Rethinking Population Health Care and Education

Mitch: This is The Scope Radio at the AAMC 2022 Learn Serve Lead conference, where we are having discussions with some of the top minds in academic medicine about how they are trying to build from the ground up and give rise to the new way of doing things.

We are joined today by three individuals who are here to talk to us a little bit about a new program. We're joined by Dr. Michael Good. He is the Executive Dean of the Spencer Fox Eccles School of Medicine at Utah Health.

As well as Dr. Karyn Springer. She is the Assistant Dean of the Population Health Clinical Learning program at University of Utah Health, as well as the Senior Medical Director of the Graduate Medical Education Strategy at Intermountain Healthcare.

And finally, we're joined by Taylor Dean. He's the Program Manager at University of Utah Health for the Population Health Scholars Program. Now, the Population Health Scholars Program is a new medical education program developed with a very special collaboration between both the Spencer Fox Eccles School of Medicine at University of Utah and Intermountain Healthcare.

So, keeping with the idea and theme of this conference and of these kinds of discussions we're having, I'll kick it off to you guys. What is it that makes this Population Health Scholars program so different? How is this helping us rise up and build from the ground up?

Dr. Good: Yeah, I think this is really exciting for me. Dr. Springer and I, and Taylor and I, have talked before that, first of all, this is a partnership. What we're creating here, no one of our organizations could do it by themselves. It's the coming together in a collaborative, synergistic way that allows this Population Health Scholars program to be created and to move forward.

So, what is population health? I think certainly in my own medical school, it was exclusively focused on the care of the individual patient that's right in front of you. And that always will be first and foremost in a physician's work and in our medical education program, whether it's the patient in the clinic or in the hospital, in the operating room, the delivery suite. First and foremost, we take care of the patient who's come to us to help solve their health challenges.

But increasingly, and we think in a really innovative way here at University of Utah, we're also thinking about patients as a population, a group. How do we improve the health of a population, for example, a community, a municipality, a group of individuals with a certain disease? Different populations will have different healthcare needs, but we look at health and wellness not only from the individual patient, but from the collection of patients, the group, the population.

And Dr. Springer can share the way that Intermountain Healthcare is using this approach in the delivery of care. We are trying, and I believe one of the first medical schools in the country, to introduce in a meaningful way the concepts of population health into our medical education program. Did I get it close?

Dr. Springer: Yes, very. I think you're right, Dr. Good. The uniqueness of this program really is being able to get upstream in helping our new physicians, future physicians really understand that practicing medicine, while we continue to focus on the patient, like you mentioned, in the exam room, in the delivery suite, in the OR, which is still important, there are so many additional things that affect health besides just that particular thing.

And being able to train students in that environment and help them see not only from an academic side of what that means, from the theories, etc., but also see what it looks like in practice and actually delivering that care is very important. And that really addresses the whole person.

And I think that's really the focus of population health, is that it looks at, "Well, how is this person's health affected by their spiritual background, by their emotional background, by their social determinants of health, their housing, their food insecurities, other things like that, their access to care?" and not just focusing on that particular problem.

And seeing how the connection of understanding the importance and teaching it in a medical-center-type classroom, seminar, etc., and then connecting that with, "Hey, this is actually what it looks like to practice," is a huge way of actually getting upstream to teaching our future physicians how they will need to practice going forward.

Taylor: I think that that is the really great opportunity that we have with this program. And part of the reason it was developed is because they get an educational experience through their participation in the Population Health graduate certificate, so they get recognized through that.

They learn those foundational concepts and then, through this collaboration, are actually in the communities that they'll be serving in the future working with the leading institution about implementing that population health.

So, they really get both the background and then the application which is a really exciting and a unique component of the program.

Dr. Good: So, the program is. . . We're into the second year. As Taylor was mentioning, the first couple of years are a lot of what we call foundational knowledge, learning the underlying science, if you will, the research studies that say, "These particular approaches work in a population health context."

But Dr. Springer, one of the things you've done that's been just great is each of our scholars in the program . . . And we should mention in the first 2 years we've had, I think it was, 11 scholars the first year, 10 the second year, and then we're planning for 15 in the third class. One aspect is what's learned in the classroom, if you will, but also there's a phenomenal mentoring component of the Population Health Scholars Program that's already been implemented. Why don't you tell us a little bit about that?

