primary care and other care services, the American College of Preventive Medicine (ACPM) estimates that many states are dramatically lacking in this specialty. In 2006, ACPM’s report to the IOM estimated that there were approximately 10 000 physicians in public health practice at that time, far short of the ideal recommended number of 20 000, a standard confirmed by the IOM in 2007.^9,10

The University of Michigan School of Public Health (UMSPH) has had a special interest in training preventive medicine physicians in the specialty area of PH/GPM for careers in public health by providing a strong grounding in applied public health practice preparatory to joining the state’s public health workforce. While the placement of trained physicians in governmental public health organizations serving medically underserved communities has been one of the UMSPH preventive medicine residency’s primary objectives, a new focus of the residency is to improve integration of preventive medicine and primary care. This integration is intended to assist with placement of graduates in Federally Qualified Health Centers (FQHCs), such as Community Health Centers (CHCs), and to meet the new ACGME requirements for provision of direct patient care. Consequently, the residency has developed mandatory clinical rotations in CHCs funded by the Health Resources and Services Administration (HRSA) to create a training venue for preventive medicine residents to integrate preventive medicine and public health, while simultaneously offering primary care clinical services to the underserved populations in Michigan. CHCs were chosen as rotation sites because they collectively represent the largest primary care network in the United States and are situated in areas and populations of underserved or unmet health care needs.¹¹ With formal affiliation agreements for CHC rotations at multiple locales in largely urban, poor areas of Detroit, Jackson, and Lansing, Michigan, the PMR curriculum is intended to incorporate clinical and preventive medical practice into public health settings, while also requiring residents to utilize public health practice skills at clinical sites.

The newly developed CHC rotation identifies required tasks that incorporate multiple learning objectives that enable the resident to develop the requisite skills to extrapolate individual care experiences to a broader public health perspective. To better equip residents to apply primary care services to a population health approach, residents engage in 9 different tasks during their CHC rotations (see box on this page) to achieve the ACGME competency-based learning objectives. These tasks primarily emphasize the delivery of quality primary care and clinical preventive services (tasks 1–4); however, the residents are also asked to produce a related public health educational seminar and public health case study, among a number of other population-oriented tasks.

Community Health Center (CHC) Clinical Rotation Tasks and Learning Objectives

Task 1 Deliver supervised clinical and clinical preventive medicine services at the CHC for the clinic patients (CHC learning objectives 1Aa, 1Ab, 2Aa, 2Ba, 2Bb, 3Aa, 3Ab, 3Ba, 3Ca, 3Cb, 3Cc)

Task 2 Develop familiarity with the US Clinical Preventive Task Force recommendations and apply age/patient-appropriate recommendations for patients (CHC learning objectives 2Aa, 2Ac, 2Ba, 2Bc, 3Aa, 3Ab, 3Ac, 3Bc, 3Ca, 3Cb, 3Cc)

Task 3 Demonstrate proficient clinical diagnostic and case management skills as assessed by the CHC site preceptors; demonstrate increasing responsibility for patient management as assessed by site preceptors and program directors (CHC learning objectives 1Aa, 1Ab, 2Ab, 2Ba, 2Bc, 3Aa, 3Ac, 3Ca, 3Cb, 3Cc)

Task 4 Identify patient needs within the clinic setting; create patient access to recommended resources during clinical operations (CHC learning objectives 1Aa, 1Ab, 2Ab, 2Ac, 2Ba, 3Aa, 3Ac, 3Ca, 3Cb, 3Cc)

Task 5 a) Implement an on-site public health practice seminar for medical staff and/or administration at the CHC on a public health issue encountered during the clinical rotation b) Conduct a literature search on current evidence-based data to support up-to-date public health interventions c) Develop and deliver a 30 minute educational presentation d) Provide an evaluation of current clinical practices addressing this public health issue e) Generate recommendations for enhanced public health intervention in the clinic for this issue using quality improvement methodologies as appropriate in the CHC (CHC learning objectives 3Da, 3Db, 3Dc, 3Dd)

