Clinical Population Medicine: Integrating Clinical Medicine and Population Health in Practice

Clinical Population Medicine (CPM) represents a promising approach to clinical care, research, and health system design that leverages principles from public health and medicine to in order to mitigate health inequities and optimize population health. In this introduction to their virtual issue, Dr. Orkin and colleagues[1] challenge us to think about how we can "...create and support integrator practitioners and institutions that can deliver CPM expertise..."

To help address society's current and future health issues, medical schools offer a multitude of combined medical degrees (e.g. MD-PhD, MD- MPH, MD-MBA, MD-MPP) and residency programs designed to train clinicians in broader fields of research and practice. In addition to training more medical students in CPM-related fields, we can accelerate the development of a medical workforce with CPM expertise by training more researchers and practitioners from CPM-related fields in clinical medicine. A strategy for medical schools to help create and support a stronger CPM workforce is to attract more, and enhance the competitiveness of, applications from non- traditional students and professionals with CPM skills and experience.

"Non-traditional" is a loosely defined term often used to describe medical school applicants that are not coming from undergraduate backgrounds in the sciences, or those applying from higher levels of education or employment.[2] Non-traditional applicants face unique barriers to application; particularly those who have not completed all academic prerequisites for admission and/or the Medical College Admissions Test (MCAT). They must invest additional time and finances to complete prerequisite coursework or prepare for the MCAT, or both. This becomes increasingly difficult when compounded by competing priorities such as full-time employment, supporting a family, or paying off student debt. These factors contribute to non-traditional students typically being underrepresented within medical school classrooms. There is some evidence[2] to suggest that students from non-traditional backgrounds are increasingly represented within medical schools however published data on this trend is scarce. Admission statistics from one Canadian medical school (recognized for its approach to diversifying its applicant pool[3]) show that approximately 11% of admitted students in 2017 were over 25 years of age, 8% had completed graduate studies, and 6% of admitted students come from educational backgrounds in CPM-related fields such as public health, global health, or epidemiology.[4] However, it is difficult to ascertain whether these proportions are high or low given that all institutions do not disclose admission statistics with the same level of detail.

There are a few ways that medical schools and their funders could further support non-traditional applicants who are trained in CPM-related fields. Many undergraduate medical education programs have taken steps to modernize their admission requirements. For example, among Canadian schools these steps include: dropping conventional science-focused academic prerequisites; lowering minimum GPA requirements; not assessing, or only assessing performance on specific components of the MCAT; placing increased weight on inter-personal and decision-making skills assessments; and giving additional weight to applicants with graduate degrees.[5] Implementing measures like these within specific application review streams may attract more non-traditional applicants with CPM expertise and help enhance the competitiveness of their applications in relation to more traditional applicants.

Additionally, medical schools may consider designing programs that provide non-traditional students without traditional undergraduate science prerequisites with a year of foundational science education before entering the foundations year of medicine. Such programs could be designed off the "career changer" medical school admission streams and post- baccalaureate pre-medical education programs in the United States.[6,7]

Finally, the financial demands of retraining to meet the traditional academic requirements of medical programs need to be addressed. Medical schools, governments, and other health education funders may consider creating or extending financial support programs (e.g. scholarships, grants, and student loans) specifically for prospective applicants leaving employment in CPM-related fields to pursue medicine.

Dr. Orkin and colleagues' discussion about the role of educational institutions for integrating and embedding knowledge from clinical medicine and population health is noteworthy. This editorial prompts further reflection upon the skillsets of future clinicians that are currently being selected for by medical school admission policies. Developing a broader collective of CPM "integrator practitioners" will depend in part on the opportunities that individuals currently studying and working in CPM-related fields have to realize their aspirations of practicing medicine.

References

1. Orkin AM, Bharmal A, Cram J, Kouyoumdjian FG, Pinto AD, Upshur R. Clinical Population Medicine: Integrating Clinical Medicine and Population Health in Practice. Ann Fam Med . 2017 Sep 1;15(5):405-9.

