Kaiser San Francisco and UCSF

Internal Medicine/Preventive Medicine combined residency program

During my rotation at AHRQ, I contributed to projects that support the work of the U.S. Preventive Services Task Force. I helped develop educational material on taskforce recommendations, contributed to fact-checking evidence reviews, and led a journal club discussion about new research informing future recommendations. I also attended the annual USPSTF meeting, where I observed the evidence review and grading of task force recommendations.

Through these experiences, I gained a deeper understanding of how rigorous evidence reviews, public input, and expert consensus come together to shape national recommendations. I also learned how research gaps are identified to improve preventive care moving forward.

I pursued Preventive Medicine because I am passionate about improving health outcomes at both the clinical and population levels. I chose AHRQ for my residency rotation to learn firsthand how evidence informs national health policy and to contribute to work that advances preventive care across the United States.

Note from APTR:

Regrettably all residency rotations were paused by the current administration in mid-March. The APTR contract that supports the program was officially terminated "at the convenience of the government" on April 14, 2025.  

Renaissance School of Medicine at Stony Brook University

I pursued Preventive Medicine because I believe in the power of upstream interventions to improve population health and address health disparities at their roots. My background in family medicine reinforced my commitment to patient-centered care, but it also highlighted the importance of addressing the social and structural determinants of health. Preventive Medicine allows me to bridge clinical practice, public health, and policy in ways that can create lasting, meaningful change for communities.

I chose the AHRQ for its central role in shaping evidence-based policies that impact healthcare nationwide. During my rotation at AHRQ, I had the opportunity to engage in several meaningful projects aimed at advancing healthcare quality and preventive medicine. A significant part of my work involved contributing to the synthesis and analysis of evidence that informs healthcare decision-making and clinical recommendations. I participated in discussions surrounding methodologies used in preventive health services and collaborated with interdisciplinary teams to evaluate and enhance healthcare quality measures. My responsibilities also included reviewing and interpreting public health data to support evidence-based recommendations, ensuring they were relevant and actionable for both policymakers and clinicians. In addition to these core activities, I attended professional development sessions and agency-wide meetings, which enhanced my understanding of the federal healthcare quality improvement process and the complex interplay between research, policy, and clinical practice.

Stony Brook University

During my rotation at the Agency for Healthcare Research and Quality (AHRQ), I had the privilege to engage in various activities that enriched my understanding of preventive medicine and its application in evidence-based recommendations. I participated in weekly meetings with the U.S. Preventive Services Task Force (USPSTF) division, where I was exposed to discussions on the methodologies and processes behind developing guidelines. One of the most valuable aspects of this experience was participating in mock exercises that helped me practice applying these methods in a real-world setting. I also took part in journal club discussions, where I presented on the topic of Perinatal Mood and Anxiety Disorders, fostering a robust dialogue with my peers. 

University of Kentucky

University of Michigan School of Public Health

I chose this rotation because of its reputation among other residents who had completed it, which were uniformly positive. I learned a great deal about USPSTF processes and procedures, honed the skill of rapidly developing expertise in a very specific topic, practiced careful, thoughtful communication of public health recommendations to different audiences, and experienced wonderful mentoring.

I worked on:

• Lots of reading! To understand USPSTF procedures but also to prepare for meetings on current topics
• Journal Club presentation
• Slides preparation -  two different topics for a USPSTF presentation at an upcoming AAFP conference
• PPIP written and submitted to AAFP for publication
• Didactics weekly
• Meetings with AHRQ program
• Weekly meetings with USPSTF team members

This is a welcoming environment that provides well-developed structured learning and opportunities for hands-on engagement with the process. I was able to practice critical public health skills in a real-world setting and was delighted to find a community with AHRQ coresidents and wonderful mentorship as well!

Johns Hopkins University Bloomberg School of Public Health - General Preventive Medicine

As a primary care physician with greater than 10 years of experience in various health systems, I recognized the importance of proactive health care especially at the population health level to shift the needle on managing health risk. Preventive medicine gave me a unique opportunity to combine my experience in clinical medicine with public health principles to address health behavior at a systems level. My decision to select AHRQ was a strategic one to understand how evidence based practice influences health care quality and policy at the federal level. 

During my 8-week rotation at the Agency for Healthcare Research and Quality (AHRQ), I engaged in several impactful projects, gaining invaluable insights into the development and review of evidence-based guidelines that shape clinical practice and policy. Working closely with several medical officers and staff at AHRQ, I assisted in crafting recommendations with the U.S. Preventive Services Task Force (USPSTF). Prior to this rotation, I viewed the USPSTF recommendations as final products without fully appreciating the rigorous analytical framework and systematic evidence review involved. Being part of this process, particularly during the March Taskforce meeting and various Wednesday subcommittee meetings, allowed me to witness firsthand the careful deliberation and communication skills required to develop and relay these guidelines to the public. One significant project I was able to participate in was the review of public comments for a pending recommendation statement which gave me a rare glimpse into how the public shapes guidelines, highlighting gaps in research thus providing critical insights for where funding should go from other federal arms like NIH or HRSA. 

My professional journey will next take me to an addiction medicine fellowship, where the lessons in thoughtful review and communication of evidence based practice will be critical not only in the exam room but also the boardroom as I help develop and implement programs to improve a population health.

Emory University Preventive Medicine Residency & Fellowship

Recognizing the significant impact of preventive measures on individuals and communities, I pursued a career in preventive medicine due to its focus on preemptive health measures to avert diseases. Opting for a residency rotation at AHRQ was a strategic choice, driven by the understanding that a thorough grasp of the USPSTF guideline determination process would enhance my ability to effectively communicate the importance of preventive care to patients.
During this rotation, my goal was to understand how gaps in literature on clinical preventive services are identified, addressed, and how evidence is assessed, ultimately contributing to the dissemination and implementation of recommendations for the benefit of diverse stakeholders.

