Preventive medicine education is an increasingly

Using Clinical Cases to Teach Prevention Case-Based Teaching in Preventive Medicine Rationale, Development, and Implementation John W. Epling, MD, Cynthia B. Morrow, MD, MPH, Sally M. Sutphen, MSc, MPH, Lloyd F. Novick, MD, MPH Abstract: The importance of prevention teaching is increasingly recognized in medical education, but its implementation in medical school curricula is hampered by its cross-specialty nature, lack of curricular time, and perception as a topic of less importance than the traditional basic and clinical sciences. The Case-Based Series in Population-Oriented Prevention (C-POP) was developed to address national objectives for prevention education in a format that recognizes the students abilities and preferences for case-based learning. This series uses small-group discussion cases that can be adapted to a variety of settings and instructor capabilities. These cases guide the learners from a specific clinical problem to the broader clinical and population-based prevention issues for the topic. The cases were developed with the use of local health department scenarios and data and have been taught and refined in a number of settings. As part of the curriculum development project, evaluation tools that examined prevention skills and orientation were developed and tested. With its emphasis on small-group learning, clinical relevance, and adaptability to a variety of learner and instructor needs, the C-POP project effectively integrates prevention concepts into medical education. (Am J Prev Med 2003;24(4S):85 89) 2003 American Journal of Preventive Medicine Introduction Preventive medicine education is an increasingly important component of medical education at all levels. National calls for healthcare and health system reform emphasize prevention education as essential to making the best use of healthcare expenditures and to reducing the underuse of proven preventive interventions. 1 3 The growing influence on clinical practice of publications like the U.S. Preventive Services Task Force reports, the Put Prevention Into Practice program, the Healthy People 2000 and 2010 initiatives, and the publication of the American Medical Association s Roadmaps for Clinical Practice: Primer on Population-Based Medicine 4 reveals the high priority placed on delivery of preventive services by physicians. Medical education also is evolving to incorporate new methods of instruction and to validate curricular innovations with outcome assessment. It is no longer simply adequate to deliver knowledge via a single instructional method and to hold the learners responsible for its incorporation into their practice. The evolution of multiple methods of information delivery (texts, lectures, small-group discussion, and educational technology), practical assessment techniques From SUNY Upstate Medical University, Syracuse, New York Address correspondence and reprint requests to: Lloyd F. Novick, MD, MPH, Preventive Medicine Program, Department of Medicine, SUNY Upstate Medical University, 714 Irving Avenue, Syracuse NY 13210. E-mail: PMP@upstate.edu. (standardized patients, observed structured clinical examinations), and an emphasis on measuring change in specific competencies across a curriculum is beginning to address the need for refocusing medical education to ensure the quality of physician training. 1,5 The Case-Based Series in Population-Oriented Prevention (C-POP) and the evaluation tools described in this supplement to the American Journal of Preventive Medicine were developed to meet this need. The C-POP series is an integrated set of small-group discussion cases that addresses the major curricular objectives in prevention education. This article will discuss the background and rationale for the design of the case series, review the development of the series, and discuss the other aspects of the C-POP project. Why a Case Series in Prevention? Prevention education, as described by the Association of Teachers of Preventive Medicine (ATPM), 6 is an amalgam of the basic sciences of epidemiology and biostatistics and the clinical sciences of disease prevention, health promotion, and public health. Epidemiology and biostatistics are often taught as a basic science in the preclinical years of medical school but through a variety of different methods and course structures. Clinical disease prevention and health promotion, as well as public health education, are frequently taught longitudinally in the clinical years with either formal integration into the clerkships or by outlining specific Am J Prev Med 2003;24(4S) 0749-3797/03/$ see front matter 2003 American Journal of Preventive Medicine Published by Elsevier Inc. doi:10.1016/s0749-3797(03)00028-x 85