2. Jauhar S. From All Walks of Life -- Nontraditional Medical Students and the Future of Medicine. N Engl J Med. 2008 Jul 17;359(3):224-7.

3. Sawisky G. Nontraditional medical students. Can Fam Physician. 2011 Oct;57(10):1123-4.

4. Micheal G. DeGroote School of Medicine. McMaster University Undergraduate Medical Program Class of 2020. Hamilton, Canada; 2017.

5. The Association of Faculties of Medicine of Canada. Admission Requirements for Canadian Faculties of Medicine. Ottawa, Canada; 2015.

6. Routes of Admission [Internet]. The Warren Alpert Medical School of Brown University. 2017. Available from: https://www.brown.edu/academics/medical/admission/apply-alpert-medical-school/routes-admission

7. Goucher Post-Bac Premed: Linkage Opportunities [Internet]. Goucher College. 2017. Available from: http://www.goucher.edu/learn/graduate-programs/post-baccalaureate-premed-program/linkage-to-medical-school

Competing interests: None declared

The editorial by Dr. Orkin et al. introducing the inaugural virtual issue of Annals of Family Medicine, promotes the integration of clinical care and community health under the rubric of Clinical Population Medicine (CPM). Reading it caused me to reflect on the split between clinical medicine and community health, and the various ways this separation is being addressed by Family Medicine.

The history of the division between clinical medicine and public health beginning over a hundred years ago and its impact on health care and population health has been well documented.[1] Clinicians interested in population health generally have had to leave clinical practice behind to pursue careers in public health. While many have worked to heal this rift between the care of individuals and the care of populations over the past century, the past decade has seen a remarkable resurgence of effort on a larger scale and in multiple areas; many of these efforts are being led by family physicians. Here are three examples that come to mind. Dr. Scott Fields and Dr. Jennifer Devoe help lead the OCHIN Community Information Network,[2] that links a network of community clinics through a common electronic medical record to improve care of vulnerable population and "to engage clinicians and patients in collaborative efforts to improve population health."[3] Second, Dr. Laura Gottlieb's research has provided evidence for the effectiveness of better addressing social determinants of health in primary care practices; she is currently the Director of the Social Interventions Research and Evaluation Network (SIREN),[4] which promote research to address social determinants of health in primary care.[5] Third, Dr. Bela Matyas established the Solano County Population and Public Health Hub with the intent of merging clinical and population data both to improve public health and to provide health-related population data that can be linked by practices to individual patients.[6]

Technology offers increasing opportunities for incorporating population health into clinical practice that are just beginning to be realized. However, most primary care physicians already work at capacity to care for individual patients. To be integrated into clinical practice, CPM will have to decrease, or at least not increase, the current workload for primary care physicians. This will require new infrastructure support, a commitment from clinical, organizational and health policy leadership and changes in payment systems. By highlighting the concept of CPM, Orkin et al provide rallying point for those working toward this common goal.

1. White KL. Healing the Schism: Epidemiology, Medicine, and the Public's Health. New York, NY:Springer-Verlag; 1991.
2. https://ochin.org/ochin-research/about-ochin-pbrn/ accessed on 9/29/17.
3. Devoe JE, Sears A. The OCHIN community information network: bringing together community health centers, information technology, and data to support a patient-centered medical village. J Am Board Fam Med. 2013 May-Jun;26(3):271-8.
4. https://sirenetwork.ucsf.edu/about-us accessed on 9/29/17.
5. Gottlieb L, Tobey R, Cantor J, Hessler D, Adler NE. Integrating social and medical data to improve population health: opportunities and barriers. Health Aff (Millwood). 2016;35(11):2116-23.
6. https://www.networkforphl.org/_asset/hptrjt/5A---Public-Health-Data-Matyas.pdf

