Dual MD–MPH Degree Students in the United States: Moving the Medical Workforce Toward Population Health

Abstract

Objective

A growing need exists to train physicians in population health to meet the increasing need and demand for physicians with leadership, health data management/metrics, and epidemiology skills to better serve the health of the community. This study examines current trends in students pursuing a dual doctor of medicine (MD)–master of public health (MPH) degree (MD–MPH) in the United States.

Methods

We conducted an extensive literature review of existing MD–MPH databases to determine characteristics (eg, sex, race/ethnicity, MPH area of study) of this student cohort in 2019. We examined a trend in the MD community to pursue an MPH career, adding additional public health and health care policy training to the MD workforce. We conducted targeted telephone interviews with 20 admissions personnel and faculty at schools offering MD–MPH degrees in the United States with the highest number of matriculants and graduates. Interviews focused on curricula trends in medical schools that offer an MD–MPH degree.

Results

No literature describes the US MD–MPH cohort, and available MD–MPH databases are limited and incomplete. We found a 434% increase in the number of students pursuing an MD–MPH degree from 2010 to 2018. The rate of growth was greater than the increase in either the number of medical students (16%) or the number of MPH students (65%) alone. Moreover, MD–MPH students as a percentage of total MPH students more than tripled, from 1.1% in 2010 to 3.6% in 2018.

Conclusions

As more MD students pursue public health training, the impact of an MPH degree on medical school curricula, MD–MPH graduates, and MD–MPH career pursuits should be studied using accurate and comprehensive databases.

Some students who matriculate into US medical schools pursue a second degree, including the master of public health (MPH).¹ Reasons for pursuing an MPH degree include wanting to broaden their training as a clinician, learn about population health research, and pursue a career in public health.² Changes in the health care delivery system (eg, telemedicine, emphasis on population health, social determinants of care, health care access) provide additional motivations for medical students to study public health. This motivation has been heightened by the coronavirus disease 2019 (COVID-19) pandemic, which has shed light on the role of public health in the control of emerging infectious diseases. Moreover, the COVID-19 pandemic has focused attention on disparities in health that have contributed to the high mortality rate among people of color in the United States.³

Even before the pandemic, consensus was growing among health care leaders that tomorrow’s health care system must focus on quality outcomes and value, consistent with achieving the triple aim of better care, better health, and lower costs.⁴ As such, health care provider organizations and payers have shifted attention to population health, which is defined as “an opportunity for health care systems, agencies, and organizations to work together in order to improve health outcomes of the communities they serve.”⁵

Population Health in Medical School Curriculum

In response to a health care system that is increasingly focusing on the health of communities (ie, population health), US medical schools have also begun to change the way they educate students. New accreditation requirements in the Liaison Committee on Medical Education (LCME)⁶ recommend additional population health requirements in US medical schools, and medical schools are subsequently developing or strengthening curriculum in health policy and finance, epidemiology, data analytics, delivery system science, quality and patient safety, environmental health, and health behavior change.^7,8 Some medical schools are asking applicants about their interest and experience in the social, behavioral, economic, and environmental causes of morbidity and mortality.⁷ The Medical College Admissions Test now includes psychosocial factors affecting health, health policy and financing, and the needs of vulnerable populations.^9,10

New Employment Opportunities

The policy shift to population health is creating new employment opportunities for those with both a doctor of medicine (MD) degree and a master’s degree, including the MPH.¹¹ Training in evidenced-based approaches to health quality improvement and reducing health inequities opens new job opportunities for the MD–MPH graduate.^12,13 Career opportunities can be found in state and local health departments, the Centers for Disease Control and Prevention (CDC), research, clinical leadership in health plans, or medical group and health care systems.¹⁴ These new job opportunities are focusing on population health in part because financial incentives are switching to value-based purchasing, which requires clinical managers to understand quality metrics and what can be done on a population level to reduce risk and improve health.¹⁵ The MPH degree provides training in traditional public health science, which includes disease patterns and the underlying causes of morbidity and mortality in a population rather than individual patients.¹⁶ Thus, the dual degree incorporates many of the same competencies needed in population health management.¹⁶

Research Question and Methods

Little is known about how medical schools and students are responding to these changes in health care delivery and finance. How has the move toward population health affected medical school curriculum and medical education? Are more students taking additional training in population health or pursuing an MPH degree? Literature on the dual MD–MPH degree for medical students is limited. Furthermore, the databases available are incomplete or limited to members of their respective professional organizations. In addition, no studies have examined the curricular training that MD–MPH students receive or differences in the practicum or required research projects for MD–MPH students. The objective of our study was to examine the dual MD–MPH degree in the United States by addressing the following questions:

1. What is the size and breadth of MD–MPH programs in the United States and how have they changed over time?

2. What are the demographic characteristics of matriculating MD–MPH students, and what are their specialty choices, career aspirations, and educational tracks in the public health field?

