Teaching Health Policy in Graduate Medical Education: Proposed Curricular Components

A 15-point framework for teaching health policy in undergraduate medical education was published earlier this decade. At the GME level, several programs – both institutional and specialty-specific have described their experience teaching health policy to their own learners. We therefore expand on the previously described framework adapting it for the development of a GME curriculum focused on U.S. domestic health policy. In addition, we analyze how well the currently employed Milestones address important health policy concepts.


Introduction
The Accreditation Council for Graduate Medical Education (ACGME) has defined Systems Based Practice (SBP) as one of six core competencies for physicians. This competency describes layers of systems affecting patient care, including that of clinic and hospital policy as well as state and federal laws, therefore necessitating that physicians understand the healthcare environment and know how to work within these complex systems to provide care for their patients (NEJM Knowledge+, 2018). Domestic health policy represents a major component of SBP.
Physicians must understand how health policy shapes our healthcare system to achieve true competency in this area. As defined by the World Health Organization, health policy represents the "decisions, plans, and actions that are undertaken to achieve specific health care goals within a society" (World Health Organization, 2017) Recent health policy debates and the subsequent engagement of medical professionals in the political dialogue highlights the importance of health policy as a competency (Lancet, 2017).

Lack of Medical Education in Health Policy
Physicians receive little education in health policy as part of their medical training (Goetz, et al, 2010;Greysen, et al, 2009). Over half of medical students are dissatisfied with the health policy education in medical school (Agrawal, et al, 2005). Therefore, we describe a framework for developing a graduate medical education (GME) curriculum focused on U.S. domestic health policy.
Few publications describe existing health policy curricula at the undergraduate medical education or GME level (Bischof, et al, 1996;Short & Hodgetts, 1997;Furin, et al, 2006;Foster, et al, 2008;Strelnick, et al, 2008;Nagler, et al, 2010;Chick, et al, 2014). Despite calls for more emphasis on the "social, economic, and political aspects of health care delivery" from medical educators (Cooke, et al, 2006) and recent interest in learning health policy, leadership, and medical economics by students, perceived education in health policy remains unacceptably low (Patel, et al, 2014).
Graduates consistently report their education in health policy as less adequate than instruction in other subjects. In 2013, 59% of graduating medical students ranked their education in health policy as adequate (AAMC, 2013). By comparison, 94% rated education in the care of hospitalized patients as adequate (AAMC, 2013).
If incoming residents feel inadequately prepared to deal with the issues of health policy as they relate to daily clinical practice, how can program directors best ensure that trainees possess competency in these topics? We propose a curricular framework with 19 components to teach health policy at the GME level.

An Existing Framework for Teaching Health Policy with Adjustments for GME
A framework with proposed components of a medical school curriculum in health policy currently exists (Patel, et al, 2011). The 15-point Patel framework contains the following components: (1) Adverse events, medical errors, and malpractice; (2) Comparative effectiveness;(3) Health care safety net; (4) Health disparities; (5) Health information technology; (6) Health insurance;(7) History and consequences of major health care legislation; (8) Medical decision making;(9) Medical economics; (10) Models of care management and control; (11) Quality improvement;(12) Quality indicators, measures, and outcomes;(13) Patient safety; (14) Physician workforce; and (15) U.S. health care system, financing, and payment. The Patel framework can serve as the building blocks for a health policy curriculum at the GME level, with adjustments as needed for each specialty. Upon review of the Patel framework, the existing literature, and expert opinion, we feel the need to elevate four additional components as necessary for trainees in all specialties to understand health policy in the U.S. Topics within these components are partially covered in other curricula, yet certain aspects must be addressed from a health policy perspective.
First, a discussion of the policy process at the federal and state levels has been excluded from the Patel framework. For physicians to understand how to change policy, it is necessary to understand the process of developing legislation through stakeholder input, the legislative process, and implementation by the executive branch of government (Greysen, et al, 2009;Heiman, et al, 2016). Second, the business aspects of medicine (e.g.physician reimbursement, practice management, organized medicine) affect a physician's daily life and are heavily influenced by policy decisions. Other authors also recognize the importance of the business aspects of medicine (Heiman, et al, 2016;Dequesada, et al, 2015). Third, leadership principles often taught in team-based trainings (e.g.TeamSTEPPS ® ,LifeWings ® ) may not necessarily include hospital management, negotiation, or professional advocacy (Bayer, et al, 2017;Combes & Arespacochaga, 2012;Gonzalo, et al, 2017;Crosson, et al, 2011). These principles are among several skillsets today's medical student leaders must learn. Lastly, ethical principles in health care address issues codified in laws such as HIPAA or touch upon resource allocation in health care. While not specifically mentioned as a separate component in the Patel framework, the authors indicate that faculty expertise in ethics is crucial to interdisciplinary instruction (Patel, et al, 2011). Other educators similarly address health care ethics in their curricula, therefore ethics in health care should be its own curricular component (Nagler, et al, 2010).

