Texas Needs Physicians Trained in Public Health

A New 4-Year Integrated MD/MPH Degree Program 

Texas Medicine Magazine Logo

The Journal – April 2010


By Sharon P. Cooper, PhD; Joseph B. McCormick; Cynthia L. Chappell; Nanette Clare, MD; Leonel Vela, MD, MPH; Tatjana Walker; Mary Ann Smith; Lynne P. Heilbrun; Debra L. Stark; Reed Schoenly; Ximena Urrutia-Rojas, RN, DrPH; and Claudia S. Miller, MD, MS

Dr. Cooper, professor and regional dean, The University of Texas School of Public Health, San Antonio Regional Campus; Dr McCormick and Mr Schoenly, UT School of Public Health, Brownsville Regional Campus; Dr Chappell and Dr Smith, UT School of Public Health; Dr Clare, Ms Walker, and Dr Miller, UT School of Medicine at San Antonio; Dr Vela, Lower Rio Grande Valley Regional Academic Health Center; Ms Heilbrun and Dr Urrutia-Rojas, UT School of Public health, San Antonio Regional Campus; and Dr Stark, UT Health Science Center at San Antonio. Send correspondence to Sharon P. Cooper, PhD, UT School of Public Health, San Antonio Regional Campus, 8550 Datapoint, Suite 200, San Antonio, TX 78229; e-mail: Sharon.P.Cooper@uth.tmc.edu.  


Abstract

Traditionally, medicine and public health have not worked as synergistic disciplines because they are based on fundamentally different models. However, a number of very recent imperatives emphasize the need for dual training in these fields to address major public health problems facing society as well as the documented and forecasted workforce shortages. In response to this need, two University of Texas institutions based in San Antonio, Texas, partnered in 2007 to offer a dual 4-year Doctor of Medicine/Master of Public health (MD/MPH) degree program, one of a handful in the nation. Approximately 65 students (or 10% of three consecutive medical school classes) are currently enrolled. The dual-degree program meets the requirements of both degree programs while giving shared MPH credit for relevant courses taken in the medical curriculum and medical school credit for some courses in the public health curriculum. However, 75% of the MPH coursework originates at the School of Public Health.

Initial results from focus groups conducted after the first year showed a high degree of student satisfaction, with frequent comments that the program was broadening their perspective on medicine and influencing their career and life goals. A dual MD/MPH degree is an important option for all medical students as a means of addressing pressing health issues in our society through combined training in medicine and the broader areas of prevention and population health. The four-year MD/MPH program, while posing challenges for faculty and students, attracts community- and prevention-minded medical students, reduces training costs (housing/living costs and lost time and wages before entering residency), and allows students to progress with the rest of their class.


Background

Historically, medical schools integrated health promotion and disease prevention into their curricula as a part of medical practice before the development of free-standing schools of public health.1 However, since then, medicine and public health have had a long-standing tenuous relationship, based on fundamentally different underlying theoretical models upon which each discipline is based. Medical education has focused on individual treatment and diagnosis through a biomedical model, whereas public health education is based on a population- and prevention-focused model. Remarkably, estimates are that less than 1% of all physicians have formal training in public health.2,3 To address the costly separation between medicine and public health and to work toward a shared future,4 the American Medical Association and the American Public Health Association created the Medicine and Public Health Initiative (MPHI) in the mid-1990s. Although promising successes in bridging the gap have been noted, a follow-up 10-year assessment recommended renewed commitment by leadership at the national level, while recognizing the importance of local "ownership and leadership … to translate the MPHI into meaningful action."3

The Institute of Medicine (IOM) conducted a parallel study, assessing the shortage, training needs, and maintenance of an adequate public health physician workforce.5 The IOM defined public health physicians as "those whose training, practice and world view are based in a large part on a population focus rather than individual practice, that is, on assuring the availability of essential public health services to a population using skills such as leadership, management, and education as well as clinical interventions."5 On the basis of expert opinion and current data, the IOM committee estimated the existence of approximately 10,000 public health physicians and estimated the shortage to be of equal magnitude. Among the recommendations made were the development of competency-based certification programs and the recruitment of physicians to Master of Public Health (MPH) degree programs.