3. What models and strategies are available for MD–MPH students to complete the dual degree?

Research design and data sources

We used a mixed-methods approach that incorporated qualitative and quantitative data analysis to answer these questions. First, we reviewed reports and websites from MD and MPH accrediting bodies and associations of medical and osteopathic schools and public health training programs, including the Association of American Medical Colleges (AAMC),¹⁷ Association of Schools and Programs of Public Health (ASPPH) (unpublished data, ASPPH annual data collection, 2010-2018, August 2019), and the American Association of Colleges of Osteopathic Medicine (AACOM).¹⁸ The accreditation bodies included the Council on Education for Public Health (https://ceph.org) and the LCME (https://lcme.org). The LCME reports annual data from all the medical schools in the United States based on an annual medical school questionnaire.¹⁹

Second, we analyzed data on MD–MPH students and graduates from 3 sources: 2016 and 2018 ASPPH membership data (unpublished data, ASPPH annual data collection, 2010-2018, August 2019), 2010-2019 AAMC membership data (unpublished data, aggregate graduate count data by medical school for the 2008-2009 through 2018-2019 academic years, 2019), and 2018 AACOM data.¹⁸ The ASPPH membership data included the number and sociodemographic characteristics of MD–MPH students in the United States for ASPPH members, which represent >62% of the 170 CEPH-accredited schools and programs of public health. The AAMC database characterized the 87 medical schools with a dual MD–MPH degree option and the number of graduates from spring 2010 to spring 2019. These data reflected 62 of the 87 MD–MPH dual-degree schools and programs because the AAMC does not mandate reporting on MD–MPH matriculants, graduates, or demographic information. The AACOM data included 18 accredited osteopathy schools offering a dual doctor of osteopathy (DO) and MPH degree.

Finally, we selected ASPPH members with more than 5 MD–MPH matriculants or 5 MD–MPH graduates in 2018 (N = 25) for in-depth assessments. We based follow-up surveys on a nonrepresentative subgroup of CEPH-accredited schools and programs of public health. We reviewed these institutions’ MD–MPH admission websites to examine admission criteria and curriculum content. We also conducted interviews with 20 admissions officers. During the interview, we asked how the MD–MPH is structured and financed and how MD students have affected curricular content and the ways that course materials are organized and presented. We also inquired about faculty workload, mentoring needs, the MPH practicum, and timing of when an MD student takes MPH coursework.

Results

Of 177 accredited medical schools in the United States, 87 are allopathic schools (ie, offering an MD degree) and 18 are osteopathic schools (ie, offering a DO degree) where medical students are able to formally pursue the MPH degree as part of a joint program, a joint offering, or because the degree is offered through a university-affiliated school or program of public health (Table 1). These dual-degree schools and programs include 87 of 141 LCME-accredited US allopathic schools and 18 of 36 osteopathic schools. MD–MPH matriculants represented 3.6% of the total MPH enrollment and <1% of the total medical school enrollment.

Table 1.

Characteristics of medical schools with dual MD–MPH degrees (N = 177),^a United States, 2018^b

Characteristics	Total
Accredited medical schools, no.a	177b
Accredited schools where MD and DO students can pursue an MPH degree, no. (%)b	105 (60)c
Medical school enrollment, no.d	121 639
Students pursuing MPH degree, no.e	22 235
Students pursuing MD–MPH dual degree, no.e	796
MD–MPH as a percentage of MPH enrollmente	3.6
MD–MPH as a percentage of medical school enrollmentd	<1.0
MPH graduates, no.e	9889
MD–MPH graduates, no. (%)e	257 (2.6)
Mean no. of MD–MPH students per schoole	5

Abbreviations: DO, doctor of osteopathy; MD, doctor of medicine; MPH, master of public health.

^aIncludes 141 allopathic schools and 36 osteopathic schools.

