Chin, Nancy P. PhD, MPH; Aligne, C Andrew MD, MPH; Stronczek, Amanda MPH; Shipley, Laura Jean MD; Kaczorowski, Jeffrey MD
The American Academy of Pediatrics’ Committee on Community Health Services has explicit criteria that define the practice of community pediatrics.1 The community pediatrician is expected to understand the sociocultural context of child health, be a committed advocate for children, and be skilled in linking families in need with appropriate community agencies and services. Although community pediatrics thus defined is a valuable approach to caring for any community, the implicit charge is to focus on the sites of highest morbidity and mortality: generally poor, medically underserved communities of color. These communities are beset by a variety of difficult conditions (e.g., lead-contaminated housing, violent neighborhoods, drug dealing, inadequate public education, and limited access to health care), which have a negative impact on children’s health, yet which often are not recognized as constituting “health” problems in traditional medical training. Community pediatrics faces the challenging task of delivering medical care and stimulating social change amidst a complicated web of circumstances with which the average pediatrics resident has little knowledge or experience.
National objectives for pediatrics resident education set by the Accreditation Council for Graduate Medical Education (ACGME) recommend experiential training in the community as a way to educate residents about the fundamentals of community pediatrics that are not easily learned in an inpatient clinical setting.2 Because these recommendations are relatively recent, little information is available on the effectiveness of such educational interventions. The objective of this study was to use residents’ self-reports to assess the extent to which a community pediatrics rotation provided residents with knowledge, attitudes, and skills useful for improving the health of children at the community level.
The Greater Rochester, New York Area
Rochester, New York presents a unique site in which to educate future community pediatricians because although the city is home to several Fortune 500 companies, it is also the 11th poorest big city in the nation for children younger than 18 years, 37.9% whom are living in poverty.3 Moreover, the vast majority of these children (96%) are children of color, who are isolated in neighborhoods segregated by both income and race.4 Rochester’s neighborhoods have higher rates of violence than comparable midsized cities. Because of the age of housing in poor neighborhoods, lead contamination is a significant problem. Rochester has responded by creating an unusually large number of agencies working to provide impoverished community members with health and human services. These agencies have been indispensable collaborators with the University of Rochester Medical Center in educating both medical students and residents.
Pediatric Links with the Community
The Pediatric Links with the Community (PLC) rotation was initiated in 1996 by pediatricians who were recent graduates of the University of Rochester Medical Center’s training program. By 2002, 154 pediatrics residents and over 150 medical students had participated in PLC activities in collaboration with over 40 different community organizations in Rochester and the surrounding area. All pediatrics and medicine–pediatrics residents at the University of Rochester Medical Center, about 24 per year, participate in the two-week community-based rotation early in their residency training. PLC provides a structured experience in underserved neighborhoods by linking residents with a variety of agencies serving poor, urban families. During the experience, residents work with both medical and nonmedical providers at sites that include homeless shelters, settlement houses, soup kitchens, and public schools. The program’s goals include enhancing residents’ knowledge about community-oriented health care, engaging residents in partnerships with community-based organizations to expand their understanding of community resources for poor and special-needs children, and motivating residents to assume partial responsibility for the health of children in their communities (for more information about PLC, visit 〈www.plccare.org〉). The majority of Rochester’s pediatrics residents (1997–2001) are white (82%), female (69%), and from medical schools outside the Rochester area (76%).
Before formulating the study question, all PLC residents were asked to write a short essay describing important experiences, either positive or negative, that they had during their community rotation. Twenty-five of these essays were selected for inclusion in a booklet describing and promoting the PLC rotation. We used these 25 essays as a pilot sample to determine the project’s feasibility and to look for knowledge, skills, and attitudes themes. Because selection for inclusion in the booklet was based on the richness of the narratives and eloquence in describing the impact of the experience on residents’ learning, the essays were not necessarily representative but they were useful in a preliminary review.
An interdisciplinary team of four investigators from anthropology and public health as well as pediatrics conducted a retrospective, qualitative analysis of the selected essays. All four investigators independently identified three themes: (1) increased knowledge regarding the lived experience of childhood poverty; (2) renewed enthusiasm for social advocacy; and (3) skill in how to refer needy families for special resources.