Similarly, the Association of Schools of Public Health released a report in 2008 forecasting the critical shortage of public health workers (estimated to reach 250,000 more workers needed by 2020), especially noting the shortages of public health physicians, nurses, epidemiologists, health care educators, and administrators.6 The World Health Organization concurrently called for a return to primary health care as a comprehensive prevention-based approach and solution to the growing inequities and costs in health care globally.7 Nevertheless, most primary health care programs offer minimal training in primary prevention. Simultaneously, physicians have little incentive to practice prevention, given the insufficient-to-nonexistent reimbursement rates for these services.

Combining Doctor of Medicine and Master of Public Health (MD/MPH) degree programs is a potentially productive approach for rapidly achieving these goals, ie, integrating medicine and public health training so as to prepare physicians to address the broader areas of population-based prevention and wellness. The dual degree provides a means of addressing pressing problems such as obesity, diabetes, substance abuse, reemerging infectious diseases, environmental health concerns, health disparities, border health, and many others in new and more cost-effective ways. The MD/MPH degree program further provides training geared to the unique needs of medical practice, health care institutions, public health departments, and public and private health organizations.


Implementation of Dual Degrees

Recognizing that future physicians must be able to address both individual patient care needs and the health needs of the communities they serve, The University of Texas Health Science Center at San Antonio (UTHSCSA) School of Medicine and The University of Texas School of Public Health (UTSPH) explored the possibility of providing a broader educational opportunity for UTHSCSA medical students by offering a dual MD/MPH degree. The goal was to ensure that medical students developed the skills necessary to improve population health while learning to provide excellent individual medical care. More than 75 MD/MPH programs are offered across the country,3 but fewer than 10 offer a curriculum in which both degrees can be completed in 4 years. After considerable groundwork that began in 2003 and included a request by the medical school dean for an MD/MPH task force, formal meetings to design this program began in 2006 with UTHSCSA partnering with UTSPH. The UTSPH San Antonio Regional Campus has a long-standing collaborative relationship with UTHSCSA. In addition, the UTSPH Brownsville Regional Campus, which is the Public Health Division of the Regional Academic Health Center (RAHC) of the Lower Rio Grande Valley, is located in South Texas. This campus is close to UTHSCSA's Medical Education Division of the RAHC in Harlingen, where medical students may choose to complete their third and fourth years of medical school.

The University of Texas School of Public Health regional campus network of public health education is unusual among schools of public health in the United States in that it provides a wealth of educational, research, and service resources across the state (Figure) [PDF]. The San Antonio Regional Campus is near the UTHSCSA School of Medicine, and, as noted, the Brownsville Regional Campus is near Harlingen. All of the campuses are linked by an extensive videoconferencing (ITV) and computer network, which facilitates communication, shared governance, expanded course offerings, and research collaborations. The online and ITV courses may originate from the main campus in Houston or from any of the five UTSPH regional campuses.

The dual-degree program minimizes duplication in course content, streamlines academic interactions, and reduces the time and costs incurred compared with earning the two degrees independently. The dual-degree program, designed as a 4-year curriculum, is the only program of its kind currently offered in Texas. Students in the MD/MPH program enroll separately in both universities. Shared crediting of some coursework enables students to complete both degrees in 4 years. Progress and academic standing in one program does not affect progress in the other program, although students receive shared credit only for courses satisfactorily completed. If they choose, students may extend the program and take more than 4 years to complete the MPH degree or may elect to take a year away from their medical studies. Alternatively, if students complete the 5 required core courses (typically 16 hours) and are unable to complete other program requirements, they may opt to withdraw from the MPH program and instead earn the Certificate in Public Health.