While completing my AHRQ rotation, I had the opportunity to learn about the systematic process of evidence review and grading by Task Force members. I also assisted the team in scoping out and conducting high level summaries of peer reviewed articles that could potentially inform Task Force guidelines, critically appraised a peer reviewed article that could potentially inform recommendation on a prevention topic, critically appraised a national survey as part of resident rounds activities, and attended Task Force meetings.

My experience at AHRQ strengthened my desire to work in governmental public health. It also made me realize the need for healthcare research because recommendations from the USPSTF are informed, and sometimes limited, by the available evidence.

Preventive Medicine and Public Health Fellowship
Mayo Clinic

My experience with AHRQ gave me a new appreciation for the work that goes into making and maintaining national health guidelines, which is not a process well known to most people in healthcare. I spent two months working closely with AHRQ medical officers learning how research is aggregated, appraised, and applied in guideline decision-making. I attended Task Force meetings that allowed me to see recommendation statements in various stages of their development. Most notably, I was given the unique opportunity to work on projects that shape our national guidelines and the future of research funded by Congress.

In public health policy, it can be hard to feel like you are moving the needle. However, this rotation with the Task Force felt like my work had impact. The staff I worked with all took great pride in their work, and that translated to how I felt throughout the rotation. The highlight of my experience was attending the Task Force meeting that convened in person at HHS headquarters in Rockville, MD. It was perhaps best described as experiencing a sense of patriotism- being in a room with distinguished minds from all across America who come together for a common purpose to serve. 

Types of projects I worked on:

• Extracting priority topics for research needs and gaps 
• Fact checking draft recommendation statements
• Drafting sections of recommendation statements
• Composing journal segments related to Task Force recommendation topics
  

The most eye-opening part of the rotation was simply seeing how much work goes into creating a guideline. I have a better idea of what it means to critically appraise research and apply it to a population. I also learned a lot about communications.

Note:

Dr. Lees had a reflection published in the American Journal of Preventive Medicine in December 2024. Her commentary was titled "Evidence-Based Humanism: A Reflection from the APTR-AHRQ Preventive Medicine Residency Rotation Program"  

Emory University Preventive Medicine and Public Health Residency Program

This rotation was a highlight of my medical training. I chose AHRQ because coming from a Family Medicine background, the USPSTF recommendations are our guiding star, and this rotation is an incredible opportunity to work with medical officers serving Task Force members and understand the processes of the Task Force. It is a way to see how preventive medicine is applied on a national level and how it can affect the lives of many. It combined my training in preventive medicine, clinical medicine, and public health.

I saw large scale decisions being deliberated on by the Task Force members. I learned about the USPSTF methodologies and how evidence is considered for such big decisions. I contributed to a variety of projects, including reference checks on a draft recommendation statement, drafting clinical vignettes for American Family Physician, presenting a journal club article, and editing USPSTF slides for a CPSTF meeting. Key concepts I learned from this rotation include: critically appraising literature and evidence, the USPSTF methodology and process, scientific writing, and some of the role of CEPI/AHRQ in national healthcare endeavors.

My program director reported he saw improvement in my writing after this rotation. The medical officers were incredibly kind and provided education, mentorship and career guidance. As a Preventive Medicine fellow, this was a wonderful way to see prevention put into action.

Stony Brook Preventive Medicine Residency

My AHRQ-APTR rotation was great. It allowed a unique opportunity to attend a biannual US Preventive Services Task Force (USPSTF) in-person meeting at the Agency for Healthcare Research and Quality (AHRQ) headquarters during which I attended presentations on scientific evidence and experienced USPSTF deliberations on several in-progress recommendations. As a part of the rotation, I also received a robust training on the USPSTF methodology for evaluating the quality of scientific evidence, developing preventive health recommendations, and strategies to address important evidence gaps, particularly in the areas of health equity. I also learned about AHRQ’s ongoing efforts related to the dissemination and implementation of the task force recommendations.

As a AHRQ-APTR resident I was given the opportunity to attend weekly task force progress meetings during which USPSTF members reviewed new evidence and developed draft language for recommendation statements. I also had a chance to take a "deep dive" into the task force’s process for developing recommendations for preventive screening services by working on the project that compared and summarized diagnostic accuracy characteristics of screening tests used in the USPSTF Grade A and B recommendations. In addition, I helped draft a monthly "Putting Prevention into Practice” feature for the American Family Physician journal contextualizing a recently published recommendation from a clinical practice perspective and critically appraised and presented recently published research relevant to the topic of one of the in-progress USPSTF recommendations. This rotation also allowed me a unique chance to continue developing my evidence synthesis skills by assisting with literature review for an in-progress evidence report. 

Aside from the phenomenal educational experiences listed above, participating in this rotation broadened my understanding regarding critical prevention focused population and public health efforts spearheaded by AHRQ, CDC, NIH, and other leading federal agencies and gave me a greater sense of appreciation for evidence-based preventive medicine practice.

General Preventive Medicine  |  Johns Hopkins University

Preventive Medicine residency brings the opportunity to bring my early career of database administration and data analysis with my current career as an Air Force pediatrician. Through pursuit of the Public Health Informatics certificate, I want to hone my previous information systems training with my medical training to develop, deploy, test, and monitor data-driven solutions to positively affect the health of populations.