Mapping Milestones
Each ACGME-accredited specialty has developed a set of Milestones to assess residents in the achievement of the core competencies. We (Dark and Haddock) reviewed the list of Milestones for each of the twenty-five primary specialties (excluding transitional year) under the umbrella of the ACGME available as of September 28, 2016 (ACGME, 2016). These Milestones were evaluated to determine their alignment with the nineteen curricular components we identified as important to a health policy curriculum for GME [ Table 1].  The most common curricular components reflected in the Milestones of a majority of all training programs were medical decision-making; comparative effectiveness; quality improvement; patient safety; adverse events, medical errors, and malpractice; ethical principles in health care; and leadership principles in health care.
We then surveyed a panel of physicians, nurses, and medical educators with extensive backgrounds in health policy to rank the list of components according to the greatest importance for learners. The panelists' backgrounds include health policy fellows and fellowship directors, health care consultants, health services researchers, and government officials. The difference between these two lists highlights areas of health policy where the modern-day education of physicians may be neglectful.
Many components ranked most important by experts are not addressed in the Milestones of a majority of medical specialties [ Table 2]. Most notably, these include health insurance (16% representation), history and consequences of major health care legislation (4% representation), health disparities (36% representation), and U.S. healthcare system, financing, and payment (36% representation). If Milestones accurately reflect residency education, it is concerning that many residents may graduate without a firm knowledge of the most important health policy topics that they will encounter throughout their career. Table 2. Components of a health policy curriculum in graduate medical education as represented in current specialty milestones and ranked in order of importance by policy experts.

Implementing a Health Policy Curriculum for GME
Creation of a health policy curriculum is likely best handled at the institutional GME level rather than at the individual departmental level to allow for pooled resources, centralized funding, and avoid redundancy. As health policy expertise is typically scattered throughout an institution, a collaborative process between GME and individual departments is key to success. One idea would be to combine asynchronous curricula -developed centrally -with individualized speakers and activities to solidify key principles across the training spectrum.
At our institution, the Center for Medical Ethics and Health Policy operates a GME curriculum called the "Ethics, Professionalism and Policy Program" (EP3) which centralizes didactic and asynchronous materials for multiple clinical departments. Several EP3 modules -Care in the Social Context, Health Care Economics, Medical Error, and Confidentiality -address issues pertinent to our health policy curriculum.
Within our department, we subsequently create specialty-specific content focused on active learning, small groups, and case-based exercises rooted in the institution-wide EP3 curriculum.
To address issues not covered by the EP3 curriculum, we offer additional didactics and small group exercises that supplement our residents' education in health policy. The addition of health policy education in our department has not detracted from other clinical subjects as we have shifted some of our traditional emergency medicine education to asynchronous learning when possible. When no departmental expertise is available, institutional resources or guest speakers have proved critical. A solution that leverages UME resources, GME resources, and hospital resources has helped to avoid duplicity.

Conclusion
While often excluded from the formal education of physicians, health policy is a critical subject that affects the lives and livelihoods of both patients and physicians. The implications of health care policies for society are equally important, considering that over one-sixth of the economy is devoted to health care (CMS, 2017). Teaching health policy in GME, therefore, must be a priority for all medical specialties.
Expanding on an existing framework for teaching health policy to medical students, we recommend four additional components that should be incorporated into resident training. These components include: the policy process, business aspects of medicine, leadership principles, and ethical principles in health care. Where there is overlap with other educational priorities, we recommend an approach from the health policy perspective. We prioritize these components based on the recommendation of a panel of clinicians and health policy experts. We also implore program directors and institutions to put renewed focus on the following important components -health insurance, history and consequences of major health care legislation, health disparities, and U.S. healthcare system, financing, and payment -which currently do not receive enough attention in residency curricula as reflected in our Dark C, Pillow M, Haddock A MedEdPublish https://doi.org/10.15694/mep.2018.0000260.1 Page | 7 comprehensive review of the Milestones across specialties.
We recommend a centralized approach from institutional GME programs to address shared curricular needs in health policy. In parallel, individual specialty programs should supplement institutional efforts with tailored content designed to solidify these concepts with a specialty-specific focus.

Take Home Messages
Health policy affects the lives and livelihoods of patients and doctors Teaching health policy in graduate medical education should be a priority for educators Physicians must understand the current U.S. health care system including its financing and payment mechanisms Programs should supplement GME education about health policy with specialty-specific lessons