Population health should be major focus in remaking med ed

As the dean of Jefferson College of Population Health—the nation’s first college dedicated to the practice—David B. Nash, MD, was a man ahead of his time.

That said, he’s happy to watch the medical education community catch up.

“Being the sole college of population health is probably not a good position,” Dr. Nash said. “Being the first of many is a great position. If you’re the sole school, people wonder, ‘Is this an enduring thing?’ If you’re the first of 10, people say, ‘Wow, that’s great. This is something I want to participate in.’”

The concept of population health—a practice that focuses on the health outcomes for a group of individuals rather than a single patient—has proven to have staying power. Since Jefferson, part of Philadelphia’s Thomas Jefferson University, launched its program in 2008, at least four other schools focusing on population health have sprung up. In addition, other medical school programs have made population health a central component of their curricula. Set to launch a new curriculum heavily vested in population health, Sidney Kimmel Medical College—Jefferson’s sister school—is among them. 

Dr. Nash will detail his work in population health and its future in medical education as a keynote speaker during the ChangeMedEd™ 2017 National Conference. Taking place Sept. 14–16 in Chicago, the event aims to further the work of the AMA’s Accelerating Change in Medical Education initiative by bringing together innovators from medical and health professions education, health systems and related fields. Registration is open until Aug. 31.

Having spent nearly three decades in academic medicine, Dr. Nash is aware of its shortfalls. That was never more apparent to him than when he looked at the curriculum his daughter encountered when she began her career as a medical student. It was, Dr. Nash said, “exactly the same” as his own 37 years ago.

“Not every university has a college of population health. I get it,” Dr. Nash said. “But America’s 147 allopathic medical schools need to retool the factory floor for the future, so changing med ed is part of that retooling. Historically, we’ve built a rear-wheel drive, gas-guzzling car for a marketplace that wants a Tesla. That is the change that medical education is going through.”

For that reason, Dr. Nash strongly supports the AMA’s initiative. In particular, he touts the effect it has had on generating interest in population health within medical schools.

The initiative “has been the spear in making this transition,” Dr. Nash said. “The AMA can say with pride that it is playing a part in the transformation [of population health] in undergraduate medical education.” 

Eighteen percent of the United States’ gross domestic product is spent on health care. That percentage is higher than any other country’s in the Western world. And the return on investment, Dr. Nash says, is uninspiring.

“The nation is obsessed, appropriately, with what’s going on on Capitol Hill,” Dr. Nash said. “That’s insurance reform, not health and wellness reform. I’m going to try to say, ‘Timeout. We’ve lost sight of what we are trying to do, which is improve health.’ One core tenet of that is universal access. So, yes, what goes on on Capitol Hill is important as it relates to universal access and affordability, but it still is not getting at the heart of waste and error and lack of value. The conversation is not broad enough and deep enough because our discourse is so limited.”

Broadening the conversation means encouraging institutions to learn about what is going on in their communities and to address root causes. For instance, Dr. Nash said, using population-health theories would dictate that rather than a health system’s investing in a bariatric surgery center, it should work with social-services entities to improve school lunches in the community.

That type of thinking runs contrary to health care’s predominantly fee-for-service economic model, however. Dr. Nash favors simplifying payment so that it is focused on results. Or, as he puts it, “No outcome, no income.”

“We have to make it economically viable for the system to promote prevention in health,” Dr. Nash said. “We have to reward providers for keeping people out of the hospital. We have to reward care coordination and care at home. It’s a dance of changing the economic incentives to drive a change in clinical behavior, which will drive an improvement in outcomes.”

While population health is, in itself, a relatively new concept on the health care landscape, studying outcomes among patient populations is not entirely foreign. Five decades of health-services research has taught a great deal.

“So what have we learned in 50 years?” Dr. Nash said. “A bunch of things. Among them: Socioeconomics are the most important determinant of health. Doctors respond to economic incentives. There’s waste in the system, and we could reduce that waste and transfer those resources to health and wellness.”

A change in the system, Dr. Nash believes, can begin with a collaborative effort among institutions at the UME level.

“There is no single group that will say, ‘You will change,’” Dr. Nash said. “The most powerful force for change is the marketplace. We are facing a market that is demanding these types of changes. And the students—in a very positive way—they want this content in the medical school curriculum.” 

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