Twenty-five additional essays were then randomly selected using a random number generator and independently reviewed by the same investigators for evidence of these themes. The sample size in qualitative studies is determined by the number of cases needed to reach a redundancy of themes, which typically happens within five cases. We chose to review 25 cases to capture any variation that may have occurred over the five-year project period from 1997 until 2002. The random selection helped ensure that we did not simply select the most favorable responses. Nevertheless, residents had been aware that the PLC directors reviewed each essay, and this may have restrained them from being critical or may have predisposed the residents to bias their reports in favor of positive learning experiences.
The additional essays were examined for theme and narrative plot elements that would suggest a causal sequence of events leading to some transformation of the learner.5 There are interrelated reasons why a narrative analysis provides an important dimension to this evaluation: (1) the essays consist of residents’ accounts of their time spent in the community and, as such, constitute a narrative, that is a series of events woven together around a theme or a plot; (2) narrative events establish a causal sequence of action and reaction so that one can trace the development of the learner through time; and (3) a narrative approach in which the resident controls the content and the format highlights events and people of interest to him or her rather than the researcher, which allows the resident to supply the interpretation. Therefore, a narrative analysis, in combination with the general qualitative approach, allows for an evaluation of learning in two dimensions: identification of a learning cycle through the examination of the overall structure of the essay, and identification of recurring themes around self-reported instances of acquiring new knowledge, attitudes, and/or skills according to the program goals.
Furthermore, education researchers have identified a process among adult learners, called transformative learning, in which students pass through a discernable cycle of extraordinary experiences, emotional confusion, and reevaluation of formerly held values and beliefs. Transformative learning, in the words of education theorists, is “a dialectic in which understanding and action interact to produce an altered state of being.”6 Conditions that foster transformative learning include membership in a learning community characterized by empathy, solidarity and trust, and openness on the part of the learner to exploring new situations and points of view. Transformative learning typically begins with a disorienting experience that challenges the learners’ assumptions. Learners begin to identify new roles and relationships that add to new knowledge of the situation and, finally, learners gain a new understanding of conditions that generates a commitment to action. Transformative learning is often an emotional process realized by feelings of fear, doubt, anxiety and/or anger. Using a narrative approach, we examined the essays for any evidence of such a transformation.
Of the 25 essays reviewed for the presence of one or more of the three identified themes, 20 reported acquisition of new knowledge, 14 expressed a renewed attitude of enthusiasm, and 16 cited new skills. All 25 essays mentioned at least one of the three themes.
Increased Knowledge Regarding the Lived Experience of Childhood
Most young physicians in the United States have had no personal experience of poverty, and the lack of direct experiences leaves a gap in their understanding of life in poverty. One resident wrote, “Definitely, the more time spent in poor neighborhoods, in shelters or in different homes adds to my understanding of what everyday life is like for these people, and most importantly how I can better help them and their children.” Residents noted that hearing peoples’ stories gave them new insights to the life challenges of the poor, making them less judgmental and more empathetic. Another resident put it this way: “The stories I heard really crystallized for me the incredible burden [the poor] are carrying.” Previously unrealized burdens and challenges of poverty that distressed and surprised the residents included housing conditions, as noted by a third resident: “The one-year-old…waved sleepily to me from between her baby sitter and her cousin on their couch bed as we checked her tiny, moldy, infested, unheated apartment for lead.…” The limited influence the poor have in changing their situation was also a matter of comment. After walking through a substandard apartment with the lead inspection team, another resident quoted the mother as saying, “Maybe the landlord will listen to you [the resident].”
Interactions with families in poverty also gave the residents new knowledge of the poor as having hopes and a sense of agency rather than the fatalistic, passive attitudes the literature often attributes to the poor. A first-year resident wrote of her conversation with an alcoholic mother entering a detoxification program: “I think it’s really easy sometimes to make judgments about people—that they’re a lousy parent or a bad person—it’s a real reality check sometimes to actually talk to some of them. …I have to admire her for having the courage to finally take that step [into detox].”