Dr. Springer: Yeah, thank you. So, one of the things that I think . . . And I can think back to my medical school time, as well as you, where you get involved as a first-year, and just class and how excited. You remember how excited you are. "Please get me into the clinical aspect. Let me see what I'm really going to be like."

And so this program provides an opportunity to connect one-on-one with a practicing physician within Intermountain Healthcare. And that allows the student to really be able to see and ask those questions of not only just, "What is it like to be in your specialty? What is it like to be a physician? How do you balance and integrate work and life, and what is your practice like?" but it actually allows that student to go shadow with their mentor as a first-year, be involved in projects.

If that mentor is involved in some sort of research project, getting them involved in that aspect, being able to really see what it's like to be a member of the Intermountain Healthcare Medical Group, because that's really where they're going to end up in the future.

And this is very unique, because unlike just a short type of mentorship or coaching relationship, it's meant to be longitudinal. We instruct our mentors. We train them to help how they should mentor, and tell them, "This is definitely through all four years of medical school," and we hope even into residency. And then ideally, the circle comes forward when they actually join our practice. And then hopefully they become mentors themselves for the future scholars.

Dr. Good: Just to make sure I understand it right, each scholar in the program is paired one-on-one with a practicing physician. And that is a longitudinal relationship over at least the four years of medical school . . .

Dr. Springer: At least the four years.

Dr. Good: . . . If not as we get into this and learn more. Oh, that's phenomenal. And then you also mentioned . . . I guess we should add in the forgivable loan scholarship component of this. So, again, highly competitive. We have about 125 medical students in each class currently at the Spencer Fox Eccles School of Medicine at the University of Utah. And so of those 125 for the past couple of years, it's been 10 to 11 in the Scholars program. Headed to 15, but again, highly competitive. And with it comes a 50% tuition forgivable loan scholarship.

So, Taylor, why don't you tell us a little bit about the forgivable loan scholarship and particularly how the forgivable part is implemented?

Taylor: Yeah, that's an important part, especially from the student's perspective.

Dr. Good: There you go.

Taylor: So, it's a really unique component of the program that we hope will really benefit these students in the long run. This program, we aim to emphasize primary care and population-health-related specialties in the future, so this financial assistance component can go a long way in that regard.

But as students are accepted into the program, they receive 50% of their tuition and fees covered through their participation provided by the endowment from Intermountain Healthcare.

Dr. Good: That's probably an important point to mention here at this point. Very appreciative of an endowment gift from Intermountain Healthcare. And that endowment generates the funds that are able to cover the 50% tuition benefit.

Taylor: And so with that benefit, the students, as I mentioned, receive . . . or as you all mentioned, they receive 50% of their tuition covered in the hopes that they'll then return and work for Intermountain Healthcare in the future. And that work and employment in the future will then count towards forgiveness of the loans that they receive during their time in medical school.

This will come in a one-to-one ratio. So, for example, a student in the first year of the program has received their first year of tuition covered. Their first year of work and employment within Intermountain Healthcare in the future will then forgive that component of the loan, and that will transpire for those four years until, hopefully, the entire loan is forgiven. And they then just continue on with Intermountain after that.

Dr. Springer: And I would even go stronger than that, Taylor. It's not just that we hope. They are guaranteed an offer with Intermountain Healthcare for an employment offer in one of those specialties.

One of the big challenges in a medical student's life is, "Okay, am I going to get into residency?" And then after that is, "Well, where am I going to find a job?" The competitiveness of that, and, "Is it going to be something where I'm going to have to potentially go somewhere because I have to get my loans paid back and not be able to choose exactly where I want to be?"

And so this endowment from Intermountain Healthcare, the tuition support, and then the guaranteed offer post-residency I think really looks at the comprehensive nature of how we can help the students, not only just in learning, but also, hopefully, relieve some of the stress that comes along with that process of being a medical student and the transition to being a physician practicing generally.

Dr. Good: Dr. Springer, I think that's so important. We're here at the AAMC meeting, and just this morning, the session I was at was with medical student leaders from across the country and the deans of the medical schools. And they talked about that stress at the transition points from undergraduate medical education to residency, and then from residency into practice.

The other thing I like about the structure of this program is it's good for Utah and it's good for the Rocky Mountain West. Obviously, we're quite proud of our graduates of our medical school. They are highly competitive for the best residencies across the nation. Many of them will do their residency in our Utah-based training programs.