After months of planning and negotiating to assure that the academic requirements of both schools could be met within the 4 years of the medical school curriculum, both institutions signed an agreement to launch the MD/MPH program beginning in academic year 2007-2008. An MD/MPH coordinating committee, comprising two faculty representatives from each institution and the respective associate deans of academic affairs, ensures that policies for the MD/MPH dual-degree program retain the academic integrity of both degrees while promoting a variety of interinstitutional exchanges; these include adjunct faculty appointments, shared teaching, joint research, and faculty enrichment. The coordinating committee also appoints one student representative per class, who serves as a liaison for MD/MPH program activities and encourages student feedback. Students apply to the UTSPH and UTHSCSA graduate degree programs independently and are accepted according to the admission schedules and policies of each school. All students share the same two School of Public Health advisors, who advise in a group setting to ensure optimal communication and coordination of courses and activities with the medical school schedule. Students have the option of changing their committee and adding a third committee member from the UTHSCSA faculty to serve on the individual advisory committee if the student chooses the thesis option rather than the comprehensive examination for his or her culminating experience. The role of the student advisory committees is to help students select coursework, a practicum site, and a culminating experience topic. Students in the dual-degree program receive separate diplomas from each school after meeting the requirements of each degree program. Accreditation for the MD and MPH degree programs is through the participating schools as approved by the Texas Higher Education Coordinating Board.


Curriculum

The dual-degree program incorporates the requirements of both degree programs, while providing up to 12 MPH semester credit hours for relevant courses taken in the medical school. The MPH portion of the dual-degree program requires 45 semester credit hours – 33 semester credit hours from UTSPH plus the 12 hours of specified shared course credits from the School of Medicine. The MPH degree teaches skills in 5 core disciplines including biostatistics, epidemiology, environmental health, health administration/policy, and health behavior. Students must complete 1 core course in each of the 5 disciplines in addition to other electives, a practicum, and a culminating experience.

Most begin their MPH coursework during the summer before their arrival at the UTHSCSA medical campus by completing online UTSPH courses in epidemiology and biostatistics. As recommended in the course sequence, none of the first-year students take MPH courses during their first semester of medical school enrollment (there is a 3-week overlap from summer courses); instead, they are encouraged to devote their first semester to adjusting to medical school. In the spring, they may take an additional core course as well as a weekly public health seminar series that brings all of the MD/MPH students formally together for the first time. During the break between the end of their first year of medical school and the beginning of the second year, students may choose to attend the South Texas Environmental Education and Research (STEER) program, a 4-week program at the Texas-Mexico border that meets the requirement for their MPH practicum and provides forward credit for a fourth-year elective in the MD curriculum. At the end of their second year, a subset of medical students may choose to transfer to the Regional Academic Health Center in Harlingen and complete their MD/MPH requirements at the UTSPH Brownsville Regional Campus. The students continue to take shared credit medical courses, as well as MPH core courses, electives, and the culminating experience (thesis, policy analysis, or other significant project) until they reach the 45 semester credit hours required for the MPH degree (Table 1) [PDF]. Students with a strong interest in international issues may choose an MPH concentration in global health. The global health concentration consists of 12 credit hours and requires specific coursework as well as a practicum and culminating experience that address global health concerns. At least one of the UTSPH faculty members on the MPH Student Advisory Committee must be a member of the global health faculty.


Shared Credit Hours

Admission to the MD/MPH program confers eligibility for shared credits. The UTSPH counts up to12 semester credit hours in approved shared credit courses taken in the Medical School curriculum (Table 2) [PDF]. Nine of the 12 hours occur during the normal course of the medical school curriculum; 3 credit hours come from approved medical school electives.


Program Status

The first MD/MPH cohort in San Antonio matriculated in summer 2007 with 19 students (nearly 10% of the entering medical school class.) More than 85% of these students, in their third year of medical school, have completed all but the culminating experience and 12 hours of electives. The second MD/MPH cohort includes 24 students, the majority of whom matriculated into medical school in fall 2008. Remarkably, 5 students from this cohort need only 1 elective and their culminating experience to complete their School of Public Health requirements. Another 6 students lack only 2 electives and their culminating experience to graduate from both schools in 2012. In spring 2009, the third cohort of 27 students joined the program.

Overall, we have successfully retained 91% (64 of 70) of the enrolled students.


Lessons Learned

As expected, newly developed programs are dynamic and require adjustments along the way. We learned from our first cohort of MD/MPH students that assigning individual advisors right away is not effective. Instead, for efficiency and consistency of information, the regional dean and a global health faculty member conduct group advising to the whole cohort. Further, we learned that the students from the previous cohort were an integral and valuable component in the advising process, and we began inviting them to supplement our group advising sessions. The students have been sharing their time generously and participating enthusiastically. Students have the freedom to choose alternate advisors if they pursue the thesis in their second or third year as they begin to formulate ideas for their culminating experiences.