clerkship objectives that cover those of prevention. Concern about this state of affairs is echoed in many publications attempting to study the success of preventive medicine integration. 7 11 Additionally, there have been several attempts to formalize the competencies required of medical students in prevention, the most widely known of which is the ATPM objectives inventory. 6 This inventory is a guiding document for curriculum designers in prevention education to address the specifics of the philosophy of prevention, specific skills and knowledge for clinical prevention, quantitative methods, health services organization and delivery, and community dimensions of medical practice. Educational interventions focused on these objectives ideally will broaden the perspectives of students in an overall curriculum focused primarily on diagnosis and treatment to consider prevention and the population aspects of the diseases they encounter. This population perspective addresses a number of topics in medicine that traditional curricula do not. First, it imparts an understanding of the determinants of health status in a population and draws attention to the true causes of disease such as substance abuse, lifestyle issues, and poverty. 12 Second, studying population data clarifies an understanding of the reality of racial, social, and economic health disparities. Examples of the integration of clinical medicine and public health services provided in the setting of prevention education can provide a model for eliminating these disparities. Finally, the population perspective and biostatistical concepts are necessary as a foundation for the increasingly important skills of evidence-based medicine. Along with an emphasis on increasing prevention education, medical schools are generally increasing the small-group focus of instruction as a way to improve the educational process. 5 A well-known model for this type of learning is problem-based learning, which involves presentation of a clinical case and subsequent elucidation of learning needs by the student group to be researched between the sessions. A common alternative to this labor-intensive and student-directed process is the small-group discussion, in which a clinical case (i.e., presentation of an example patient s history, physical information, or both) is presented and a facilitated discussion ensues, covering the specified objectives of the session. The problem-based learning model is ideally integrated into a complete curriculum, allowing for self-directed learning by the student groups, an approach taken by Trevena and Clarke 13 in their innovative population health curriculum. The small-group discussion can also be integrated into an existing traditional curriculum without the need for global curricular change. In these small groups, the use of clinical cases in the preclinical courses can serve as an enticement into the material of the case for students who appreciate the relevance that clinical discussion brings to their learning. In the clinical years, the use of these cases mirrors the students primary mode of learning that of learning from their patients histories and clinical situations. There are two main challenges in the development of small-group, clinical case based curriculum. First, the facilitators are of primary importance. Small-group discussions cannot proceed in a focused manner without a facilitator; ideally, in most clinical case discussion settings, the facilitator should be a relative content expert such as a physician or other health professional with experience in the topic. As large medical school classes are often divided into many small groups with different preceptors, there may be variations in the clinical skills or specialties of the preceptors that will result in differential education. An advantage of using a variety of preceptors is that each brings a new and possibly unique perspective on the clinical situation, encouraging learners to broaden the differential diagnoses and consider the multiple perspectives necessary as an expert clinician. Preceptor development and management are very time-consuming and difficult tasks, but they are crucial to the success of the learning intervention. Another challenge is controlling the discussion generated by a clinical case. Discussion about a particularly controversial topic in a case can overwhelm the session, and important objectives may be missed, resulting in a variable learning experience for different small groups from a class. However, it is just that type of discussion that lends the richness of exploration into topics that makes small-group learning attractive and effective. The balance between these extremes ultimately relies on the facilitator, but it is more easily achieved by the organization of the cases and inclusion of specific learning objectives. A new approach to prevention education is needed to overcome the traditional difficulties in teaching prevention: a primarily lecture-based teaching curriculum, difficulty of integration in the clinical years, and a view of prevention as a less important part of medical education. As a new approach, the combination of clinically derived cases in small-group discussions with specific learning objectives can transform the potentially dry subject matter of the discipline into interesting clinical scenarios that motivate students to learn the requisite skills and knowledge in the discipline. To take the relevance of the educational activity an additional step forward, the clinical case data can be derived from recent local clinical and public health events in the community. Basing these clinical scenarios on real patient and population data reinforces the students ability to apply the information to their future clinical encounters as well as provide an enjoyable context for learning. 14,15 86 American Journal of Preventive Medicine, Volume 24, Number 4S