But in a way, we want our graduates to go out and benefit from some of the other great residency programs across the country, on the coasts, everywhere. I won't do any names. We all have our favorites.

But there's about a 65% to 70% probability that someone coming out of a residency program will practice where they graduate from residency. And so to me, this creates a great incentive to what I call "get them home."

Bring them back. As you point out, guaranteed employment in the largest health system in Utah, now in the Rocky Mountain West with some of the recent additions.

And so I just think it's one of those rare win-win-win. This is good for the student, it's good for our health systems, and ultimately it's good for the people of Utah and the Rocky Mountain West because we get the great highly trained physicians back into our workforce and caring for our citizens.

Dr. Springer: Yeah, I think it speaks to the power of collaboration, and I think that is very unique. You don't see that. I think we've had conversations about this before, that there really aren't programs that are like this throughout the country where you have an academic public institution like the University of Utah and then a private not-for-profit institution like Intermountain Healthcare really collaborating and seeing the big picture for the community, for the students, for the general health of our population, and really trying to find a creative collaborative solution to bringing physicians back to where we need them.

I mean, as you know, Utah ranks 49th or 48th out of 50 states in terms of primary care per capita.

Dr. Good: Some work to do.

Dr. Springer: So, we have some work to do. This, I think, represents an opportunity to help hopefully ameliorate some of that as well as put a little buffer in for the future of how to continue to improve and not just be a one-time solution, but an ongoing, scalable, sustainable solution to that problem.

Dr. Good: Let's talk about a couple of other aspects of the program. Taylor, you mentioned it quickly, but it's probably worth pointing out the Scholars now have added credential when they graduate. Tell us a little bit about that aspect, the certificate.

Taylor: Yeah. This is a great development that occurred over the last year with a lot of collaboration from the Department of Population Health at the University of Utah. I want to mention Dr. Fagerlin and Dr. Ozanne, who are the directors and co-directors of that certificate.

But you can almost envision this as a . . . Most of us have a major that we went through in college and then some of us chose to do a minor as well. And so along with their primary education and getting an MD, these students also receive a Population Health graduate certificate.

And so through this experience, they're provided a lot of additional foundational knowledge of what population health looks like. So, they're in the classroom learning about different population-health-related concepts, how it's applied in different settings. We have a plethora of different speakers from across both the University of Utah Health system and Intermountain, as well as started to provide some support and knowledge in this realm as well.

So, students participate in that, and then they also have the opportunity to participate in a population-health-related capstone project. So, they're exploring topics that are . . . that they're specifically passionate about, that they see their role or career moving towards in the future.

And so they are emphasizing certain population-health-related topics that they want to get involved in, and then making change in the sense that they're doing extra work on this capstone project that they can then implement in the future.

And so, like we mentioned, a really unique component of the program and hopefully we'll emphasize or highlight them as they move into their residency process of, "Hey, this student who's done this extra work and has an additional layer of knowledge that the others might not." And so, really an exciting component as well.

Dr. Good: Yeah. Well stated. And residency positions for a variety of reasons across the country become more and more competitive. That added credential makes our graduates, the graduates of the Population Health Scholar program, even more competitive for those highly sought-after residency positions in the country.

So, again, I'm glad you . . . Thanks for the shout-out for Dr. Fagerlin and Dr. Ozanne, because they've really, in partnership with you, put together that certificate. And I'm really, really pleased with that.

Taylor: Through the development of this program, we've also really been exploring these enrichment-type opportunities with Intermountain Healthcare. So, on top of the mentorship component of the program, we've also had collaboration with a few different entities of Intermountain: Castell, their population health arm; SelectHealth, the payer behind Intermountain; as well as just a few additional community health initiatives that they have in place there.

And so students have the opportunity to get involved in these areas as well with mentors outside of their paired mentor, but folks in the community who are working on these things or in these organizations who have a really specialized skill set. Students are exposed to this early on and they can gravitate and, once again, find those opportunities that speak to them.

And we've had a great experience with this so far, and it continues to build as we've developed relationships and learned a little bit more about the different things that Intermountain are doing and how we can position students to learn firsthand how that care is being provided and how population health is being implemented.

I don't know if you have anything to add to that.

