ChangeMedEd Initiative

New model for managing chronic disease begins in medical school

Timothy M. Smith , Contributing News Writer

Chronic disease is a full-blown public health crisis in the U.S., yet much of undergraduate medical education (UME) remains grounded in acute care. The good news is there’s a new model—as well as a novel tool—for incorporating chronic disease prevention and management (CDPM) education into pre-clinical and clinical settings. An AMA webinar provides insights into how these two can help medical students recognize barriers to care and locate helpful community resources.

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The webinar, “A Systems Approach to Chronic Disease Education and Practice,” produced by the AMA Accelerating Change in Medical Education consortium, features speakers from the AMA’s CDPM Interest Group, a team of medical educators dedicated to improving CDPM in medical education and practice, and drawing on health systems science—the “third pillar” of medical education.

“There really weren't any longitudinal patient cases or experience during the first year, [when] students are very eager to have some patient experience,” said Mrinalini Kulkarni-Date, MD, associate professor and chief of the Division of Endocrinology at University of Texas at Austin Dell Medical School, noting that she and her colleagues wanted to teach chronic disease management previous to the disease state.

“So while we were doing a great job of talking about diabetes or hypertension in terms of what those disease states are—how they manifest, the pathophysiology behind them—we wanted to talk more about the population risk assessment, the disease burden both on patients and on families,” she said.

With support from its deans and basic science faculty, the medical school created a virtual patient family with diabetes.

"We chose an East Austin family,” Dr. Kulkarni-Date said. “We made it very local. The students, as they learn about this family, they become very familiar with Austin resources.”

The school’s goals are to help students recognize social determinants of health—including the various cultural influences and the psychosocial barriers to care—and identify local resources patients need to manage their disease.

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"We also wanted [students] to experience interprofessional care team roles in chronic disease management” and understand longitudinal care of chronic disease, Dr. Kulkarni-Date said. This includes “looking at not only how is the burden of chronic disease affecting our patient, but how has the family structure affected it as well?”

The school introduces students to the family early on—in the middle of year one’s basic science course. In year two, they start a longitudinal clerkship.

“So the longitudinal family lives on, where the students are talking more about evidence-based guidelines, systems issues,” she said.

At the same time, students are learning to use the H&P 360, a revision to the traditional history and physical exam. The H&P 360 is based on a format developed at University of Michigan Medical School and later refined and tested by the AMA’s Chronic Disease Prevention and Management interest group. Now four member schools of the Accelerating Change in Medical Education Consortium—University of Michigan, Eastern Virginia Medical School, Florida International University and University of Chicago – are implementing the H&P 360 in clinical teaching settings

The idea behind the H&P 360 is that by including questions in six domains besides the traditional biomedical information in the routine history—such as mental health conditions, social support and environmental or physical resources—physicians’ care of patients will improve.

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In the social support domain, for example, students might ask questions like:

  • “Who do you turn to when life gets stressful?”
  • “Are you afraid you might be hurt in your apartment building or house?”
  • “Who do you rely on when you are unable to do something yourself?”
  • “What community resources or programs do you use to improve or maintain your health?”

“The family component comes at key points in the curriculum to integrate learning,” Dr. Kulkarni-Date said. “I will do an interactive session right alongside our biochemistry, basic science faculty. And we sort of actually go back and forth—we tag team. While the students are learning about the biochemistry of insulin resistance, they're learning it in the context of a patient who is presenting with acanthosis nigricans, for example. And we talk about the genetics, the clinical presentation, and it's a really nice synergy.”

The webinar also features a presentation by Lauren Mazzurco, DO, on how to empower learners and faculty members to support curricular changes like this one. Slides and a video recording are available in the “Resources” section of the AMA Accelerating Change in Medical Education digital community (registration required).