J Community Health (2012) 37:647–652
DOI 10.1007/s10900-011-9495-y
ORIGINAL PAPER
From Primary Care to Public Health: Using Problem-Based
Learning and the Ecological Model to Teach Public Health
to First Year Medical Students
Cora R. Hoover • Candice C. Wong •
Amin Azzam
Published online: 20 October 2011
Ó Springer Science+Business Media, LLC 2011
Abstract We investigated whether a public health-ori-
ented Problem-Based Learning case presented to first-year
medical students conveyed 12 ‘‘Population Health Com-
petencies for Medical Students,’’ as recommended by the
Association of American Medical Colleges and the
Regional Medicine-Public Health Education Centers. A
public health-oriented Problem-Based Learning case gui-
ded by the ecological model paradigm was developed and
implemented among two groups of 8 students at the Uni-
versity of California, Berkeley-UCSF Joint Medical Pro-
gram, in the Fall of 2010. Using directed content analysis,
student-generated written reports were coded for the pres-
ence of the 12 population health content areas. Students
generated a total of 29 reports, of which 20 (69%) con-
tained information relevant to at least one of the 12 pop-
ulation health competencies. Each of the 12 content areas
was addressed by at least one report. As physicians-
in-training prepare to confront the challenges of integrating
prevention and population health with clinical practice,
Problem-Based Learning is a promising tool to enhance
medical students’ engagement with public health.
We have no prior publications related to this work, although we did
present key findings in a workshop at the AAMC Western Group on
Educational Affairs (WGEA) Conference in May 2011.
C. R. Hoover
A. Azzam (&)
University of California, Berkeley-UCSF Joint Medical
Program, 570 University Hall #1190, Berkeley 94720, USA
e-mail: amin_azzam@berkeley.edu
C. R. Hoover
e-mail: corahoover1@gmail.com
C. C. Wong
University of California, San Francisco, CA, USA
Keywords Medical education
Problem-based learning

Medical students
Public health
Teaching methods
Introduction
In order to train physicians who can provide patient care
and also meet the health needs of the larger population,
medical educators and health planners increasingly agree
that public health content and a public health perspective
should be an integral part of the undergraduate medical
curriculum [1, 2]. If we are to achieve cost savings and
maximize lives saved, a prevention-based approach that
addresses behavioral and environmental factors is an
essential complement to increased health coverage and
clinical preventive services [3]. This recognition is reflec-
ted in recent collaborations between the Association of
American Medical Colleges (AAMC) and the Centers for
Disease Control and Prevention (CDC) to promote inno-
vative approaches to public health education at selected
Regional Medicine-Public Health Education Centers
(RMPHECs) [2]. It is also reflected in the independent
development of public health coursework and programs at
multiple medical schools nationwide [4].
Recently revised Liaison Committee on Medical Edu-
cation (LCME) accreditation standards that mandate
teaching of public health (also referred to as ‘‘population
health’’) [2, 5], as well as plans for increased testing of
public health concepts on the United States Medical
Licensing Examination (USMLE) [6], will further
encourage the broad adoption of curricular changes. These
changes should facilitate meeting the Healthy People 2020
Objective to ‘‘Increase the inclusion of core clinical pre-
vention and population health content in M.D.-granting
medical schools’’ [7]. Standardization of public health core
123
648 J Community Health (2012) 37:647–652

Table 1 Population health competencies for medical students recommended by Regional Medicine-Public Health Education Centers [2] and
number of learning objects addressing each competency
All graduates from medical school should demonstrate the following competencies to contribute Number of learning objects that
to improving the health and health care for defined populations (e.g., their patient panels, covered the competencyb
local communities, states, nations, and global regions)a