I pursued a rotation at AHRQ to gain experience at a federal, non-military agency and understand the roles of the many other agencies under the Department of Health and Human Services. As one of these agencies, AHRQ provided a superb environment to understand how evidence-based recommendations are generated starting with thoughtful research plans through final recommendations. I was able to observe the operations of several subcommittees working to refine the USPSTF approaches and methodologies which furthered my appreciation and understanding of the recommendation process. I plan to use this experience to guide my future Preventive Medicine practice and will be an advocate for the efforts within AHRQ and a promoter of USPSTF recommendations.

Nadia Saif, MD, MPH
University of Maryland Baltimore | Preventive Medicine Residency Program

I chose to pursue Preventive Medicine training after completing my Family Medicine residency because of my desire to supplement my clinical training with public health skills. I love data and hoped to gain the skills to appropriately use data and numbers to contribute to population health impact in my future career.

I chose to complete a residency rotation at AHRQ to gain a greater understanding of critical appraisal of evidence and how evidence informs the clinical preventive services recommendations that we use in primary care. During my rotation, I had an in-depth look at how the USPSTF formulates clinical preventive services recommendations, from choosing topics to review and creating research plans through dissemination of final recommendations. I learned about the role of AHRQ in coordinating the USPSTF, and AHRQ's collaborations with various partners. I participated in several projects and initiatives during my rotation, including: performed a fact check for consistency and accuracy for a draft recommendation; created presentation slides that review a final recommendation for use by USPSTF members at an upcoming partner meeting; critically appraised a recently published article relevant to a clinical prevention topic and presented this to AHRQ medical officers.

My experience at AHRQ also provided an in-depth look at the workings of a federal agency and reinforced my interest in governmental public health as a future career path due to ability to do work that affects public health policy.

Learn more about the APTR-AHRQ Preventive Medicine Residency Program

I chose Preventive Medicine because of my passion for public health and desire to guide awareness and change at a population-based level while focusing on maternal health, racial and health disparities in underserved communities, education, patient advocacy, clinical prevention, and research. My unique training allows me to practice full-scope public health and clinical medicine.

The APTR-AHRQ/USPSTF rotation was an invaluable experience and an excellent opportunity to learn the rigorous methodology of developing the USPSTF recommendation statements. I have a much deeper appreciation and understanding of this comprehensive process. During my rotation, I was involved in several projects, including drafting presentation slides to support AHRQ leadership in a national meeting, critically appraising literature and presenting on a randomized controlled trial to AHRQ medical officers to inform USPSTF recommendations, and completing several fact-checks to ensure the accuracy of the evidence in draft recommendation statements during the development process. I gained in-depth knowledge of the diverse draft prevention topics. During resident rounds, my AHRQ preceptor and the other medical officers provided great mentorship on synthesizing evidence accurately and critically when evaluating recommendation statements. I am very thankful to have worked with such an incredible and collaborative team that significantly supports the US Preventive Services Task Force's work.

I was fortunate to participate in the USPSTF meeting calls and gain insight into how the evidence is judiciously evaluated, reviewed, and prioritized for draft recommendations. It was also a remarkable experience to attend the USPSTF meeting in-person and witness firsthand the tremendous preparation and dedication that goes into each recommendation statement serving our nation and guiding clinicians!

Learn more about the APTR-AHRQ Preventive Medicine Residency Program

Emory University, Department of Family and Preventive Medicine

Some of the projects that I was able to participate in during my rotation were reviewing public comments about draft recommendations on prevention topics, critically appraising literature, and contributing to plans for research that informs recommendations.

As a board-certified family medicine physician, I was grateful for the opportunity to have trained within family medicine and be able to learn and appreciate the unique needs of my patients across the spectrum of life. During my second year in family medicine training, the COVID-19 pandemic happened, and the intersectionality of many social and structural determinants affected access to care, and health inequities were worsened as a result. As a clinician, I wanted further training in understanding how to collectively and objectively examine the unique circumstances and needs of marginalized collectives and communities and plan interventions that can promote broader community-oriented health and wellness. This was my primary reason for pursuing training in preventive medicine.

In particular, I chose the AHRQ rotation during my preventive medicine fellowship because I have an interest in understanding the development and impact of USPSTF recommendations on communities and populations I was working in. As a family medicine physician, I implemented the recommendations within communities I worked in. Through the preventive medicine lens, I wanted to understand the intricate processes that lead to recommendations to empower a nation's health.

Johns Hopkins University General Preventive Medicine Residency

I chose to pursue a combined family medicine and preventive medicine residency program because as a medical officer in the Indian Health Service, I am charged with the health of both individuals and populations. I wanted a training program that would prepare me to understand the individual and systems level factors that impact the health of AI/AN communities. AHRQ provided an ideal setting for me to experience clinical preventive medicine. Attending the USPSTF meeting highlighted how deliberate each of the decisions of TF really is, and how the TF uses evidence to arrive at their conclusions. As a rotating resident, I was able to participate in a number of different projects and initiatives for the Agency, When I use the TF recommendations in my clinical practice, I can have confidence in the process and rest assured that TF recommendations are predicated upon the best available evidence. 

AHRQ Residency Tasks Completed:

• Verified accuracy of data and citations for a draft recommendation statement prior to posting for public comment. 
• Reviewed, summarized, and provided disposition to address public comments before finalizing a recommendation statement. 
• Co-authored a Putting Prevention into Practice case study based on a recently published USPSTF recommendation. The case study is scheduled for publication in the American Academy of Family Physicians' scientific journal. 
• Provided consultation on current and relevant USPSTF recommendations for policies and communication products for CCHQ Medical Affairs Branch and DHHS Office of Disease Prevention and Health Promotion. 
• Prepared presentation slides for USPSTF members to present at an upcoming partner meeting. 
• Attended USPSTF deliberation meetings during recommendation development. 
  