Renewed Enthusiasm for Social Advocacy
“What a refreshing change it is to experience the field of pediatrics outside the hospital.” Of the renewed sense of advocacy, a resident wrote: “Initial idealism and enthusiasm for ‘changing the world’ had given way to a defeatist attitude of ‘what could one person possibly do that could make a difference?’ Over these past two weeks I have had the privilege of seeing just how much ‘one person’ can do. I am inspired.” This renewed attitude was in part inspired by the new network of community professionals who mentor PLC residents as indicated in the previous quote and in this comment: “In addition to the frustration and anger that I experienced, I was overwhelmed at times by the dedication of our community to its children and families.… I spent a lot of time with amazing people who will serve as role models.”
Skill in How to Refer Needy Families for Special Resources
The main self-reported new skill residents gained was an increased ability to make appropriate referrals to community resources for poor and special needs families. This gave rise to this observation about the universal utility of this skill: “One of the…messages I’ll carry with me no matter where I end up in my career is that there are many community resources available to people who need help. I won’t simply refer the family to a social worker and not worry about what happens. I’ll search out programs that make a difference…and feel confident referring people to them.” Yet another resident reported feeling more empowered to initiate referrals to resources, “Now when a child or parent asks me about a resource, I will have an idea of where to start. More importantly, even when people don’t ask, I can recommend a starting point for additional support or care.”
Narrative Evidence of Transformative Learning
All of the essays in both the pilot and study phase of this evaluation consistently showed evidence of a transformative cycle of learning. That is, the structure of the essays revealed an initial disorienting experience characterized by anxiety, fear and doubt, establishment of new social relationships and integration into agency activities, reevaluation of existing assumptions, acquisition of a new point of view, and a renewed commitment to a newly defined role and action strategies.
Figure 1 contains one essay, used with permission from its author, Dr. Danielle Thomas-Taylor. It discusses two identified themes and contains a narrative structure that traces a transformative process.
Curriculum evaluation that involves the analysis of complex psychosocial phenomena such as the transformation (or not) of a learner through structured experiences is best done using a qualitative research approach. Qualitative research seeks to understand a situation from the point of view of those most affected (in this case pediatrics residents) within a specific social context (outreach to poor communities). Although a variety of data-collection and analytic tools are available to the qualitative researcher (including in-depth interviews, focus groups, and participant observation), we chose to use the twofold approach of identifying recurring themes between essays and conducting a narrative analysis of individual essays. The themes easily fit beneath knowledge, attitude, or skill development labels, and in each essay we were able to identify at least one. The narrative structure outlined a consistent transformative process that was seen in all the essays.
The results observed from the residents’ essays on their PLC experiences occurred as part of an identifiable transformative process. Transformative learning, however, is not a linear process, nor is it demonstrated solely through self-report. Students move back and forth between old and new interpretations of the world. Reported shifts in attitude and knowledge precede but do not necessarily predict changes in behaviors. What still remains to be evaluated is the extent to which residents’ self-reports are translated into actual practice and to what extent transformation is sustained as residents move from residency into practice. A follow-up survey of PLC residents five years after the end of their residency program can determine what percentage of these graduates apply their newly acquired knowledge, attitudes, and skills by routinely engaging in activities associated with community pediatrics.
Learning during the PLC rotation met program goals and expectations around residents’ self-reported increased knowledge of how pervasive poverty impacts children and their families. Residents’ knowledge of the lived experience of the poor shocked and angered them. This new knowledge, in combination with an interdisciplinary network of role models from the community, inspired them to recall their reasons for becoming pediatricians, resulting in a renewed enthusiasm for advocacy and a confidence that they could effect social change.
The study design used here does not have the capacity to assess skills, nor can it determine how a self-reported change in attitudes towards community pediatrics shapes actual practice. These are behaviors that need to be demonstrated. However, the residents’ reported acquisition of and self-confidence in these skills and attitudes are a necessary precursor to changes in daily practice. Further research is needed to determine if this increase in reported knowledge, attitudes, and skills is appropriately applied to a given situation.