Task 6 Identify an occupational and/or environmental health issue within the clinical rotation and provide a written case report which assesses the public health importance of the health issue, as well as the risk factors to the individual and the general public/occupational cohort, and appropriate public health interventions (CHC learning objectives 1Bc, 2Bc)

Task 7 Utilize health information systems within the CHC to better understand the broad application of these systems to public health practice in terms of data access and analysis needed to adequately assess community-level health problems (CHC learning objectives 1Ba, 3Ba)

Task 8 Participate in CHC administrative meetings in order to develop an understanding of managerial decision-making related to implementation of clinical and preventive medicine services (CHC learning objectives 1Bb, 2Bc, 3Ba, 3Bb)

Task 9 Develop familiarities with the laws and regulations applicable to the delivery of safe, private, confidential clinical care to clients, especially those related to HIPAA and CHC institutional requirements (CHC learning objectives 1Aa, 1Ab, 1Ac, 3Aa)

To assess the integrative nature of the new CHC rotation, the PMR residency staff mapped CHC rotation-specific learning objectives to ACGME clinical preventive medicine competencies for residents training in the specialty of PH/GPM and to a subset of nationally recognized Core Competencies for Public Health Professionals recently updated by the COL.³ The intent of this mapping exercise was 3-fold: to evaluate how well the current core competency-based CHC clinical preventive medicine learning objectives mapped to clinical competencies for PH/GPM; to assess how well the objectives mapped to a subset of COL public health core competencies; and to assess the overall integration of clinical and public health skill sets utilized by resident trainees while engaged in direct patient care tasks at the CHC rotations.

METHODS

The CHC learning objectives were developed directly from the ACGME core clinical preventive medicine competencies required for all preventive medicine residents regardless of specialty, under “IV.A.5.a).(1).(k) skills in clinical preventive medicine,”⁷ utilizing steps outlined in the Competency to Curriculum Toolkit.¹² These skills are made up of 3 core competencies: “IV.A.5.a).(1).(k).(i) Develop, deliver, and implement appropriate clinical services for both individuals and populations in order to diagnose and treat medical problems and chronic conditions”; “IV.A.5.a).(1).(k).(ii) Apply primary, secondary, and tertiary preventive approaches to individual and population-based disease prevention and health promotion”; and “IV.A.5.a).(1).(k).(iii) Develop, implement and evaluate the effectiveness of appropriate clinical preventive services for both individuals and populations.”⁷

The CHC learning objectives utilized by the residency program were derived from the subcompetencies that address the delivery of the clinical service, rather than its development (Table 1). Residency staff chose the “implementation” sub-competencies because upon graduation postgraduate year 3 (PGY3) residents should be able to apply, illustrate, and deliver the required clinical and public health services as outlined in both the ACGME core and specialty PH/GPM competencies. CHC learning objectives were categorized as either “individual-level,” addressing clinical or primary care patient skills, or as “population-level” for those that addressed the knowledge, skills, and attitudes dealing with populations or public health. By following the steps delineated in the Competency to Curriculum Toolkit,¹² residency staff identified 12 individual-level CHC learning objectives and 13 population-level CHC learning objectives (Table 1), all of which are encompassed by the 9 general tasks that residents must complete (see box on page S358).

TABLE 1—

ACGME Core Competencies, Subcompetencies, and the University of Michigan School of Public Health Preventive Medicine Residency Learning Objectives for a Community Health Center Rotation in Clinical Preventive Medicine