• Participated in didactic lessons describing core preventive medicine topics, and the USPSTF methodology and processes for developing evidence-based guidelines.
• Critically appraised evidence and presented findings to AHRQ medical officers to inform USPSTF recommendations.

Learn more about the APTR-AHRQ Preventive Medicine Residency Program

University of Maryland School of Medicine

In navigating my education and career options, I have always been driven, to some degree, by the idea of prevention. Preventive Medicine offered me the opportunity to follow that passion and balance clinical care with public health. I eagerly wanted to learn skills in epidemiology, health policy, communication, and quality improvement, and to gain public health experience.

The AHRQ residency rotation with the USPSTF is an exciting opportunity to see how primary and secondary prevention efforts are designed for evidence-based population health. At AHRQ I reviewed draft recommendations on prevention topics and their supporting evidence for consistency and accuracy, reviewed public comments about draft recommendations, and prepared communication tools such as practice bulletins and presentations for clinician audiences related to prevention recommendations. The key preventive medicine concepts I learned were how to analyze evidence regarding the performance of proposed clinical preventive services, how to incorporate considerations of risk-benefit analysis in population-based care, and how to communicate effectively with the public, physicians, other health care professionals and health-related agencies.

Learn more about the APTR-AHRQ Preventive Medicine Residency Program.

Stony Brook General Preventive Medicine Residency Program

During my rotation, I had the opportunity to observe and assist with a variety of tasks to support the work of the United States Preventive Task Force (USPSTF).
The projects I assisted with included fact-checking recommendation statements and drafting the feature titled “Putting Prevention into Practice” (PPIP) to be
published in the American Family Physician journal. In addition, I had the opportunity to review a draft report.

I gained a deeper understanding of and appreciation for the USPSTF recommendations. In addition, I had the opportunity to practice a variety of skills and receive valuable feedback in many areas, such as critical review of a journal article, presentation, peer review of a journal article, and drafting questions for PPIP. I chose preventive medicine because it can create a positive impact for a population on a large scale, and address health disparities. I was grateful to be part of the Agency of Healthcare Research and Quality (AHRQ) USPSTF team and I am inspired by their work.

Learn more about the APTR-AHRQ Preventive Medicine Residency Program

UCLA

I worked on projects/presentations related to communication of USPSTF work with other federal agencies, a dissemination/education project and provided technical assistance to the development of a final recommendation statement. I chose AHRQ as a rotation in my Preventive Medicine Training because I wanted experience working in governmental public health at the federal level. I had the opportunity to learn a bit about how AHRQ interacts with some of the other federal agencies (especially NIH) and learned technical skills in evidence review and analysis. I learned how to formulate detailed plans for reviewing evidence around clinical topics and the importance of scope in topic selection and prioritization.

Johns Hopkins University |  Preventive Medicine Residency

While at the Agency of Healthcare Research and Quality (AHRQ), I had the opportunity to participate in and contribute to the work of the United States Preventive Task Force (USPSTF). There are many steps in the creation of a USPSTF recommendation, all the way from selecting topics for review to developing communication strategies for newly minted recommendations. My projects included fact-checking draft or final recommendations, assisting with reports to Congress on research gaps, and writing articles for medical journals discussing new recommendations. The breadth of these responsibilities truly helps Preventive Residents understand the vital process to create a USPSTF recommendation.

This rotation further cemented my interest in how evidence becomes policy. I chose the AHRQ rotation because they are one of the few organizations that actually has the breadth of knowledge and regulatory power to create such policies. In just over a year, a topic becomes a systematic review, then is translated into a recommendation that impacts the care of millions. The ability to have this large of an impact is why I went into Preventive Medicine. Our specialty is the only residency in which physicians learn to treat populations, not just individuals, and I hope to take the important lessons from my rotation at AHRQ to continue to provide this type of care.

How has your experience at AHRQ Impacted your career path and goals?
Seeing how evidence becomes policy has continued to increase my interest in policy research. I have become more interested in government service, and was able to see roles in the Federal government where original research is created.

Paul Ambrose Scholar: Elisha Tribble, Mercer University

The Paul Ambrose Scholars Program prepares public health and clinical health professions students to promote change and be leaders in addressing population health challenges at the national and community level.  Students from across the health professions to commit their time and effort to improve health within their communities through the planning and implementation of a community-based project.

This project aims to collaborate with the Georgia Sheriffs' Association to develop a curriculum for Choosing Healthy Activities and Methods Promoting Safety (C.H.A.M.P.S.) regarding the dangers of e-cigarette use and vaping to help decrease the usage of e-cigarettes in adolescents. This project has been created and presented to the Georgia Sheriffs' deputies, who currently offer the C.H.A.M.P.S. program to schools in 94 counties in the state of Georgia. The new curriculum will be evaluated to determine vaping education's benefit, perceived impact, and sustainability. This project hopes to achieve the Healthy People 2030 goal of reducing e-cigarette use in the adolescent population by targeting early intervention. The anticipated impact of this early education is to see an overall decrease in the usage of e-cigarettes and vaping products in adolescents.

The curriculum was created to be cohesive with the current C.H.A.M.P.S. curriculum presently in use across Georgia. The new vaping education was presented to the Georgia Sheriffs' deputies to educate the presenters on the material to prepare them to use the new education in the classroom. Then, to evaluate the new curriculum, an anonymous survey completed by the deputies will determine benefit, perceived impact, and sustainability.