1. Assess the health status of populations using available data (e.g. public health surveillance data, 9
vital statistics, registries, surveys, electronic health records and health plan claims data)
2. Discuss the role of socioeconomic, environmental, cultural, and other population-level 11
determinants of health on the health status and health care of individuals and populations
3. Integrate emerging information on individuals’ biologic and genetic risk with population-level 4
factors when deciding upon prevention and treatment options
4. Appraise the quality of the evidence of peer reviewed medical and public health literature 4
and its implications at patient- and population- levels
5. Apply primary and secondary prevention strategies that improve the health of individuals 8
and populations
6. Identify community assets and resources to improve the health of individuals and populations 7
7. Explain how community engagement strategies may be used to improve the health of communities 4
and to contribute to the reduction of health disparities
8. Participate in population health improvement strategies (e.g. systems and policy advocacy, 6
program or policy development or other community-based interventions)
9. Discuss the functions of public health systems including those that require or benefit from the 4
contribution of clinicians, such as public health surveillance, preparedness and prevention of
chronic conditions
10. Describe the organization and financing of the US health care system and their effects on access, 7
utilization, and quality of care for individuals and populations
11. Discuss the ethical implications of health care resource allocation and emerging technologies on 4
population health
12. Identify quality improvement methods to improve medical care and population health 1
a
Public health competencies reproduced from Maeshiro et al. [2]
b
Learning Objects are written reports prepared by medical students. Please see ‘‘Results’’ section for details

content will be helpful as medical schools seek to meet
these stepped-up requirements; Table 1 lists one potential
framework for specific competencies, as recently recom-
mended by the AAMC and the RMPHECs.
Medical training and medical practice traditionally
focus on the treatment of disease in individuals, rather than
the prevention of disease in the context of the larger
community and society. Several past initiatives to further
public health in medical education have met with mixed
success, reflecting the historic challenges of integrating
public health and medical practice [8]. Recent promising
strategies for promoting public health in undergraduate
medical education include longitudinal integration of
public health content, certificate programs, combined MD/
MPH degrees, stand-alone courses, and community-based
projects that give students hands-on experience with public
health practice [4, 9].
An additional approach to teaching public health content
in the classroom setting is case-based learning, engaging
small groups of students using clinical case studies. For
example, faculty at the SUNY Upstate Medical University
developed the Case-Based Series in Population-Oriented
Prevention (C-POP), a framework that was successfully
implemented at several institutions in the early 2000s
[10–12]. Problem-Based Learning (PBL) is a more student-
driven version of case-based learning, emphasizing prob-
lem solving and critical thinking [13]; the majority of US
medical schools use PBL in a limited fashion to teach core
clinical content [14]. PBL is based on experiential learning
theory, which states that learning is optimized when
learners encounter a problem or have experiences that
trigger questions for them [15]. After finding the answers to
these questions, they reflect on the learning process, mak-
ing generalizations that they can then apply to novel but
similar problems or experiences [16]. The Sophie Davis
School at the City College of New York has used PBL in
the form of an extended case study to prompt learning
concerning health disparities and community needs
assessment [17]. The University of Washington School of
Public Health sponsors a 2-year Masters in Public Health in
Community-Oriented Public Health Practice (COPHP) that
is built on the PBL approach [18].
The University of California, Berkeley-UCSF Joint
Medical Program (JMP), a pre-clerkship medical school
program housed within the UC Berkeley School of
Public Health, uses PBL as the main format for the core