Competing interests: None declared

As an editor of the Practical Playbook, cited by Orkin et al in their editorial, I would like to thank you for bringing attention to the need and opportunities for leadership in clinical population medicine.(1,2). But I would also like to point out that integrating clinical care and population health has been part of the role of family physicians since inception of the discipline. The 1966 Report of the Ad Hoc Committee on Education for Family Practice of the Council of Education of the American Medical Association defined a family physician as someone who "accepts responsibility for the patient's total health care within the context of his environment, including the community and the family or comparable social unit."(3) As they discuss, the family physician "exerts leadership to improve the quality and quality of resources and services in the area in accordance with demonstrated need."(2)

Similarly, the 1996 IOM report on Primary Care discusses the central role of family physicians as practicing in the context of family and community and goes on to discuss the importance of understanding "of the circumstances and facts that surround a patient, such as the patient's living conditions, family dynamics, work situation, and cultural background."(4) "In the broadest sense, primary care must also be linked to the larger community and environment in which people work and live. This also requires that primary care clinicians know the major causes of mortality and morbidity for the community served and that they be aware of what may be happening in the community - such as occupation dangers, patterns of childhood injuries, patterns of lead poisoning or other environmental hazards, homicides, issues of domestic violence, and epidemics."(3) Finally, the report calls out the need for primary care physicians to engage in coordination of health care services, including knowledge of the work of other community agencies.(3)

The 2012 IOM report on Primary Care and Public Health, and the 2016 IOM Workshop Summary on Collaboration between Health Care and Public Health make similar points, best summarized by Michael McGinnis of the National Academies in the forward to the Practical Playbook: the time is right, the knowledge is at hand, and technology is providing the tools to integrate what goes on within our clinic doors with our public health community.(5,6)

As we move forward, we are carrying out a vision of family medicine that has been part of our charter.

References:
(1) Michener JL, Koo D, Castrucci BC, et al. The Practical Playbook: Public Health and Primary Care Together. New York, NY: Oxford University Press; 2016.
(2) Orkin AM, Bharmal A, Cram, J, et al. Clinical Population Medicine: Integrating Clinical Medicine and Population Health in Practice. Ann Fam Med 2017;15:405-409.
(3) Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for the Family Practice of the Council on Medical Education. Chicago, IL: American Medical Association; 1966.
(4) Institute of Medicine. Primary Care: America's Health in a New Era. Washington, DC: The National Academy of Science; 1996.
(5) Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press; 2012.
(6) Institute of Medicine. Collaboration Between Health Care and Public Health: Workshop Summary. Washington, DC: The National Academies Press; 2016.

Competing interests: None declared

The College of Family Physicians of Canada has declared that one of the principles of family medicine is that "the family physician is a resource to a defined practice population." The rise of electronic medical records (EMRs) in primary care in Canada and the United States has shifted the way must think about the role of primary care physicians. Orkin et al. have termed this Clinical Population Medicine (CPM) and have very skillfully assembled a set of papers that highlight the opportunity available from these "integrators." However, using primary care EMR data for population health is not a straightforward activity. There is a great deal of variability in how physicians interact with their EMR and how information is captured during that interaction. Consideration for CPM should be integrated into EMR design and physician workflow. Further, while EMRs are designed for rapid data entry, they are still focused on individual provider-patient interactions and are not optimized for the large data queries necessary for CPM, nor are they designed to provide meaningful reports to clinicians.

The Canadian Primary Care Sentinel Surveillance Network has addressed many of the challenges of CPM in Canadian primary care by developing tools and processes for standardizing extracted EMR data and developing static reports and dynamic reporting tools. These reports include information at the practice (physician), site (clinic), network (region), province, and national level.

I applaud the effort of Orkin et al. to bring attention to this emerging field of CPM and CPCSSN for their leadership in Canada in this area over the last number of years. For more information about CPCCSN, visit www.cpcssn.ca.

Competing interests: None declared