Development of the C-POP Curriculum The C-POP cases were developed with funding from grants from the Josiah Macy Jr. Foundation and the U.S. Health Resources and Services Administration. These small-group format discussion cases were designed to improve a traditional curriculum in preventive medicine at State University of New York (SUNY) Upstate Medical University. Three cases Bicycle Helmet Effectiveness in Preventing Injury and Death, 16 Adolescent Suicide Prevention, 17 and Sexually Transmitted Disease in Adolescents 18 had been taught previously in the clinical years. Their development and teaching highlighted a very successful interaction between the preventive medicine teaching faculty and the clinical faculty in neurosurgery, psychiatry, and obstetrics/gynecology. Development of the four other cases Outbreak of Tuberculosis in a Homeless Men s Shelter, 19 Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York, 20 Community Health Assessment, 21 and A Critical Look at Prevention: Colorectal Cancer Screening, 22 followed an assessment of the preventive medicine competencies that were left untreated by the first set of cases. All the cases, except Community Health Assessment 21 and A Critical Look at Prevention: Colorectal Cancer Screening, 22 begin at the level of a clinical case presentation and gradually move the learners from clinical diagnosis and treatment issues, through clinical preventive services, and ultimately to population-oriented prevention. The clinical and population data for most of the cases are based on actual data from the Onondaga County Health Department, which increases the realism of the case for the students. A Critical Look at Prevention: Colorectal Cancer Screening 22 proceeds along a similar vein, but a clinical exercise is included as an optional activity at the end of the case to review patient-specific variables in screening decisions. Community Health Assessment 21 is an interactive discussion about health indicators that begins at the local community level and then broadens to include national data and health status indicators. All of these cases use either data abstracted from clinical cases or community health data from the Syracuse and Onondaga County, New York, area as their basis. Inclusion of this data often by itself generates interesting discussion, as students originally from outside the community learn a little more about the area in which they are beginning their clinical careers. In Outbreak of Tuberculosis in a Homeless Men s Shelter, 19 the students are introduced to the issue of homelessness in the community and how the health department serves such a population. In Sexually Transmitted Disease in Adolescents, 18 census-tract mapping of sexually transmitted disease (STD) rates in the community incites discussion about neighborhoods and socioeconomic status outside the immediate area of the medical school. In Adolescent Suicide Prevention, 17 a headline-grabbing cluster of suicides occurring in the most popular shopping mall in the area is discussed; students can see the health department initiated interventions to prevent the suicides by visiting the mall today. The population-oriented prevention activities in the cases are also based on actual local health department activities. In Racial and Ethnic Disparity in Low Birth Weight, 20 an exploration of Onondaga County s racial disparity in low birth weight is explored by the students in much the same way as it was by the health department. In A Critical Look at Prevention: Colorectal Cancer Screening, 22 the population survey of colon cancer screening rates was used as a basis for a screening summit involving local primary care physicians, surgeons, gastroenterologists, and public health officials to develop an implementation of national screening standard for the local community according to resources and existing practices. The case series was taught twice at SUNY Upstate Medical University to students in their preclinical years and refined. The cases were then distributed to our collaborating institutions. The directors of the epidemiology curriculum at the University of Rochester (New York) and the University of California at Davis have both implemented the series at the preclinical level. The director of the preventive medicine residency program at the New York State Department of Health Albany Medical Center is adapting the cases for use with residents. The feedback collected from these sites was also incorporated into the case revisions. All these sites have published their experiences in implementing the cases in their preventive medicine curricula. 