123
J Community Health (2012) 37:647–652
pre-clerkship curriculum, fully integrating the basic, clin-
ical, and social sciences. The JMP enrolls 16 medical
students each academic year, all of whom complete pre-
clerkship years at UC Berkeley before going on to UCSF
for their clerkship years. The JMP curriculum distributes
the usual 2-year pre-clerkship curriculum across 3 years
because all students simultaneously pursue master’s
degrees in health sciences. In 2002, the JMP consolidated
the entire pre-clerkship course structure into a compre-
hensive PBL curriculum consisting of a series of paper-
based clinical cases.
Methods
Case Development and Implementation
In the spring of 2010, the authors developed a public health-
oriented PBL case, envisioned as the first step in a more
extensive integration of public health into the JMP’s pre-
clerkship curriculum. The goal of the public health-oriented
PBL case was to motivate students to explore public health
concepts and contemplate the physician’s role in promoting
population health within the context of the primary care
doctor-patient relationship. The case, based on a fictional
child patient with asthma and obesity, was located in the
nearby community of Richmond, California; the real loca-
tion gave students the opportunity to seek out publicly
available information on the health and social issues in the
actual community. The case begins with a patient visit to a
family physician in a community clinic, progresses to
examination of county- and city-level health surveillance
data, and culminates in the fictional physician’s participation
in a neighborhood health meeting represented by advocacy
groups, community-based organizations and the local health
department. The ‘‘ecological model,’’ a paradigm commonly
used to conceptualize the continuum of health from the
individual to the community to larger social and political
forces [19], was the guiding principle of the case. The general
issues raised by the case were directly informed by the
clinical and research experience of the authors.
Kim et al. [20] have proposed a conceptual framework
for developing medical school teaching cases, based on
the core attributes ‘‘relevant,’’ ‘‘realistic,’’ ‘‘engaging,’’
‘‘challenging,’’ and ‘‘instructional.’’ This useful framework
guided the development of the case, along with the notion
of ‘‘thick narrative,’’ or telling a story using description,
conversation, and multiple viewpoints [13]. The ‘‘thick
narrative’’ approach allowed for the inclusion of fictional
direct quotes from multiple family and community mem-
bers, as well as a description of the physician’s experience
of mixed emotions when confronted with health problems
649
that are less amenable to clinical solutions because they are
due to social factors.
The newly developed public health case was added to the
JMP’s first year curriculum in the fall of 2010, replacing a
traditional case of a single patient with an exclusively bio-
logically-determined disease. The new case was imple-
mented by two PBL tutorial groups of 8 students each. It was
not formally labeled as a public health case, and students
were given no specific direction as to which content areas to
pursue in their engagement with the case. In accordance with
JMP’s standard PBL format, students generated learning
issues and assigned topics for individual study during class
tutorial, and then returned to class on subsequent dates to
present the material they had prepared individually. Each
student prepared a written report of several pages [called a
Learning Object (LO)] to accompany the oral presentation of
their assigned topic. All students were responsible for mas-
tering material presented in class and included in other stu-
dents’ written LO’s, including LO’s produced by the other
group of students. The LO’s thus provided a valuable
opportunity to catalog the content and scope of public health
material voluntarily pursued in the PBL learning process.
Data Collection and Analysis
In order to assess how well the case triggered investigation of
public health topics, the 29 LO’s produced by the students for
the case were examined for key public health content areas,
as articulated in the twelve ‘‘Public Health Competencies for
Medical Students’’ listed in Table 1. A directed content
analysis [21] approach was used to code each LO for the
presence or absence of each of the twelve content areas. The
three investigators independently coded all LO’s, then
compared their notes, noted areas of disagreement, and
resolved discrepant items by consensus. A content area was
considered to be present if it was explicitly discussed in the
LO, not simply mentioned in passing or ‘‘cut and pasted’’ into
the LO from websites. A content area that could be inferred
but was not explicitly addressed was also not considered to
be present. Our study was reviewed by the UC Berkeley
Center for the Protection of Human Subjects and deemed
exempt from formal review.
Results
Of the 29 student-generated LO’s, 20 (69%) contained
information relevant to at least one of the 12 public health
competencies. All 12 recommended ‘‘Public Health Com-
petencies for Medical Students,’’ were addressed by at least
one of the student-generated LO’s (Table 1). The public
health competency that was addressed most frequently was
‘‘Discuss the role of socioeconomic, environmental,
123
650 J Community Health (2012) 37:647–652

Table 2 Sample learning object titles and content areas

Pathophysiology of asthma
Asthma triggers and immune response
Bronchoconstriction and mucus secretion
Epidemiology of asthma
Asthma rates and distribution in US and worldwide
Disparities in asthma rates due to environmental factors
Family medicine: scope of practice and training
Key elements of primary care medical practice (e.g. comprehensiveness, coordination, advocacy, prevention)
Lifestyle, income, and practice conditions for family physicians
Summarize Contra Costa County community health indicators
Demographic trends and characteristics
Disparities in health conditions and outcomes by race/ethnicity and geography
County-based health care coverage
Spreadsheet comparing features of several local county-based health care programs for the low-income uninsured (e.g. eligibility, cost,
covered services)
Key players in the health care infrastructure of Richmond
History, services, and location of community hospitals and primary care clinics
County-based coverage program for the uninsured
Programs for reducing violence in Richmond
Detailed description of four local organizations focusing on violence prevention and youth development
What public health problems are physicians in America addressing?
‘‘Prescription produce:’’ a Massachusetts initiative allowing primary care physicians to prescribe fruits and vegetables from farmers’
markets
‘‘CeaseFire:’’ a physician-led Chicago program using ‘‘violence interrupters’’ to intervene in community disputes, using principles of early
intervention and outbreak control