Dr. Springer: I'm so glad you mentioned that. Those enrichment opportunities really represent a way for students to help expand their passion. And the thing with medical school . . . Obviously, you have to have the base science knowledge, and I think if people can feel . . . I mean, this is not unique to, of course, medical students or people who are working, right? If people find their passion, that helps, I think, really create additional resilience and wellness and things like that.

And as a first-year medical student, a second-year medical student, you are very busy learning all sorts of things. And I think that while you might theoretically know that some of these things are out there, it would be potentially difficult to find.

And so the unique thing about the Scholars Program and what Taylor was talking about, these enrichment opportunities that are connected as well with the pathway certification and classes, is that these are things that are really presented to the students almost like a menu of options for them to choose from, and just really expanding.

It's one of those things where as a medical student, you may not even know what you don't know. Well, I will say you definitely don't know what you don't know and what's out there. And I think having these opportunities where it's like, "Hey, look, have you considered working with pediatric health initiatives? We'd heard from them. Or working with SelectHealth and understanding how data applies? Or we've looked at Precision Genomics and how that applies to population health."

All these different opportunities are things that allow the students to really, which is why we call them enrichment opportunities, enrich their education and really hopefully create that passion and that flame of, "Hey, yeah, this is exciting. I want to be able to do this now and in the future."

So, beyond the competitiveness of their applications to residency or whatever else for jobs in the future, etc., that is something I think really goes a long way.

Dr. Good: Well stated. When people find their passion, in some ways it's almost magical.

For me, another really exciting part of the Population Health Scholars program that in some ways is being worked on in the drawing board right now is next year we'll enter the third year of the program, which includes really the heavy clinical years. And one of the things I'm excited about is the scholars, the students, will spend actually probably large parts of their clinical learning in the value-based clinics of Intermountain Healthcare.

Tell us a little bit about that, because I was certainly impressed as I learned about them in and of their own, but then what a wonderful learning environment they're going to be for the Population Health Scholars, particularly as they enter their third and fourth year.

Dr. Springer: Yeah. I'll talk about just one aspect and then maybe I'll have Taylor talk about the second aspect. The first aspect is really just the traditional type of rotations, the block rotations where we have a pairing with a preceptor and, of course, the student.

And the preceptor, I think, is one of those in primary care, in pediatrics, in family medicine, so internal medicine, where we have these value-based care clinics within Intermountain where they are focused on looking at not just generating visits and RVUs and producing things like that, but really taking a little bit more time with the patients.

Most of them have 30-minute visits. They have care managers or care advocates or care guides who are involved with the patient so they can get data ahead of time about, "Hey, this person has this care gap need," or, "This person needs to have this done," or, "This has an issue with social determinants of health of some sort." And those things are all incorporated within the visit, so that's really the focus of our value-based care clinics.

And so being able to expose, again, like we said, "Here's all the actual education piece," and then being able to translate to, "Hey, this is what the value-based care clinic is and actually how you might practice," is the connection with that.

The second part of that is we're really looking at creating a longitudinal integrated clerkship experience for our population health or LICs. And I might have Taylor just talk a little bit more about the work we've done on that.

Taylor: Yeah, this has been a really exciting component of the program and I know something that the students are really looking forward to. But as we shift as a medical school towards this longitudinal integrated curriculum . . . which is really focused on three things for those who may not be aware. It's that longitude relationship between the student and the patient, the student and the preceptor, and the student and the place. It really emphasizes those three components.

And so as we've shifted to the third and fourth year of these students' education and how we can supplement that with population-health-related learning, one really exciting component is the shift to this model where students are paired with an Intermountain physician or doing their rotations at Intermountain clinics where they're paired with Intermountain physician preceptors in all of the different specialties.

They're really located and practice their clinical learning at one or two unique sites over the course of the entire third year. It's a little bit of a shift away from the traditional models where, and you both probably know much more than me, they spend eight weeks or so . . .

Dr. Good: I graduated from medical school, believe it or not, almost 40 years ago. It was four weeks of cardiology at Place A, four weeks of pediatrics at Place B, four weeks of OB. And so that word longitudinal is really important because, as you say, these will be months long, and probably in some cases year-long, assignments at an institution, a place, a facility.

And that's actually really important in Utah, because so much of our state is rural. And so we envision our students, many of them, being part of our rural communities and rural healthcare on that longitudinal basis.