At the start of this project, there was no vaping education presented in the C.H.A.M.P.S. program. Through a collaborative effort with the Georgia Sheriffs' Association, this project broadened the current C.H.A.M.P.S. curriculum and educated younger adolescents on the dangers of vaping and e-cigarette use. Data from this study suggest that this program is beneficial, sustainable, and improves education in the adolescent population regarding the dangers of e-cigarette use.

Project Timeline

• September 2022: Vaping curriculum went "live" in counties across Georgia
• March 2022: Vaping education survey sent to deputies who taught in the C.H.A.M.P.S. program
• May 2022: Review and analysis of survey data began

Paul Ambrose Scholar: Emily Starman; University of Iowa School of Dentistry

Community-Based Project Name: Open Heartland: A Pilot Project to Increase Access to Oral Health Care 

This project was to establish a working partnership between the University of Iowa College of Dentistry (COD) and Open Heartland. Open Heartland is a grass roots organization in Iowa City, IA that works with Hispanic, Spanish-speaking immigrant families to provide community resources, including healthcare. I worked with COD administration and faculty to develop a pilot program to refer patients from the UI Mobile Clinic to the COD. Patients were ideally going to see fourth year students in the Family Dentistry clinic for comprehensive exams and radiographs free of cost. A treatment plan could then be developed and completed with a payment plan based on the Iowa Medicaid fee schedule. This was significant since most all adults are not eligible for Medicaid or dental insurance due to their immigration and/or citizenship status. A dental event was held separately from the UI Mobile Clinic at Open Heartland in January 2022 to establish a patient pool for the pilot program. An educational activity for children and educational flip books in Spanish were also used/made. Patients were selected based on evidence of urgent dental needs and desire to be treated at the COD. Seven adult patients were ultimately selected and contacted to make appointments in Family Dentistry with me (Emily Starman, D4) as their clinician. Comprehensive exams, radiographs, and treatment plan formulation was completed for each pilot patient, including extensive oral health education. All appointments were completed using an interpreter over the phone. Patients will then be scheduled with new fourth year students after my graduation to complete treatment in Fall 2022 as necessary.

Project Timeline

• August 2021: Opened Heartland Mobile Clinic #1 in Iowa City, IA
• October 2021: Opened Heartland Mobile Clinic #2
  
• January 2022: Dental Event at Open Heartland
  
• March-May 2022: Saw patients for comprehensive exam, cleanings, and treatment planning.
  
• May 2022: Opened Heartland Mobile Clinic
  
• May- June 2022: Plan for future patient care and pilot programming with mobile clinic patients

Griffin Hospital

I collected resources related to a primary focus of the USPSTF and associated methodologies. This included work to prepare my journal club presentation, which explained some of these methodologies in detail. I also shared the collection of resources I gathered, as it is anticipated to be a continued interest and may be taken up by a later resident. I completed three fact checks of draft recommendations, ensuring the legitimacy of the data from which conclusion were drawn for guideline development. I helped prepare an early evidence draft for a report to congress, helping to describe the anticipated trajectory of the USPSTF over the coming year. I prepared a draft presentation to be presented at an upcoming conference, where representatives of the USPSTF will highlight some of the most important recent and upcoming recommendations. I developed a PPIP manuscript, which provides clinical context for the recommendations made by the task force. I was also fortunate enough to interact with other areas of AHRQ related to my own research interests, and to attend some meetings to learn more about what AHRQ is doing in that space.

How has this rotation met your expectations?
It was a fantastic rotation. Overall, the best possible situation I could imagine. I've wanted to do this rotation for over 10 years, and completing it (even remotely) was a fantastic experience.

Wigdan Farah, MBBS

Mayo Clinic; Preventive Medicine Fellowship

The APTR-AHRQ rotation provided me with a great experience and exposure to the US Preventive Service Task Force work and methodology. During my remote rotation, I was able to work with great and supportive mentors and participate in several projects, AHRQ and Task Force meetings, and educational meetings, including verifying scientific references used in a draft recommendation statement and contributing to drafting questions for the "Putting Prevention into Practice" feature of the American Family Physician journal, in addition to creating a database with the most appropriate Task Force recommendation to address the need of a particular population. I also presented critical 
appraisal for a randomized control trial at journal club, participated in resident rounds, and attended USPSTF meetings.

What were the key concepts you learned during the rotation?
The process of developing evidence based recommendations and learning about the different strategies to tailor the recommendations to address the need of different populations.

Johns Hopkins Bloomberg School of Public Health

During my time at AHRQ, I learned a lot about the USPSTF process and the importance of each recommendation. As a primary care provider and preventive medicine resident, this has helped me understand how to communicate and apply their recommendations in a clinical setting. I worked on many projects that involved fact-checking their recommendation statements on various topics. The fact-checking process helped me understand the evidence and the nuances around these topics. Furthermore, I gained a profound respect for the process, the thoroughness, and the details needed to develop a recommendation statement. I was also able to help draft a response to public comment.

I will cherish these experiences as I move into my subsequent rotations and my career, and I am thankful I got the chance to be part of such a dedicated and amazing team.

How has your experience at AHRQ Impacted your career path and goals?
I plan to resume clinical practice after my preventive medicine residency, thus this rotation was helpful in highlighting the importance of how to communicate the USPSTF recommendations, which is a great skill to have in a primary care practice.

Stony Brook University Hospital  

The APTR-AHRQ rotation was a great experience. During the rotation, I contributed to writing questions for the "Putting Prevention into Practice" feature of the American Family Physician journal. I also assisted in fact checking recommendation statements on a variety of topics. The AHRQ team is very collaborative and they encourage resident input and innovation. I was able to design a database for recommendations based on various needs of the workgroup. I also presented at journal club, participated in resident rounds and attended USPSTF meetings.