cultural, and other population-level determinants of health
on the health status and health care of individuals and pop-
ulations (n = 11).’’ The two next most frequently addressed
competencies were ‘‘Assess the health status of populations
using available data (n = 9)’’ and ‘‘Apply primary and
secondary prevention strategies that improve the health of
individuals and populations (n = 8).’’ The least frequently
addressed competency was ‘‘Quality improvement methods
to improve medical care and population health (n = 1).’’
Titles and major content areas of representative LO’s
addressing both public health and foundational and basic
science topics are presented in Table 2.
Discussion
We created and implemented a public health-oriented PBL
case for the JMP’s first-year pre-clerkship curriculum.
Directed content analysis of the student-created LO’s from the
case demonstrates that PBL can be a powerful tool to expose
medical students to key public health content areas; a total of
69% of the student-created learning materials addressed at
least one core public health competency. We believe that by
placing this case early in the pre-clerkship medical curriculum
(e.g. fall of the first-year of medical school), we have set a
strong foundation for students to consider the role of popu-
lation health in other cases later in their curriculum.
Our team observed one student group during their class
tutorial; although the class discussion was not transcribed
and formally analyzed, several interesting developments
were noted. The ‘‘thick narrative’’ format made the case
gripping and vivid, and helped students engage more
actively with both the case’s overt and hidden content. One
striking and unanticipated element of the student engage-
ment with the case was the discussion among students
about physician role and responsibilities. This included
active debate among participants as to whether addressing
public health issues ‘‘is really our responsibility as future
physicians,’’ as well as reflection concerning the physi-
cian’s potential role in advocacy and community engage-
ment around public health issues. One student commented,
‘‘We can go beyond being just a patient advocate to being a
community advocate.’’ This sort of reflection appeared to
be facilitated both by the PBL format and by the ecological
model paradigm that was used to structure the case. Not
only did the case setting move from the primary care
physician’s office to the larger community, but also the
physician depicted in the case moved beyond the clinic
setting to familiarize herself with both the community’s