Competency7	Sub-Competency	Learning Objectives
1. IV.A.5.a).(1).(k).(i): Develop, deliver, and implement appropriate clinical services for both individuals and populations in order to diagnose and treat medical problems and chronic conditions	1A. To implement appropriate clinical services for individuals in order to diagnose and treat medical problems, the residents should be able to:	a. Deliver supervised clinical services at the CHC for the clinic b. Demonstrate proficient diagnostic and clinical case management skills c. Recognize the laws, regulations and professional ethics applicable to the delivery of safe, private, confidential clinical care to clients
	1B. To implement appropriate clinical services for populations in order to diagnose and treat medical problems, the residents should be able to:	a. Utilize health information systems within the CHC to better understand the broad application of these systems to public health practice in terms of data access and analysis needed to adequately assess community-level health problems b. Participate in CHC administrative meetings and discuss and assess community needs for medical services c. Identify an occupational and/or environmental health issue within the clinical rotation and provide a written case report which assesses the public health importance of the health issue, as well as the risk factors to the individual and the general public/occupational cohort, and appropriate public health interventions
2. IV.A.5.a).(1).(k).(ii): Apply primary, secondary, and tertiary preventive approaches to individual and population-based disease prevention and health promotion	2A. Apply primary, secondary, and tertiary preventive approaches to individuals for disease prevention and health promotion, the resident should:	a. Distinguish between primary, secondary and tertiary prevention b. Assess patients’ willingness to incorporate preventive measures using the Stages of Change Model c. Examine best practices for implementing preventive measures within clinic administrative and staff meetings or seminars, and incorporate them into practice, e.g., motivational interviewing
	2B. Apply primary, secondary, and tertiary preventive approaches to populations for disease prevention and health promotion. The resident should:	a. Identify what approaches are culturally appropriate and successful in the clinic community, from active discussion with preceptors and staff b. Participate in clinic health education campaigns c. Generate recommendations on appropriate preventive approaches for enhanced public health intervention in the clinic for an identified public health issue
3. IV.A.5.a).(1).(k).(iii): Develop, implement and evaluate the effectiveness of appropriate clinical preventive services for both individuals and populations.	3A. To implement appropriate clinical preventive services for individuals, the resident must be able to:	a. Deliver supervised clinical preventive medicine services at the CHC for the clinic patients b. List US Clinical Preventive Task Force recommendations for patients, and apply age/patient-appropriate recommendations c. Incorporate current knowledge of immunization schedules and guidelines
	3B. To implement appropriate clinical preventive services for populations, the resident must be able to:	a. Develop or enhance community-based services with interdisciplinary clinic team members based on an understanding of community public health needs b. Collaborate with community resource agency representatives c. Engage in a clinic preventive health outreach activity (e.g., screening clinic)
	3C. To evaluate the effectiveness of appropriate clinical preventive services for individuals, the resident must be able to:	a. Demonstrate proficient case management skills by following up with patient screening results and care plans b. Monitor patient’s adaptation to recommended changes health behavior c. Recognize barriers or challenges to patient adoption of recommended clinical preventive services
	3D. To evaluate the effectiveness of appropriate clinical preventive services for populations, the resident must be able to:	a. Implement an on-site public health practice seminar for medical staff and/or administration at the CHC on a public health issue encountered by a patient during the clinical rotation b. Provide an evaluation of current clinical practices addressing a public health issue c. Generate recommendations for enhanced public health interventions d. Conduct a literature search for current evidence-based data to support up-to-date public health interventions

Note. ACGME = The Accreditation Council for Graduate Medical Education; CHC = Community Health Center.

The COL Core Competencies for Public Health Professionals, updated in May 2010, include a total of 76 competencies broken down into 8 broad categories: analytic/assessment, policy development/program planning, communication, cultural competency, community dimensions of practice, public health sciences, financial planning and management, and leadership and systems thinking.³ For the purposes of this study, the CHC learning objectives for residents were mapped to just 4 tier 2 competency categories comprising 34 competencies: analytical/assessment, communication, cultural competency, and community dimensions of practice. While integral to professional public health practice, the remaining 4 categories (policy development, public health sciences, financial planning and management, and leadership) were, a priori, considered by the PMR residency staff to be public health skills more likely to be developed in other required PMR practicum rotations rather than in the CHC rotations, which have a strong primary care and clinical emphasis.

A published 2008 study¹³ previously cross-walked the full UMSPH PMR training requirements with the applied epidemiology competencies (AECs) for tier 2 epidemiologists developed by the Council of State and Territorial Epidemiologists (CSTE) and the US Centers for Disease Control and Prevention (CDC).¹⁴ Using the same methodology,¹⁵ the level of public health integration into the CHC rotation’s curriculum was assessed by mapping the 13 population-level learning objectives to a subset of the tier 2 Core Competencies for Public Health Professionals as established by the COL.³ Tiers 1, 2, and 3 reflect the core competencies that public health professionals at different stages of their careers might be reasonably expected to fulfill. Specifically, tier 1 applies to entry level public health, tier 2 applies to individuals with management and supervisory responsibilities, and tier 3 applies to those in senior management or public health leaders.³ As in the study by Boulton, et al.,¹³ this study used the tier 2 competencies as appropriately representative of the minimum level of achievement for graduating residents of the UMSPH preventive medicine residency working in a public health practice setting.