The challenge of offering additional classes compatible with medical student schedules became evident as students progressed in the School of Public Health program. Responding to our request for face-to-face classes, the medical school dean for academic affairs opened the schedule, allowing these students to attend classes at the School of Public Health one afternoon a week for both fall and spring semesters of their second year of medical school.

Overall, most of the approximately 70 MD/MPH students are on schedule with the planned course sequence and will be able to graduate with both degrees in 4 years. The major challenge in the second through fourth years of the MD/MPH program is related to the development and completion of the culminating experiences. To help address this challenge, in late summer 2008, students from the inaugural cohort met faculty from both schools during a formal reception and had the opportunity to learn about ongoing research projects and mentoring possibilities. In addition, UTSPH announced recently that a comprehensive examination will be added as a fifth culminating experience option beginning with the class of 2011, our first cohort. Details of the examination are not finalized; however, we are optimistic that this will facilitate on-time graduation rates.

In fall 2008, the evaluation specialist from UTHSCSA's Academic Center for Excellence in Teaching conducted focus groups to learn the students' perceptions about their first year in the program and the quality of education they were receiving. Two focus groups, comprising 15 of the 17 active students from the initial cohort, discussed the structural and procedural aspects of the MD/MPH program, their experiences with the UTSPH courses they had taken, and the impact of enrollment in UTSPH on their understanding and thinking about the relationship between public health and the practice of medicine. They stated that the courses provided them with a perspective they saw as lacking in their medical school classes, allowed them to consider a population perspective, and helped them become more reflective. Many students felt that the dual-degree program had already, after only 1 year, shifted their perspectives in career- and life-changing ways. They also made several comments about how specific courses could be improved and expressed apprehension about the future thesis/culminating experience project. They offered specific recommendations regarding the UTSPH application and admissions process and the need for a written guidebook and a formal orientation (all have subsequently been implemented). Overall, students were favorably impressed with their MPH courses and the MD/MPH program. Their suggestions for improvement were constructive and will serve to enrich the experiences of future students.


Discussion and Conclusion

The program leaders have had to work through a host of administrative and logistical issues, but the enthusiasm, dedication, and excellent working relationships among the many collaborators, as well as support from top administrators, have allowed the successful implementation of this program. The students' enthusiasm is contagious, and their commitment to public health continues to inspire us all. Continuing challenges have included differences in the academic calendars for the School of Medicine and the School of Public Heath; ensuring that prospective students, who may not match until a month before their MPH applications must be submitted to the School of Public Health, are aware of the availability of the MD/MPH dual-degree program; and the difficulty of carving out consistent time for in-person courses or seminars given the demands upon the students' time. Nonetheless, the availability of online courses contributed critically to the viability of this program by allowing students to enroll in public health courses before matriculating in medical school and to later take core public health classes at times that fit their personal schedules.

Currently, we are developing logic models as the basis of an evaluation plan for this dual-degree program. Details about the program's mission and goals, competencies, and the logic models will be the subject of a subsequent paper. Both institutions are recipients of the National Institutes of Health Clinical and Translational Science Awards, which have the potential to further the development of this program. These awards support the creation of advanced degrees in translational science that provide training in population health research so that basic science research findings can be extended to medical practice and the community. The development of competencies for these degrees may further inform additional competencies for the MD/MPH program.

With an already low MPH tuition rate plus the reduced hours based on 12 shared semester credit hours, the total additional cost of obtaining an MPH degree concurrently with the MD degree is only approximately $8,000. Completion in 4 years eliminates additional costs of housing or delayed residency.

A potential disadvantage of the 4-year program is the increased stress of superimposing additional coursework and assignments upon an already intense medical school curriculum. However, taken together, the advantages of attracting talented, dedicated, and enthusiastic medical students to public health and the students' excellent performance, apparent satisfaction, and perceived broadened perspectives about their medical education and future careers seem to support the outcome that the advantages of a 4-year curriculum greatly outweigh the limitations.