123
J Community Health (2012) 37:647–652
needs and strategies for addressing these needs. Other
unanticipated avenues of inquiry pursued by the students
were the structure and function of the health care safety net
and the history and professional scope of family medicine.
This case represents one part of a larger attempt to more
extensively integrate core public health material in JMP’s
medical curriculum, including through the development
and modification of additional cases. It would be interest-
ing to investigate how students revisit the 12 public health
competencies later in their 3-year curriculum, both before
and after the implementation of additional public health
PBL cases. A further strategy for integration of public
health teaching could involve joint PBL learning sessions
between medical students and public health master’s stu-
dents, setting the stage for cross-disciplinary collaboration.
Experiential learning sessions involving community
members or organizations would also add depth to the
students’ exposure to public health issues.
Limitations
As a directed content analysis, our study does not seek to
predict learning outcomes for all medical students, but rather
describes an example of the potential usefulness and effec-
tiveness of classroom-based PBL for conveying a broad range
of key public health content. Additional limitations of our
study include the small number of students involved and the
unique nature of the JMP, including the program’s research
orientation and its co-location within the UC Berkeley School
of Public Health. This combination of factors may lead to the
self-selection of students who are particularly interested in
both public health issues and experimental approaches to
learning, and may not be representative of other medical
schools. Because the public health case has only been
implemented by one group of medical students early in their
first year, we are unable to correlate the introduction of public
health content with performance on medical licensing exams
or in clinical settings. In addition, our content analysis was
limited to written LO’s, and did not include class discussions
or final exam performance; inclusion of these would have
provided a more robust assessment of the learning process.
Despite these limitations, the fact that the students addressed
all 12 public competencies in the course of the case is
encouraging, and speaks to both the breadth and depth of
student engagement with the case.
Conclusion
The need for engagement with public health on the part of
the medical community has never been more acute, as
physicians-in-training prepare to confront the challenges of
651
integrating prevention and population health with clinical
practice. Medical educators must seek out creative ways to
convey public health content and make it meaningful and
relevant for students. Classroom experiences such this PBL
case may help students think through their own evolving
roles and opportunities to better the health of both indi-
viduals and populations in their future careers.
Conflict of interest Authors have no financial conflicts of interest
and received no financial support for this research.
References
1. Koo, D., & Thacker, S. (2008). The education of physicians: A
CDC perspective. Academic Medicine, 83(4), 399–407.
2. Maeshiro, R., Johnson, I., Koo, D., et al. (2010). Medical edu-
cation for a healthier population: reflections on the Flexner
Report from a public health perspective. Academic Medicine,
85(2), 211–219.
3. Milstein, B., Homer, J., & Briss, P. (2011). Why behavioral and
environmental interventions are needed to improve health at
lower cost. Health Affairs, 30, 823–830.
4. Association of American Medical Colleges, Centers for Disease
Control and Prevention. (2010). Patients and populations: Public
health in medical education conference. Washington, DC.
https://www.aamc.org/meetings/past_meetings/148152/2010_public_
health_conference_presentations_site.html. Accessed January 23,
2011.
5. Liaison Committee on Medical Education. (2011). Functions and
structure of a medical school: Standards for accreditation of medical
education programs leading to the M.D. Degree. http://www.
lcme.org/functions2011may.pdf. Accessed July 14, 2011.
6. Mann, S. (2011). After reform, more medical schools emphasize
public health. Washington, DC: AAMC Reporter.
7. US Department of Health and Human Services. (2010). Healthy
people 2020 objectives. Washington, DC. http://www.healthy
people.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.
pdf. Accessed January 23, 2011.
8. Ruis, A., & Golden, R. (2008). The schism between medical and
public health education: A historical perspective. Academic
Medicine, 83(12), 1153–1157.
9. Chamberlain, L., Wang, N., Ho, E., Banchoff, A., Braddock, C.,
I. I. I., & Gesundheit, N. (2008). Integrating collaborative pop-
ulation health projects into a medical student curriculum at
Stanford. Academic Medicine, 83(4), 338–344.
10. Epling, J., Morrow, C., Sutphen, S., & Novick, L. (2003). Case-
based teaching in preventive medicine: Rationale, development,
and implementation. American Journal of Preventive Medicine,
24(4), 85–89.
11. Novick, L. (2003). Introducing a case-based teaching intervention
in preventive medicine education. American Journal of Pre-
ventive Medicine, 24(4), 83–84.
12. McCurdy, S. (2003). Preventive medicine teaching cases in the
preclinical undergraduate medical curriculum. American Journal
of Preventive Medicine, 24(4), 108–110.
13. Bizzocchi, J., & Schell, R. (2009). Rich-narrative case study for
online PBL in medical education. Academic Medicine, 84(10),
1412–1418.
14. Kinkade, S. (2005). A snapshot of the status of problem-based
learning in US medical schools, 2003–4. Academic Medicine,
80(3), 300–301.
15. Dolmans, D. H., & Schmidt, H. G. (1994). What drives the student
in problem-based learning? Medical Education, 28(5), 372–380.
123
652
16. Kolb, D. A. (1984). Experiential learning: Experience as the
source of learning and development. Englewood Cliffs, NJ:
Prentice-Hall.
17. Chowdhury, N., Lien, S., & Yeung, H. (2010). A problem-based
learning curriculum to teach Community-Oriented Primary Care
(COPC) in medical education. In Patients and populations:
Public health in medical education conference. Cleveland, OH.
https://www.aamc.org/download/150028/data/2010_chowduhry
lienyeung.pdf.pdf. Accessed July 5, 2011.
18. University of Washington School of Public Health. (2011). MPH
in community-oriented public health practice. Seattle, WA.
http://depts.washington.edu/cophp. Accessed July 5, 2011.
123
J Community Health (2012) 37:647–652
19. McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An
ecological perspective on health promotion programs. Health
Education & Behavior, 15(4), 351–377.
20. Kim, S., Phillips, W., Pinsky, L., Brock, D., Phillips, K., &
Keary, J. (2006). A conceptual framework for developing
teaching cases: A review and synthesis of the literature across
disciplines. Medical Education, 40(9), 867–876.
21. Hsieh, H., & Shannon, S. (2005). Three approaches to qualitative
content analysis. Qualitative Health Research, 15(9), 1277–1288.