The academic and practicum curricula of the UMSPH preventive medicine residency, with the exception of the clinical rotations, have been previously outlined and mapped to AECs¹³ and, therefore, are not addressed in this study. All 25 CHC learning objectives derived from the ACGME core “skills in clinical preventive medicine” competency were mapped to the specialty PH/GPM clinical preventive medicine competencies to assess if additional learning objectives were required for the CHC rotation. The CHC population-level learning objectives were then mapped to the 4 categories of 34 COL competencies that had been selected. Residency staff, comprising 2 PMR faculty members and 1 staff in the department of epidemiology, each individually mapped the individual and population-based competencies to each set of competencies. The 3 separate mapping results were then compared, and any disagreements were identified and discussed; a majority vote (i.e., 2 of 3) settled any unresolved discrepancies.

RESULTS

Table 2 summarizes the mapping of the 25 CHC individual- and population-level learning objectives to the ACGME public health and general preventive medicine concentration’s competencies for clinical preventive medicine. All (100%) of the ACGME public health and general preventive medicine competencies were addressed by multiple learning objectives. Conversely, although most CHC learning objectives addressed multiple competencies, 2 (8%) of the 25 CHC learning objectives addressed only 1 of the PH/GPM competencies: “3Da. Implement an on-site seminar” and “3Dd. Conduct a literature search.” Overall, the PH/GPM specialty competencies each mapped to a minimum of 15 (60%) of the learning objectives. One PH/GPM clinical preventive medicine competency (“IV.A.5.a).(4).(b).(ii) analyze evidence regarding performance of proposed clinical preventive services for individuals and populations”) mapped to 22 (88%) of the CHC learning objectives.

TABLE 2—

Community Health Center Clinical and Population-Level Learning Objectives Mapped to ACGME Clinical Preventive Medicine Competencies for the PH/GPM Specialty

	ACGME PH/GPM Competencies7
CHC Learning Objectives (Clinical and Population-Level)	IV.A.5.a).(4).(b).(i) Select appropriate, evidence-based, clinical preventive services for individuals and populations	IV.A.5.a).(4).(b).(ii) Analyze evidence regarding the performance of proposed clinical preventive services for individuals and populations	IV.A.5.a).(4).(b).(iii) Manage and administer programs that provide recommended immunizations, chemoprophylaxis and screening tests to individuals and appropriate populations	IV.A.5.a).(4).(b).(iv) Counsel individuals regarding the appropriate use of clinical preventive services and health promoting behavior changes, and provide immunizations, chemoprophylaxis, and screening services, as appropriate
1Aa. Deliver supervised clinical services at the CHC for the clinic	X	X	X	X
1Ab. Demonstrate proficient diagnostic and clinical case management skills	X	X	X	X
1Ac. Recognize the laws, regulations and professional ethics applicable to the delivery of safe, private, confidential clinical care to clients	X		X	X
1Ba. Utilize health information systems within the CHC to better understand the broad application of these systems to public health practice in terms of data access and analysis needed to adequately assess community-level health problems	X	X	X
1Bb. Participate in CHC administrative meetings and discuss and assess community needs for medical services	X	X	X
1Bc. Identify an occupational and/or environmental health issue within the clinical rotation and provide a written case report which assesses the public health importance of the health issue, as well as the risk factors to the individual and the general public/occupational cohort, and appropriate public health interventions	X	X
2Aa. Distinguish between primary, secondary and tertiary prevention	X	X	X	X
2Ab. Assess patients’ willingness to incorporate preventive measures using the Stages of Change Model	X	X		X
2Ac. Examine best practices for implementing preventive measures within clinic administrative and staff meetings or seminars, and incorporate them into practice (e.g., motivational interviewing)	X	X	X	X
2Ba. Identify what approaches are culturally appropriate and successful in the clinic community, from active discussion with preceptors and staff	X	X	X	X
2Bb. Participate in clinic health education campaigns	X		X	X
2Bc. Generate recommendations on appropriate preventive approaches for enhanced public health intervention in the clinic for an identified public health issue	X	X	X
3Aa. Deliver supervised clinical preventive medicine services at the CHC for the clinic patients	X	X	X	X
3Ab. List US Clinical Preventive Task Force recommendations for patients, and apply age/patient-appropriate recommendations	X	X	X	X
3Ac. Incorporate current knowledge of immunization schedules and guidelines	X	X	X	X
3Ba. Develop or enhance community-based services with interdisciplinary clinic team members based on an understanding of community public health needs	X	X	X
3Bb. Collaborate with community resource agency representatives		X	X
3Bc. Engage in a clinic preventive health outreach activity (e.g., screening clinic)	X		X	X
3Ca. Demonstrate proficient case management skills by following up with patient screening tests results and care plans	X	X		X
3Cb. Monitor patient’s adaptation to recommended changes in health behavior	X	X		X
3Cc. Recognize barriers or challenges to patient adoption of recommended clinical preventive services	X	X	X	X
3Da. Implement an on-site public health practice seminar for medical staff and/or administration at the CHC on a public health issue encountered by a patient during the clinical rotation		X
3Db. Provide an evaluation of current clinical practices addressing a public health issue	X	X	X
3Dc. Generate recommendations to enhance public health interventions	X	X	X
3Dd. Conduct a literature search for current evidence-based data to support up-to-date public health interventions		X