^bData source: Unpublished data from the American Association of Medical Colleges (AAMC) (aggregate graduate count data by medical school for the 2008-2009 through 2018-2019 academic years, 2019) and published data from the American Association of Colleges of Osteopathic Medicine (AACOM).¹⁸

^cIncludes 87 allopathic schools (62%) and 18 osteopathic schools (50%).

^dData sources: Liaison Committee on Medical Education Annual Medical School Questionnaire Part 11,¹⁹ AACOM,¹⁸ and unpublished data from the AAMC (unpublished data, aggregate graduate count data by medical school for the 2008-2009 through 2018-2019 academic years, 2019). The number of students is based on data from schools that reported students and graduates during that year. Not all schools that offer the MD–MPH dual degree report data on students and graduates.

^eData source: Unpublished data from the Association of Schools and Programs of Public Health (ASPPH annual data collection, 2010-2018, 2019). The number of students is based on data from schools that reported students and graduates during that year. Not all schools that offer the MD–MPH dual degree report data on students and graduates.

MD–MPH Students and Graduates

The number of students pursuing the MD–MPH degree increased from 149 in 2010 to 796 in 2018, an increase of 434% (Table 2). This rate of growth was greater than the growth of either medical students (16%) or MPH students (65%) alone. Similarly, the number of MD–MPH graduates increased from 107 in 2010 to 257 in 2018, an increase of 140%. This rate of growth was faster than the growth rate for medical students (15%) and MPH students (80%). Moreover, MD–MPH students as a percentage of total MPH students more than tripled, from 1.1% in 2010 to 3.6% in 2018 (Figure). We found smaller increases in rate of growth for graduates with MD–MPH degrees as a percentage of total MPH graduates, increasing from 2.0% to 2.6%.

Table 2.

Number and percentage change of MD, MPH, and dual-degree MD–MPH students and graduates, United States, 2010-2018^{a ,b,c}

Degree	2010	2011	2012	2013	2014	2015	2016	2017	2018	Change from 2010 to 2018, %
Students
MDa	78 740	80 207	81 934	83 356	85 128	86 595	88 191	89 759	91 266	16
MPHb	13 482	14 609	14 994	14 551	18 035	19 282	20 448	21 714	22 235	65
MD–MPHb	149	155	290	286	552	572	583	800	796	434
Graduates
MDa	17 360	17 344	18 155	18 072	18 703	18 943	19 260	19 563	19 938	15
MPHb	5396	60 028	6139	6077	7368	8044	8627	8812	9736	80
MD–MPHb	107	90	117	112	152	274	145	241	257	140

Abbreviations: MD, doctor of medicine; MPH, master of public health.

^aData source: Unpublished data from the American Association of Medical Colleges, 2010-2018 (aggregate graduate count data by medical school for the 2008-2009 through 2018-2019 academic years, 2019). The number of students is based on data from schools that reported students and graduates during that year. Not all schools that offer the MD–MPH dual degree report data on students and graduates.

^bData source: Unpublished data from the Association of Schools and Programs of Public Health (ASPPH annual data collection, 2010-2018, 2019). The number of students is based on data from schools that reported students and graduates during that year. Not all schools that offer the MD–MPH dual degree report data on students and graduates.

^cAll data are numbers, except where noted.

Figure.

Percentage of total master of public health (MPH) students and graduates who earned doctor of medicine (MD)–MPH dual degrees, United States, 2010-2018. Data source: Unpublished data from the Association of Schools and Programs of Public Health (ASPPH annual data collection, 2010-2018, 2019). The number of students is based on data from schools that reported students and graduates during that year. Not all schools that offer the MD–MPH dual degree report data on students and graduates.

From 2010 to 2018, the average number of MD–MPH students enrolled in each school increased from 4.7 to 5.6. However, in 2018, six schools had ≤5 students enrolled, 7 schools had 6-10 students enrolled, and 6 schools had >10 students enrolled.

Student Sociodemographic Characteristics

In 2018, 60% of MD–MPH students were women, 50% of MD students were women, and 48% of DO students were women (Table 3). Although the overall data on race/ethnicity were similar, we found several differences. In comparison with MD students, MD–MPH students were more likely to be White (56% vs 51%) and less likely to be Asian (19% vs 22%) or mixed race (4% vs 9%). The percentages of African American (8%) and Hispanic/Latino (6%) MD–MPH students were similar. In addition, the percentage of MD–MPH students who were African American (8%) was twice that of DO students (4%), and the percentage of MD–MPH students who were Asian (19%) was lower than the percentage of DO students who were Asian (23%).