University of Michigan Preventive Medicine Residency Program

During the rotation, I was able to engage with mentors and work on several projects. This included the reviewing of public comments about a draft recommendation on a prevention topic, verifying (fact checking) scientific references used in a draft recommendation statement, performing a critical analysis of a scientific article regarding a randomized clinical trial and presenting the findings to an audience, drafting slides for leadership for use in a national presentation, and drafting a clinical scenario, questions, and answers to aid providers in understanding a new recommendation (PPIP).

The purpose of my Paul Ambrose Scholars Program (PASP) study was to gather perceptions and input on how questions about sexual orientation, gender identity, and sexual risk behaviors are included as a routine part of medical visits as well as how the implementation of these questions could affect future clinical decision-making. Perceptions were intentionally gathered from LGBTQIA+ community members as well as straight cisgender community members. The research team that I worked with on this study was led by my two mentors at Duke University, Christine M Everett, PhD, PA-C, MPH (Associate Professor, Department of Family Medicine and Community Health & Department of Population Health Sciences) and Tiffany Covas, MD, MPH (Medical Instructor, Department of Family Medicine and Community Health). The remaining team members included Truls Ostbye, MD, MPH (Professor and Vice Chair of Research, Department of Family Medicine and Community Health), Ashley Price, PhD, MPH (Research Program Leader, Department of Family Medicine and Community Health), Deanna W. Adkins, MD (Assistant Professor, Department of Pediatrics, and Director, Duke Child and Adolescent Gender Care Clinic), Adva Eisenberg, MD (Assistant Professor, Department of Medicine), Carly E. Kelley, MD, MPH (Assistant Professor, Department of Medicine), Rheaya Willis, BA (Fourth year Medical Student, College of Medicine), Lauren Hart, MPH, MSW (Research Program Leader, Department of Family Medicine and Community Health), and Jacob Christy, MS (Clinical Research Coordinator, Department of Family Medicine and Community Health).

This is a mixed-methods study with two phases. Phase 1 was an electronic survey compiling the opinions of members of both communities on the implementation of the SOGI and sexual risk behavior questions, responses to the current Duke SOGI and sexual risk behavior questions, responses to a new set of proposed sexual risk behavior questions, and interest in further participation in phase 2. Phase 2 is focus groups to gather additional information from a subset of the respondents from phase 1, soliciting more detailed feedback on the existing Duke tools for gathering patient SOGI and sexual risk behavior information, proposed revisions to both the SOGI and sexual risk behavior tool, and general questions about the best methodologies of implementing both tools (e.g., who, when, where). In collaboration with the LGBTQIA+ Community Advisory Board over the first year of PASP, the entirety of the study (protocol, electronic survey for phase 1, and focus group guides for phase 2) was modified and later approved by the Duke Institutional Review Board (IRB).

During this period, the research team was also awarded two institutional grants. The first was the Duke Family Medicine and Community Health Departmental Small Grants (DSG) Program for Research & Scholarship. The second is a pending (due to the COVID-19 pandemic) Clinical and Translational Science Institute (CTSI) Special Populations Pilot award given to studies with a community-engaged partnership and designed to facilitate research that promotes health equity for groups who have traditionally been underrepresented or excluded altogether. These will be used for phase 2 and for follow-up studies to validate a SOGI & sexual risk behavior tool to be implemented in the Duke Health System. Currently, phase 1 has recruited 1,279 participants and the team is in the process of scheduling focus groups and starting phase 1 data analysis. These focus groups will provide richer, qualitative data to utilize for both guiding future sexual orientation and gender identity (SOGI) & sexual behavior data for healthcare systems within NC and beyond.

Since this was a community-based project, our research team worked very closely with members of the LGBTQIA+ and straight, cisgender communities on different levels before submitting to the IRB for approval. The result of this collaboration and community-engagement has been a continued relationship with the LGBTQIA+ community advisory board who plan to continue guiding all future research done by providers within the Duke Family Medicine and Community Health department. This group was instrumental in guiding our direction, line of questioning, and providing clarity and education on areas that the team was unsure of how to best approach with members of the LGBTQIA+ community. The successes the research team has had largely stemmed from the relationships already built upon by Dr. Covas (Duke Family Medicine MD) with members of the LGBTQIA+ community before this study.

Throughout my two years in the Paul Ambrose Scholars Program (PASP), I learned the nuances of a community-based research study, the process of collaborating with a community advisory board, and the importance of the perspective and knowledge they bring to a research study. Without the guidance of my mentors within the Paul Ambrose program and at Duke University, my growth and understanding of the research process would not be where it is today. The Paul Ambrose program was one of the most meaningful experiences of my graduate training and has allowed me to grow both as a researcher and soon-to-be clinician.

Kiarash Rahmanian, MPH, MHS, PA-C

While the CDC has instructed residents of the United States to wash their hands, wear masks, and practice social distancing, migrants in detention facilities run by Immigration and Customs Enforcement (ICE) and Customs and Border Protection (CBP) have no control over their ability to engage in any of these practices. As a result, cases of COVID-19 have skyrocketed in immigration detention, with ICE’s own numbers indicating that over 1700 migrants have tested positive for COVID-19, and at least two migrants and four guards have died from the disease. The public health community has for years decried the unsanitary and unsafe conditions in detention facilities in the United States and the inhumane treatment of migrants, particularly women and children, seeking to enter the U.S., but in the midst of a nationwide communicable disease outbreak, the plight of migrants is at risk of being overlooked.