Another option that would help attract more physicians to public health might be fully funded scholarships for an additional year that could be devoted to full-time public health education. In medically underserved regions like South Texas, in the face of rising national and local public health threats, well-trained public health and prevention-oriented physicians are needed urgently. Many young health professionals-in-training incur considerable college and graduate school debt and can ill afford to take an extra year of training to work toward an MPH. A definite need exists for a 4-year integrated dual-degree MD/MPH curriculum to close the training gap between medicine and public health.

On the basis of our first 3 years of experience with the dual-degree program in San Antonio, we believe the MD/MPH program to be an important option for all prospective medical students, given the major public health problems that need to be addressed: widening health disparities, the shortage of public health physicians, unmanageable health care costs, and the critical need for a prevention and population health approach. The MD/MPH dual-degree program is one important way to accomplish public health objectives.

In addition to the 4-year integrated MD/MPH program described here, other 5-year MD/MPH programs exist: between the UTSPH campus in Houston and The University of Texas Medical School at Houston and Baylor College of Medicine; and between UTSPH's Dallas Regional Campus and The University of Texas Southwestern Medical School (which are considering converting to a 4-year program). UTSPH's El Paso regional campuses recently developed and received approval to offer a 4-year program with the new Texas Tech University Medical School in El Paso, extending the MD/MPH option throughout Texas and demonstrating the value added by a regional campus system.

We offer the following goal statement, written as part of a student evaluation in the MPH program by one of our MD/MPH students. It beautifully expresses the purpose of this dual-degree program and reflects the dedication and spirit of the students who choose this dual pathway:

Arielle Perez, San Antonio MD/MPH Class of 2011 wrote:

"To tap into the unparalleled potential of medicine when it's combined with public health and community understanding. To expand my knowledge of health care policy and community needs in order to mold a medical practice to better both the individual and society. To fulfill Virchow's charge of not only improving an individual's health, but also promoting the well-being of society by aiding those most in need. With this opportunity to expand myself with the MD/MPH degree, I hope to join their ranks. To expand my own knowledge, skills, and empathy in enhancing the quality of life for another human being, and being a leader for societal change."


Acknowledgments

We would like to acknowledge the many people involved with the support, development, and initial implementation of this dual-degree program: The University of Texas System's Vice Chancellor for Health Affairs at The University of Texas System Kenneth Shine, MD; former presidents of the two Health Science Centers, Francisco Cigarroa, MD, (now chancellor of the UT System) and James Willerson, MD, (now president of the Texas Heart Institute); dean of the UTHSCSA School of Medicine and the deans of UTSPH, William Henrich, MD, Guy Parcel, PhD, and Roberta Ness, MD, MPH, respectively; faculty and staff from UTHSCSA, Thomas Mayes, MD, MBA (interim medical school dean who created the MD/MPH taskforce), Adela Gonzalez, PhD, MPA, Roger Perales, MPH, and Ray Howard, MBA; faculty and staff from UTSPH, Stephanie McFall, PhD, Frank Moore, PhD, Melissa Garcia, and Rocio Chavez, MSPH; and the many contributions of our inaugural class of 2011 and 2012 student liaisons, Kristi Stone-Garza, BS and Kirsten Newhams, BA.


References

  1. Horwitz RI. A Proposal for Radical Reform of Medical Education. Cleveland, Ohio: Case School of Medicine and Health; 2003.
  2. Lane D. A threat to the public health workforce: evidence from trends in preventive medicine certification and training. Am J Prev Med. 2000;18(7):87-96.
  3. Beitsch LM, Brooks RG, Glasser JH, Coble YD Jr. The medicine and public health initiative ten years later. Am J Prev Med. 2005;29(2):149-153.
  4. Reiser S. Medicine and public health: pursuing a common destiny. JAMA. 1996;276(17):1429-1430.
  5. Institute of Medicine. Training Physicians for Public Health Careers. Washington, DC: The National Academies Press; 2007.
  6. Association of Schools of Public Health. Confronting the public health workforce crisis: ASPH statement on the public health workforce. 2008. http://www.asph.org/UserFiles/PHWFShortage0208.pdf [PDF]. Accessed January 2, 2009.
  7. World Health Organization. Primary health care: now more than ever. World Health Report 2008. http://www.who.int/whr/2008/08_overview_en.pdf [PDF]. Accessed January 2, 2009. 

 Accompanying Figure and Tables: Figure Table 1 Table 2   


 

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