Note. ACGME = The Accreditation Council for Graduate Medical Education; CHC = Community Health Center; GPM = general preventive medicine; PH = public health.

The 13 population-level learning objectives were mapped to the public health COL competencies³ (Table 3). Of the 34 COL competencies examined, 32 (94%) mapped to CHC learning objectives; 2 competencies (6%) did not map to any (“5B2. Collaborates in community-based participatory research efforts, 5B5. Maintains partnerships with key stakeholders”). One COL competency (“5B9. Uses community input when developing public health policies and programs”) mapped to only 1 CHC learning objective. Seven of the 13 population-level learning objectives (54%) addressed at least 50% of the COL competencies; all (100%) of the objectives addressed at least 29% of the COL competencies evaluated.

TABLE 3—

Community Health Center (CHC) Population-level Learning Objectives Mapped to 34 Tier 2 Core Competencies for Public Health Professionals

	CHC Learning Objectives (Population-Level)
Tier 2 Core Competencies for Public Health Professionals3	1Ba.Utilize health information systems within the CHC…	1Bb. Participate in CHC administrative meetings…	1Bc. Identify an occupational and/or environmental health issue within the clinical rotation…	2Ba. Identify what approaches are culturally appropriate and successful in the clinic community…	2Bb. Participate in clinic health education campaigns	2Bc. Generate recommendations on appropriate preventive approaches…	3Ba. Develop or enhance community-based services with interdisciplinary clinic team members…	3Bb. Collaborate with community resource agency representatives	3Bc. Engage in a clinic preventive health outreach activity (e.g., screening clinic)	3Da. Implement an on-site public health practice seminar for medical staff…	3Db. Provide an evaluation of current clinical practice…	3Dc. Generate recommendations to enhance public health interventions	3Dd. Conduct a literature search…
Analytic/assessment skills
1B1. Assesses the health status of populations and their related determinants of health and illness	X	X	X	X	X	X	X			X	X	X	X
1B2. Describes the characteristics of a population-based health problem	X	X	X	X	X	X	X		X	X	X	X	X
1B3. Generates variables that measure public health conditions	X	X				X	X					X	X
1B4. Uses methods and instruments for collecting valid and reliable quantitative and qualitative data	X					X	X					X	X
1B5. References sources of public health data and information	X	X	X	X	X	X	X	X	X	X	X	X	X
1B6. Examines the integrity and comparability of data	X		X		X	X	X			X	X	X	X
1B7. Identifies gaps in data sources	X					X	X			X	X	X	X
1B8. Employs ethical principles in the collection, maintenance, use, and dissemination of data and information	X	X	X	X	X	X	X	X	X	X		X
1B9. Interprets quantitative and qualitative data	X	X	X		X	X	X		X	X	X	X	X
1B10. Makes community-specific inferences from quantitative and qualitative data		X	X	X	X	X	X		X	X	X	X
1B11. Uses information technology to collect, store, and retrieve data	X								X
1B12. Uses data to address scientific, political, ethical, and social public health issues	X	X	X		X	X	X		X	X	X	X	X
Communication skills
3B1. Assesses the health literacy of populations served		X		X	X		X		X
3B2. Communicates in writing and orally, in person, and through electronic means, with linguistic and cultural proficiency	X	X	X	X	X	X		X	X	X	X	X
3B3. Solicits input from individuals and organizations		X		X			X	X
3B4. Uses a variety of approaches to disseminate public health information		X	X	X	X	X	X	X	X	X