Consider the parallel between immigration detention and the U.S. prison system. At the urging of public health experts and advocates, some prisons and correctional facilities across the country have begun releasing inmates accused of nonviolent crimes in order to reduce the chances of widespread outbreaks. Despite this small step towards progress in the wider carceral system, immigration detention facilities are still holding thousands of migrants and asylum seekers, the overwhelming majority of whom did not commit violent crimes. According to the non-partisan Center for Migration Studies, ICE still held over 4,000 asylum seekers determined to have a “credible fear” of persecution or violence in their home countries, even several months into the pandemic. Meanwhile, COVID-19 cases continue to rise as ICE shuffles detained migrants between facilities.

In addition to continuing to detain some migrants and asylum seekers in unsafe conditions, the Trump administration is also using COVID-19 as an excuse to ramp up immigration enforcement and deterrence strategies. Border Patrol agents have been instructed to expel people apprehended at the border without following legal requirements to determine if a migrant has a valid asylum claim. In the name of public health, hundreds of minors have been sent to Mexico, where they face the dangerous conditions experienced by people subject to the Migrant Protection Protocols (MPP, also known as “Remain in Mexico”), including rampant kidnapping, sexual assault, and murder.

The COVID-19 crisis does not only affect asylum-seekers and migrants in detention. Immigrants who live in the United States, with or without legal status, are also disproportionately harmed by the fatal intersection of anti-immigrant policy and inadequate public health measures. When the Trump administration changed the public charge rule in 2019 to discourage legally residing immigrants from using social services like Medicaid and SNAP, tens of thousands of commenters wrote to oppose the changes. Some who wrote in opposition argued that the policy would be bad for the health of immigrants and American citizens alike, citing the communicability of disease outbreaks and the dangers of discouraging vulnerable people from seeking health care. They could not have known how prescient those concerns were, as we can now see the effect the public charge rule has had on immigrants’ willingness to seek care for COVID-19. 

In addition to the damaging public charge rule, the U.S. government has doubled down on the harm to undocumented immigrants by excluding them from the 2 trillion dollar Coronavirus Aid, Relief, and Economic Security (CARES) Act. Although many undocumented immigrants are essential workers, they are not entitled to relief under the CARES Act, and even the U.S. citizen children of undocumented immigrants are unable to access the benefits of the program. Most undocumented immigrant adults are ineligible for publicly funded insurance, and their children are only eligible if they are citizens or reside in one of the few states that provide coverage to undocumented children. These exclusions from social safety-net programs, while clearly unjust even during non-pandemic times, seem downright cruel and counter-productive to the goals of public health in the midst of a dangerous pandemic disease outbreak.

The injustice of this moment, directed against some of the most marginalized members of society, presents a unique challenge to public health scholars and practitioners. As COVID-19 continues to ravage communities of color and tear through immigration detention facilities, it is incumbent upon all of us, as members of the public health community, to use our collective voice, power, and privilege to call for immediate and long-term change. This crisis has demonstrated the moral and practical dangers of excluding some populations from the benefits of publicly funded health care and denying the humanity of non-citizens seeking to make a better life for themselves and their families. We must meet this moment with persistent advocacy for justice in all of the systems that perpetuate health disparities, including a reimagining of both our health care and immigration systems. If we truly believe that the “public” in public health includes all of us, there is no other alternative. 

Rachel Fabi, PhD

Today, there are more than more than 5.5 million confirmed cases and 350,000 deaths attributed to COVID-19 worldwide.  Due to reporting discrepancies across countries (including in the US), uneven and inadequate testing, and other factors, many experts believe the actual numbers of COVID-19 cases and deaths are likely much, much higher. 

Recently, the US recorded it’s 100,000^th death due to COVID-19.  Although the number of new cases in the US is currently declining each day, the total number of cases and deaths will continue to rise, and the daily number of new cases could accelerate again if testing and mitigation strategies fail.  At this difficult milestone in the epidemic, I took some time to look back over the last few months and share my observations on what we’ve learned—in hopes that we’ll apply these lessons to the next phase of the pandemic.

Our public health system is more fragile than we thought.  Early in the epidemic, the Centers for Disease Control and Prevention were unable to provide reliable estimates on how COVID was spreading due to poor reporting infrastructure and problems receiving data from state and local jurisdictions.  Even now, the agency is still trying to detangle the data they have to more clearly document those who have tested positive using the viral tests (the primary means of tracking the spread of the virus) and those who are testing positive using the antibody tests (the primary measure of tracking who ever had the disease—regardless if they are currently infectious or not).  Combined with the failures of its labs early on to create test kits necessary to track the spread of the virus, CDC has led many (including me) to seriously doubt its ability to effectively manage pandemics without sufficient infrastructural investments and perhaps a change in leadership at multiple levels within the agency.

The healthcare “safety net” doesn’t really exist.  In the US, we use market-based approaches to provide access to healthcare services rather than socialized or nationalized models that guarantee access for everyone.  Consequently, gaps exist for populations that are either too sick for insurance companies to want to insure or they simply cannot afford to pay the high costs for coverage.  To address these gaps, federal and state governments spend billions annually implementing a myriad of programs including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) and supporting access points for services such as Federally Qualified Health Centers, Critical Access Hospitals, and others.  What has all of that spending on healthcare given us during a time when we need it the most?  Some of the largest disparities in COVID-related morbidity and mortality ever seen in modern times.  How can we legitimately claim to have a healthcare safety net when the cracks are so large that entire populations fall through them to their demise?

We are more caring, hopeful, and resilient than it usually appears.  The political discourse over the last decade has grown increasingly vitriolic.  Supporters from all sides of an issue seem to revel in the idea of demonizing each other on television and social media—and the anger isn’t limited to words.  Political violence has increased substantially over the last five years and is beginning to rival the number of domestic terrorism events pervasive during the periods of significant political unrest in the 1960s and 1970s. 