23 25 Evaluating Prevention Education An important focus of the Josiah Macy Jr. Foundation grant funding the C-POP project is on the evaluation of preventive medicine skills in medical students. 26 Academic medicine in general and preventive medicine in particular are increasingly recognizing the need for evaluation strategies that are focused on an increase in learner competencies. 26 Merely favorable evaluations of the teaching are not enough to judge a curriculum s worth in prevention education. Because much of the teaching is done not to increase knowledge alone but to instill in students a broadened perspective of their roles in their patients health, curriculum designers ideally must document change in skills and attitudes of preventive medicine across the curriculum. To this end, two types of evaluation instruments 26,27 were created to address the acquisition of preventive medicine skills and orientation, not merely knowledge, through medical school. A formal evaluation of the C-POP curriculum versus a standard didactic curriculum has Am J Prev Med 2003;24(4S) 87

not yet been performed, but it is hoped that these instruments will make such an evaluation more useful. Can Others Use the Curriculum? The C-POP series is meant to be used by preventive medicine teachers as a way to reinvigorate their curricula. The cases are suitable for longitudinal integration across a 4-year medical school curriculum, as well as in an intensive course in preventive medicine over several weeks. Rather than requiring specific learner knowledge and skills at entry into the curriculum, these cases can be adapted for medical students at any level of training as well as for residents of a preventive medicine, family medicine, or other primary care residency. Adaptation across these diverse levels of clinical experience can be found in the points of customization noted in the cases more clinically advanced learners can delve into issues of clinical prevention and clinically applied biostatistical concepts, learners engaged in public health can focus on the population aspects of the case. The experiences described in Pearson et al., 23 Applegate, 24 and Sutphen et al. 27 are examples of this adaptability. The C-POP series also accounts for the wide variability in preceptor background and skills through the use of the customization points and the facilitator guides. Whereas a public health trained facilitator may spend more time exploring ways that health departments can interact positively with community physicians, the more-clinical facilitator may discuss the clinical prevention aspects of the case. Another key to customization would be to supply local community data in place of the Onondaga County, New York, data provided. To the extent that the learners themselves could obtain this data, competencies in data sources, health indicators, and community-oriented primary care could be reinforced. The adaptability of this curriculum additionally aids in the integration of these cases into an existing preventive medicine course. The individual case objectives were formulated with attention to the major areas of the ATPM knowledge and skills inventory, 6 and, by comparing the learning objectives contained in the cases, course directors could fill gaps left by a lecture curriculum or reinforce with group discussion the important didactic objectives in the course. By using the opportunities for additional discussion noted in the cases, there can be further direction of the education. As noted in Morrow et al., 29 more cases can be developed using the C-POP framework to completely address the ATPM objectives inventory. Additional features contribute to the C-POP series accessibility as a curricular resource. A user s guide to the cases has been prepared that discusses general implementation issues of the case series. 30 Facilitator guides for each case are available from the authors that include a reproduction of the case with detailed answers and background information to assist in the teaching of the cases. These guides have been helpful in the implementation of the curriculum in the various settings described earlier, as facilitators for these courses were diverse in their clinical and prevention backgrounds. In addition, online versions of the curriculum modified for individual study are being developed. These web-based modules will closely resemble the clinical cases but will attempt to translate some of the discussion-oriented learning into an interactive electronic format. In this way, other institutions can use the case curriculum despite a shortage of faculty facilitators. Conclusion Prevention is a critical competency for physicians in the 21st century. More effective methods for teaching prevention and the broadening of the clinical focus to that of population orientation are two major challenges facing preventive medicine teachers. The C-POP series was developed to attract the interest of clinically oriented medical students with interesting clinical case presentations and to lead them through discovery of the importance of clinical and population-based prevention for the clinical conditions of the patients presented. The adaptability of the curriculum to existing course content, course structure, and learner and facilitator needs makes the C-POP series an easily integrated method of teaching prevention competencies. The Case-Based Series in Population-Oriented Prevention (C-POP) is funded by grants from the Josiah Macy, Jr. Foundation and the Health Resources and Services Administration, U.S. Department of Health and Human Services. References 1. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press, 2001. 2. Healthy People 2010. Available at: www.health.gov/healthypeople/. Accessed September 23, 2002. 3. Medical school objectives project: report I learning objectives for medical student education guidelines for medical schools. Washington DC: Association of American Medical Colleges, 1998. 4. Shatzer JH. Instructional methods. Acad Med 1998;78(suppl 9):S38 S45. 5. Peters K, Elster A. Roadmaps for clinical practice: primer on populationbased medicine. Chicago: American Medical Association, 2002. 6. An inventory of knowledge and skills relating to disease prevention and health promotion. Washington DC: Association of Teachers of Preventive Medicine, 1986. 7. Phillips B, Rubeck R, Hathaway M, Becker M, Boehlecke B. Preventive medicine: what do future practitioners really need? Are they getting it in medical school? J Ky Med Assoc 1993;91:104 11. 8. Havas S, Rixey S, Sherwin R, Zimmerman SI, Anderson S. The University of Maryland experience in integrating preventive medicine into the clinical medicine curriculum. Public Health Rep 1993;108:332 9. 9. Dickey LL, Tran K. Evaluating the teaching of clinical preventive medicine: a multidimensional approach. Am J Prev Med 2001;20:190 5. 10. Dismuke SE, Burns BW, Moranetz CA, Ellerbeck E. Curriculum assessment for prevention topics and the population perspective. Am J Prev Med 2001;20:286 90. 88 American Journal of Preventive Medicine, Volume 24, Number 4S

11. Garr DR, Lackland DT, Wilson DB. Prevention education and evaluation in U.S. medical schools: a status report. Acad Med 2000;75(suppl 7):S14 S21. 12. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207 12. 13. Trevena LJ, Clarke RM. Self-directed learning in population health: a clinically relevant approach for medical students. Am J Prev Med 2002;22: 59 65. 14. Medical school objectives project: report II contemporary issues in medicine: medical informatics and population health. Washington DC: Association of American Medical Colleges, 1998. 15. Pomrehn PR, Davis MV, Chen DW, Barker W. Prevention for the 21st century: setting the context through undergraduate education. Acad Med 2000;75(suppl 7):S5 S13. 16. Novick LF, Wojtowycz M, Morrow CB, Sutphen SM. Bicycle helmet effectiveness in preventing injury and death. Am J Prev Med 2003;4(suppl): 143 9. 17. Novick LF, Cibula DA, Sutphen SM. Adolescent suicide prevention. Am J Prev Med 2003;4(suppl):150 6. 18. Novick LF, Terán S, Dolbear G. Sexually transmitted disease in adolescents. Am J Prev Med 2003;4(suppl):133 8. 19. Morrow CB, Cibula DA, Novick LF. Outbreak of tuberculosis in a homeless men s shelter. Am J Prev Med 2003;4(suppl):124 7. 20. Lane SD, Terán S, Morrow CB, Novick LF. Racial and ethnic disparity in low birth weight in Syracuse, New York. Am J Prev Med 2003;4(suppl):128 32. 21. Cibula DA, Novick LF, Morrow CB, Sutphen SM. Community health assessment. Am J Prev Med 2003;4(suppl):118 23. 22. Epling JW, Morrow CB, Cibula DA. A critical look at prevention: colorectal cancer screening. Am J Prev Med 2003;4(suppl):139 42. 23. Pearson TA, Barker WH, Fisher SG, Trafton SH. Integration of Case-Based Series in Population-Oriented Prevention into a problem-based medical curriculum. Am J Prev Med 2003;4(suppl):102 7. 24. Applegate MS. Preventive medicine teaching cases for preventive medicine residents. Am J Prev Med 2003;4(suppl):111 5. 25. McCurdy SA. Preventive medicine teaching cases in the preclinical undergraduate medical curriculum. Am J Prev Med 2003;4(suppl):108 10. 26. Blue AV, Barnette JJ, Ferguson KJ, Garr DR. Evaluation methods for prevention education. Acad Med 2000;75(suppl 7):S28 S34. 27. Sutphen SM, Cibula DA, Morrow CB, Epling JW, Novick LF. Evaluation of a preventive medicine curriculum: incorporating a case-based approach. Am J Prev Med 2003;4(suppl):90 4. 28. Novick LF, Cibula DA, Sutphen SM, Rixey S, Epling JW, Morrow CB. Measuring orientation to population-based prevention. Am J Prev Med 2003;4(suppl):95 101. 29. Morrow CB, Epling JW, Terán S, Sutphen SM, Novick LF. Future applications of case-based teaching in population-based prevention. Am J Prev Med 2003;4(suppl):166 9. 30. Morrow CB, Epling JW, Novick LF. A user s guide to teaching the C-POP series. Am J Prev Med 2003;4(suppl):116 7. Am J Prev Med 2003;24(4S) 89