Table 3.

MPH areas of study for MD–MPH and all other MPH students, United States, 2018^a

Area of study	MD–MPH, no. (%)	All other MPH, no. (%)
Generalist	127 (49)	1729 (18)
Epidemiology	29 (11)	1949 (21)
Health policy and management	27 (11)	1459 (15)
Health education and behavioral sciences	17 (7)	1601 (17)
Global health	6 (2)	514 (5)
Environmental sciences and environmental health	0	521 (5)
Biostatistics and health informatics	0	293 (3)
Nutrition	0	213 (2)
Other (allied health, laboratory, practice, health disparities, and maternal child health)	51 (20)	1210 (13)
Total	257 (100)	9489 (100)

Abbreviations: MD, doctor of medicine; MPH, master of public health.

^aData source: Unpublished data from the Association of Schools and Programs of Public Health (ASPPH annual data collection, 2010-2018, 2019). The number of students is based on data from schools that reported students and graduates during that year. Not all schools that offer the MD–MPH dual degree report data on students and graduates.

MPH Area of Study

MD–MPH students chose many of the same concentrations as other MPH students (Table 4). In 2018, MD–MPH students were more likely than all other MPH students to choose a generalist public health track (49% vs 18%). Epidemiology and health policy and management were the second-highest MD–MPH areas of study at 11%, whereas for all other MPH students, epidemiology was the top area of study, followed by generalist and health education and behavioral sciences.

Table 4.

Sex and race/ethnicity of MD–MPH, MD, and DO students, listed as percentages of total, United States, 2018

Characteristics	MD–MPHa (n = 796), %	MDb (n = 91 266), %	DOc (n = 30 373), %
Sex
Female	60	50	48
Male	40	50	52
Race/ethnicity
White	56	51	57
Asian	19	22	23
African American	8	7	4
Hispanic/Latino	6	6	6
American Indian/Alaska and Hawaiian Native	<1	<1	<1
≥2 races	4	9	4
Unknown	7	<1	5

Abbreviations: DO, doctor of osteopathy; MD, doctor of medicine; MPH, master of public health.

^aData source: Unpublished data from the Association of Schools and Programs of Public Health (ASPPH annual data collection, 2010-2018, 2019).

^bData source: Unpublished data from the American Association of Medical Colleges, 2010-2018 (aggregate graduate count data by medical school for the 2008-2009 through 2018-2019 academic years, 2019), Liaison Committee on Medical Education Annual Medical School Questionnaire Part 11,¹⁹ and American Association of Colleges of Osteopathic Medicine (AACOM), 2018.¹⁸

^cData source: AACOM, 2018.¹⁸

Curricular Structure

In our review of the 87 medical schools that offer dual MD–MPH degrees, we noted that medical schools offered MD–MPH programs in various formats, most commonly as a fifth-year option (after completing medical school year 2, 3, or 4) or as a 4-year option in which students complete MPH courses within their 4-year medical school curriculum. A 42-unit degree, the minimum for an accredited MPH, cannot be easily completed in 1 year, especially for students who need to balance course work with clinical rotations. Thus, many MPH programs allow some of the medical school classes to count toward the MPH degree. Some medical schools offer the MPH as an online program, either with in-person classes or without in-person classes. The MD–MPH degree integrated 4-year option is attractive because it requires no additional years of study and less tuition than for a medical student who completed an additional MPH year (after 4 years of college) and encumbered a fifth year of tuition. However, the fifth-year MD–MPH option may allow students to focus their attention on public health course materials unencumbered by the requirements of the clinical training.

Telephone interviews with ASPPH MD–MPH faculty and staff members offered qualitative insights into the benefits and challenges of MD–MPH programs. Faculty and staff members reported that MD–MPH students improve overall teaching in the MPH program because they bring “valuable and novel ideas and clinical experiences to class discussions.” Admissions officers reported that having faculty devoted to MD–MPH students helps students understand their career choices and practicums beyond what many schools provide to students as they enter residency.

Medical schools offering a 4-year MD–MPH degree explain to students that the combined program is rigorous, and students should be prepared for extra work. One program website offered detailed information in its frequently asked questions (FAQ) section, helping to set student expectations before matriculation. Another consideration for a 4-year compared with a 5-year MD–MPH degree is the cost of an additional year of training, which is a concern for health professional students with a lot of debt. At least 2 respondent schools subsidize MPH tuition for their MD–MPH year, with the cost of the program paid by the university, other than living expenses. One program uses Health Resources & Services Administration traineeship funds for MD–MPH students who are interested in a primary care career. These students spend a summer with a local Area Health Education Center (AHEC) network organization. AHECs are designed to improve health by leading the nation in recruitment, training, and retention of a diverse health workforce for underserved communities (https://www.nationalahec.org).