3B5. Presents demographic, statistical, programmatic, and scientific information for use by professional and lay audiences		X	X	X	X	X		X	X	X	X	X	X
3B6. Applies communication and group dynamic strategies in interactions with individuals and groups		X		X	X	X	X	X	X	X
Cultural competency skills
4B1. Incorporates strategies for interacting with persons from diverse backgrounds		X		X	X		X	X	X
4B2. Considers the role of cultural, social, and behavioral factors in the accessibility, availability, acceptability and delivery of public health services		X	X	X	X	X	X	X	X	X	X	X
4B3. Responds to diverse needs that are the result of cultural differences		X		X	X		X	X	X
4B4. Explains the dynamic forces that contribute to cultural diversity		X		X			X
4B5. Describes the need for a diverse public health workforce		X		X			X					X
4B6. Assesses public health programs for their cultural competence		X		X		X	X					X
Community dimensions of practice skills
5B1. Assesses community linkages and relationships among multiple factors (or determinants) affecting health		X	X	X		X	X	X			X	X
5B2. Collaborates in community-based participatory research efforts
5B3. Establishes linkages with key stakeholders		X					X	X
5B4. Facilitates collaboration and partnerships to ensure participation of key stakeholders		X					X	X
5B5. Maintains partnerships with key stakeholders
5B6. Uses group processes to advance community involvement		X					X	X
5B7. Distinguishes the role of governmental and nongovernmental organizations in the delivery of community health services		X					X	X			X
5B8. Negotiates for the use of community assets and resources		X					X	X				X
5B9. Uses community input when developing public health policies and programs								X
5B10. Promotes public health policies, programs, and resources		X	X	X	X	X	X	X	X	X	X	X

Source. Core Competencies for Public Health Professionals.³

DISCUSSION

Competency mapping provided a useful assessment of the level and quality of public health and clinical integration within a newly established clinical CHC rotation as part of a preventive medicine residency PH/GPM curriculum. All 25 CHC learning objectives met in the CHC rotation were addressed by the 9 required CHC tasks that the PGY3 residents must accomplish prior to graduation. Table 2 could potentially be used by the residents for self-evaluation of their competency attainment throughout the 2-year training program. In aggregate, we found the competency mapping exercise confirmed that the CHC rotation tasks addressed all of the ACGME public health and general preventive medicine clinical preventive medicine and the majority of COL public health practice competencies, indicating a relatively high degree of public health integration into a primary care rotation.

By using the Competency to Curriculum Toolkit¹² to develop learning objectives from the 3 core clinical preventive medicine competencies under “IV.A.5.a.(1).(k) skills in clinical preventive medicine,”⁷ the residency identified 25 learning objectives for individual and public health training that could be addressed by the 9 rotation tasks for residents to perform while on a CHC rotation. The ability to demonstrate that the 25 individual- and population-level learning objectives mapped to 100% of the PH/GPM specialty clinical preventive medicine competencies assured residency staff that PH/GPM specialty clinical preventive medicine competencies were being addressed by the planned CHC rotation in addition to the core competencies.