In spite of the hate-filled cloud that seems to hang over every subject with more than one point of view, we did manage to come together in many interesting ways to support each other.  School teachers made house visits to check on their students; people around the world clapped and banged pots and pans to honor the sacrifices of healthcare workers; untold numbers of food bank volunteers literally fed hundreds of thousands of people in need; school administrators found creative ways to celebrate graduation; people from all walks of life learned how to sew countless masks for essential workers and their high-risk neighbors; mutual aid networks popped up to support the various needs of community residents; and the list goes on and on…

The biggest lesson that I hope we all have learned is that together, we are more powerful than we realize.  We stepped up when our leaders didn’t, we took care of each other when they couldn’t or wouldn’t, and we all contributed in our own way toward the same simple goal: helping each other when it mattered most. 

Now my question for you:  Can we learn to do this again?

Billy Oglesby, PhD, MSPH, MBA, FACHE

The mission of the APHVC is to “leverage public health students, alumni, and expert volunteers to augment, amplify, and promote local public health efforts in Massachusetts.” An initial wave of over 600 volunteers were deployed in April to meet emergent needs of over 90 communities across Massachusetts. This summer the APHVC will continue to deploy hundreds of public health volunteers to local boards of health to support many different services such as developing health communication materials, conducting data analysis and GIS mapping, conducting wellness checks and doing community outreach, developing policies and protocols, and more. 

While there have been many successes of the APHVC and AHD mobilization, the focus of this post is to highlight lessons learned from this collaboration for academic institutions, particularly for programs in public health or the health professions. These lessons are from my perspective as a board member of APTR and are not representative of the AHD as a whole:

(1)  Stay true to the mission of the collaboration. For the AHD and the APHVC, this has meant ensuring local boards of health continue to inform the work. Moreover, the response to COVID-19 has been rapidly evolving over the past eight weeks. Whenever discussions arose of where best to focus our efforts, the team worked hard to bring it back to whether or not the proposed action supported local health. This group reminds each other of the hard work being done at the local level and that the AHD and APHVC are there to support, augment, and amplify local health, not work in silos or out of sync with what is needed on the ground.

(2)  Keep health equity and racial justice at the center of the conversation. Article, after article, after article, in both peer-reviewed literature and mainstream media highlights disparities by race/ethnicity, disability status, income, geography, and other social factors. As Meenakshi Verma-Agrawal, Associate Professor of Practice and Assistant MPH Program Director at Simmons University reminded the group, “I think it is important that folks are applying some type of Racial Equity Impact Assessment or similar tool when decision making:

a. What would this [policy/communication] discourage/encourage us from doing?

b. What are the possible unintended outcomes of this [policy/communication]?

c. Does this [policy/communication] address historic/ structural racism?”

(3)  Provide high impact educational practices for students during the response. Although alumni, staff, and faculty from the academic institutions participate in this effort, the majority of the volunteers are students. Collaborating with community partners can provide excellent real-world problems for students to address and serve as a high impact educational practice (HIP). HIPs have been discussed in the education literature for almost two decades. HIPs are teaching and learning practices that have shown to increase success for students, particularly those with diverse backgrounds (Kuh, 2008). Service Learning or community-based learning, as a HIP, is an approach that gives students direct experience with issues they are learning about in a theoretical way (Kuh, 2008).

So there you have it, three considerations while engaging with state and local public health during a pandemic –stay focused on the mission of supporting local health, center health equity and racial justice, and utilize the collaboration as a HIP for students. Are you looking to engage community partners in the COVID-19 response? I would be happy to brainstorm ways to help you mobilize.

Kuh, George D. (2008). High-impact educational practices: What they are, who has access to them, and why they matter. AAC&U, Washington, D.C.

Carly Levy, MPH, CPH

The secret of dealing with wicked problems—and the reason for labeling them as such—is to recognize that these problems can’t be solved, but rather must be managed. Wicked problems can’t be ignored, manipulated, denied, or wished away. More than solutions, wicked problems require healing, a characteristic not at the top of the US population skills list. To heal is to make whole, a space we are currently far from. Full of holes, yes. Full and whole, nope. Don’t you love the wisdom of language?

Ironically, Covid does not “qualify” as a wicked problem, because this designation is reserved for problems humans invented rather than natural phenomena. While Covid is therefore not itself a wicked problem, the pandemic response to Covid is very much so. The excess burden of illness we are experiencing in the US represents problems that humans invented through denial of science and personal self-interest. All amplified by the interconnected nature of Covid with other wicked problems. And every wicked problem is a symptom of another problem.

One of the key principles for effectively managing wicked problems is that decision-makers must be fully responsible for their actions. This is happening in many state and local jurisdictions, but others seek to obfuscate and mislead. While the template for emergency response is imperfect, had the emergency preparedness science been respected and implemented the US might be in a different place right now.

Finally, Covid is distinguished from “true” wicked problems because for other such problems it is hard, maybe impossible, to measure success. Not so here. Success and failure can and will be measured by the rate of illness, hospitalization, and death from Covid-19. Particularly for the most vulnerable victims best by a myriad of wicked problems; and those we have made vulnerable by inadequate preparation (healthcare workers, police officers, bus and truck drivers, grocery and food service workers, custodians, and anyone working in at risk positions without adequate protection).

For wicked problems—for the Covid response and the problems Covid reveals in our society—we need righteous solutions, honorable, upright, and yes, unimpeachable. Such a response is being role modeled in many locations, to our enduring benefit. Thank you to political decision makers who are respecting science and acting to limit morbidity and mortality. Public Health means loving the world like your family. Good to be a Publichealther.

Scott Frank, MD, MS