Variability also exists in how MD–MPH students complete their practicums and capstone projects, both of which are required for CEPH accreditation. Some students pursue a project with a clinical component. Some find practicums on a website maintained by the MPH program, where MD–MPH students choose projects that align with their career goals and interests. An MD–MPH website or other electronic platform (WIKI, Google document) maintained by schools and programs to store information describes practicum and capstone projects and lists contact information and project details for students to seek out their capstone project. Furthermore, several schools list past projects where MD–MPH students can see the scope and breadth of previous MD–MPH students’ projects.

We note the robust nature of websites for schools with large MD–MPH student matriculants. Compared with websites of programs that have a few students pursuing a dual MD–MPH degree, websites for schools with large MD–MPH student bodies are interactive, with pictures, dynamic student and faculty testimonials, online videos, future career opportunities, and links to alumni career paths. Some websites describe the schools’ dual-degree curriculum in detail with FAQ so that students are clear about expectations and goals.

Discussion

The number of students who are pursuing the MD–MPH degree, the number of medical schools offering this joint degree, and the offering of population health curriculum at medical schools increased during our study period. This increase in the MD–MPH trained workforce is an important consideration for the future US health care system, in which physicians trained in public health, beyond their clinical skills, will be needed. The additional population health, health care advocacy, and epidemiology skills better prepare physicians to work in complex health systems and communities with additional abilities to manage chronic disease databases, health data analytics/metrics, and health policy.

Although public health curricula at CEPH-accredited schools and programs of public health meet standards set by the CEPH criteria, the public health curricula offered in medical schools are not standardized, well studied, or well measured. It is difficult to know if more students pursue dual MD–MPH degrees in medical schools that offer a limited population health and health policy curriculum to supplement deficient medical school training than schools that have more integrated, robust public health training integrated into their medical school curricula.

The ultimate goals of MD–MPH students should be considered in suggesting the best educational curricula in which to deliver this dual degree. Fundamentally, these students are seeking additional training in population health, community health, health policy, statistics, and epidemiology. They seek grant writing, epidemiology, and clinically relevant training. They are interested in obtaining these degrees in the most efficient way possible that does not compromise the quality and breadth of MPH training and that is sensitive to cost and debt burden. MD–MPH students want mentorship and career advice on how to maximize their dual degrees. These needs are balanced with a demanding medical school education and increasing clinical responsibilities.

Limitations

Our study had several limitations. First, it was limited by the data that are currently collected and reported by the AAMC, AACOM, and ASPPH and their accrediting bodies. Because these organizations do not mandate reporting of MD–MPH and DO–MPH students, no complete data set was available that tracks data on matriculants, graduates, sex, race/ethnicity, and career pursuits. Second, data on physicians who return to pursue an MPH separately from their MD degree were not available. As such, it is likely that our study underreported the actual number of students pursing an MD–MPH degree. Therefore, we recommend developing a single, comprehensive, accurate database that incorporates student information from ASPPH, CEPH, AAMC, and AACOM.

Third, some of the data in this article came from membership files from the aforementioned organizations. Because individual institution data are owned by the institution and we did not have permission to disclose the names of the institutions and programs, the results are shown in aggregate. The web pages from which readers could obtain or request additional information are included in the references and in the appendix.

Conclusion

The dual MD–MPH degree is being pursued by a small yet growing percentage of medical students in the United States. Improvement in reporting on dual MD–MPH degrees, along with further information on MD graduates who return to schools, is needed to better understand the cohort of physicians with training in population health. Focusing on public health is important because medical schools seek to better prepare their students to address population health and meet the health needs of local and global communities.^20-22 Redesigning medical curricula with a focus on integrated public health is important, but providing the opportunity for in-depth study will help develop health care leaders with the skills and commitment to achieve this goal.^23,24 Finally, as medical students seek formal education and training in public health careers, optimizing their training to best meet the needs of the public and the social mission of medical education is essential.

ORCID iD

Jo Marie Reilly, MD, MPH https://orcid.org/0000-0002-5250-0432