This mapping process also identified 2 CHC learning objectives that only weakly addressed the PH/GPM specialty competencies (3Da and 3Dd); notably, these are both population-level learning objectives. These objectives had been developed by residency staff to encourage residents to extrapolate patient-centered, individual-level experiences into a population health perspective, and were not expected to be major components of a clinical practice rotation. However, learning objectives that mapped to only 1 or 2 PH/GPM clinical preventive medicine competencies were seen to map to multiple COL tier 2 Core Competencies for Public Health Professionals. Regardless, residency staff plan to revise the CHC learning objectives and resultant CHC rotation tasks; for example, staff will address the inadequate learning objective “1Bc. Develop an occupational or environmental health case report” (task 6) because it mapped weakly to both the ACGME public health and general preventive medicine and the COL competencies. This task and learning objective, as well as others (e.g., literature searches, seminars), may be better addressed in other non–primary care residency rotations.

Of note, the program staff was able to identify that the same CHC learning objective (“1Bc. Identify an occupational and/or environmental health issue within the clinical rotation and provide a written case report…”) needed to be further broken down into 2 different objectives. Ideally, each objective should only identify 1 action that can be measured or evaluated by the program faculty. Therefore, 2 learning objectives—to identify the occupational or environmental health issue, and then to provide a case report—will be developed in the revised CHC learning objectives as a result of this evaluation.

Importantly, the COL public health competencies were not developed with the clinical training of a preventive medicine physician in mind, yet the 13 population-level learning objectives still mapped to a significant majority of the COL competencies that we included in our analysis. While 2 COL tier 2 competencies did not map to any of the established learning objectives (“5B5. Maintains partnerships with key stakeholders” and “5B9. Uses community input when developing public health policies and programs”), residency staff determined that these competencies would be better addressed in practicum rotations other than the CHC rotation primary care site. Thus, this specific gap was not felt to detract significantly from the integrated primary care and public health training experience. In the future, we plan to implement this competency mapping process, especially for newly developed field rotations, during the residency’s graduate medical education curriculum review to better align training with the program’s ultimate goal of preparing physicians for careers in public health practice. Additional improvements in attaining further integration can be realized through modifications to the residency’s clinically oriented rotations. While the primary objectives of the CHC rotation are to deliver clinical preventive medicine, the ability of the resident to translate the individual, patient-level experiences into population health knowledge and skills is an important goal of the UMSPH preventive medicine residency.

This study had several limitations. First, we only mapped a subset of COL competencies to the CHC curriculum, and including others may have yielded a substantially different outcome; while the other 4 domains (policy development/residency planning, public health sciences, financial planning and management, and leadership and systems thinking) are also important components of preventive medicine training, the subset we examined are those that can be addressed best during a clinical rotation. Second, the learning objectives for the purposes of this analysis were derived from the 1 core clinical preventive medicine competency and its 3 subcompetency/skill sets, and not from the specific PH/GPM competencies. A comprehensive mapping of all of the residency’s competency-derived learning objectives to the ACGME preventive medicine program requirements is a standard requirement of residency staff but was beyond the scope of this study. If future studies mapped the entire set of COL public health competencies to the complete residency curriculum, the process would be a correspondingly more time-consuming and complex effort than that required to evaluate a single field rotation like a CHC. Regardless, preventive medicine residencies already use similar curriculum mapping strategies to assess their program’s fulfillment of the ACGME competencies as part of the accreditation process. Given the focus of preventive medicine residencies on the training of physicians in both clinical and public health practice, mapping the full residency curriculum, and not just specific rotations, to both ACGME and COL public health competencies to assess the overall primary care–public health integration will be useful in guiding future curriculum development.

COL competencies enable us to better assess and address the training impact of newly required clinical rotations on public health practice in the development of preventive medicine physicians. This assessment is valuable given our program’s goal of providing a highly integrative training as a key component of our strategy to place graduates in FQHCs and CHCs upon graduation from the residency. This process is simple and easily accomplished with current residency staff. Future studies to map all of the COL competences to the full PMR curriculum will allow the residency to assess the comprehensive public health training of the residents. And, as preventive medicine educational and training programs continue to evolve, competency mapping to multiple clinical, primary care, and public health tasks could prove useful to clinical and public health program managers, directors, and educators.