The next word is equally important, integrated. So, it won't be cardiology for this period and pediatrics for this or obstetrics. We've got some early experiences where one of our students told us they were delivering babies on Monday, and they were suturing small wounds on injured patients in the ER. They were following the physicians around in their day-to-day environment. So, much more realistic, longitudinal, integrated clerkships.

And coming back to the value-based clinics, you were mentioning many of the characteristics, time, team approach. But for the audience, we gather the whole population health community, the preceptors, the students, the faculty. And I know at one of our dinners, which we do twice a year, one of your colleagues was talking about . . .

So, again, many physicians come to the office and they see the patients that have called in and requested appointments. But if I understand it right, in a value-based approach, value-based clinic, the team might meet a week or two, they look at the schedule, and say, "You know what? We really don't need to see Mike or Taylor, but boy, we really should find Joe and Mary because we know they have health problems that if we don't see them, their conditions could get worse and they could end up in the hospital." Have I got that, right? It's a very different management of a clinic.

Dr. Springer: It's really looking at right person, right care, right place, I would say, is how I would put it. And when you see your schedule, obviously, we're not going to ignore people who want to come in.

Dr. Good: Fair enough.

Dr. Springer: But the difference is our team is really looking at, "Hey, Mrs. Smith hasn't been in. She's a diabetic, and she is not controlled, and she has hypertension, and she was actually just in the ER. Let's reach out to her and find out what needs she has. Is there something we can provide to help her get the care she needs?"

Maybe it's in a clinic visit, but it may not be. It may just be, "Hey, we think that one of our home visits, we need to do that. We need to send our home visit team." Or maybe it's just my care manager who needs to talk to her weekly to help her stay out of the ER, set some goals around her health, get her care. And so it's a very unique process because we don't necessarily wait for the disasters or for people to reach out to us.

Dr. Good: It's a very proactive, prevention-oriented approach, which I think is great. And I think our students are really going to learn about population health firsthand by being part of these value-based clinics and the physicians and their teams that practice in those clinics. I mean, the list of unique things about this program keeps getting longer and longer.

Dr. Springer: I just want to point out something you mentioned about the teams. Just a quick comment about that, and we've had this conversation before. Whether or not a physician has a formal leadership position, physicians are seen as leaders.

And medicine no longer is just the physician doing everything. It really absolutely is a team approach. And that includes your medical assistants, care managers, care guides, maybe an advanced practice provider like a nurse practitioner or a physician's assistant. And the physician really is the leader of that team. The physician is seen as a leader in the community.

And I think that's a really unique part of this particular program as well, is exposing the students firsthand as a first-year to leaders like you in University of Utah Health, other leaders who are really taking charge of where academics and medicine is going, and leaders in Intermountain Healthcare. So, an integrated delivery system.

We've had meetings where you've talked with the students, our chief executive officer, our CEO, has talked with them, our region officers. And I think that is a very unique part of this program, is to start early on of telling them that they are our future leaders and that we need them to be leaders.

Dr. Good: You get me talking about teams and we'll be here all day because everything you said, Dr. Springer, is so true. Great health care is delivered by great teams. The health professions and medicine in general, it's really only been in the past couple of decades where this transformation from individuals to teams has happened.

We're blessed in Utah because, actually, the football team had a great experience last night and the Jazz are back in season. That's sports, but I think high-performance sports teams, there are lessons that we learn there about roles and responsibilities in a team. How do you divide the work? How do you communicate what each are doing? The environments that the Population Health Scholars will learn in are very team-oriented, and that'll be another unique component of their education.

I'm seeing our producer here warm up the hook, so we better . . .

Mitch: A little bit.

Dr. Good: As you can tell . . .

Dr. Springer: We can talk all day.

Mitch: Yeah, and it's so fascinating. I just don't want to keep you guys from the great other lectures and lessons that we're learning here at the AAMC.

Thank you so much for talking to us about population health. This seems like just quite a fascinating topic and a really interesting, innovative approach to how we keep people healthy and how we educate. And it's just so exciting to hear the three of you talk about all this. So, thank you so much, Dr. Good, Dr. Springer, Taylor. Thank you so much for joining us.

And if you're listening right now, you can hear other discussions from the AAMC floor at uofuhealth.org/aamc22.

And if you're interested in any other health-related podcasts, talk shows, basic information, you can also hear more of me at thescoperadio.com.