McIntosh, Scott PhD; Block, Robert C. MD, MPH; Kapsak, Gabrielle; Pearson, Thomas A. MD, PhD, MPH
Historically, clerkships have been the fundamental means by which medical students learn and practice the skills required of a physician, including information gathering, therapeutic planning, and interventions. The experiential learning and formative feedback from preceptors in clerkships are an effective means of teaching and learning procedural skills in undergraduate medical education, but they rarely expand the skills from the level of the individual patient to that of the community.1–3 However, such an expansion has been recommended by serious entities. The World Health Organization,4 for example, has recommended changes in medical education that emphasize public health and preventive medicine training. The Pew Health Professions Commission5,6 has challenged health professions schools to ensure that their students are competent in community-based care. At the same time, the Association of American Medical Colleges, in its Medical School Objectives Project report (MSOP), has made several recommendations for educational outcomes, among which is cultivating physicians who are dutiful and who “collaborate and use systematic approaches for promoting, maintaining, and improving the health of individuals and populations.”7 Future physicians are expected not only to be adept clinicians, but also to understand and work within the family, community, and cultural contexts in which their patients live.
Medical students cannot acquire these insights and skills through didactic learning alone, but when didactic learning about population health is combined with the practical experience offered in typical clinical clerkships (e.g., in medicine, pediatrics, etc.), they can learn how to apply prevention knowledge in real-life settings. Yet, such clerkships blending population health knowledge with practical experience are seldom offered and rarely required, indicating a paucity of opportunities and protected time for experiential learning of community health skills. Illustrating this problem, 32.1% of graduating medical students in 2006 reported that inadequate time during medical school was devoted to the role of community health and social service agencies; 32.1% noted this for public health, 21.4% for community medicine, 19.5% for clinical epidemiology, and 14.3% for health promotion and disease prevention.8 In addition, a large proportion of students reported that inadequate time during medical school was devoted to health policy, health services financing, environmental health, global health issues, biological/chemical terrorism, and disaster management.
Many different clinical and basic science disciplines should share responsibility and commitment for education in community health.7 Such education is inherently collaborative and requires the involvement of multiple disciplines. The intended outcome, as reported in the MSOP, is that “a population health perspective encompasses the ability to assess the health needs of a specific population, implement and evaluate interventions to improve the health of that population, and provide care for individual patients in the context of the culture, health status, and health needs of the populations of which that patient is a member.”7 Many health professions schools are developing programs to address issues of population-based health and interdisciplinary teamwork while providing students with community-based experiences and a broader understanding of the social and cultural milieu of health and disease.9–14 Many of these community-based programs have emphasized prevention at the clinical and individual levels, to provide students with experience in community-oriented primary care and, particularly, in underserved rural and urban communities.15,16 Fewer programs have addressed the social and environmental factors that contribute to the excess burden of disease and disability in these communities. The University of Rochester School of Medicine and Dentistry (URSMD) decided to create a novel clerkship to address these gaps in medical education.
In this article, we describe the development of a community health improvement clerkship, which specifically addresses the need for medical students to review population science concepts, hone social group interaction skills rather than individual-level interaction skills, and apply knowledge and expertise in a practical setting. We will describe the development of this clerkship, its current content and operation, and some early evaluation results.
The most important anticipated outcome from this clerkship is physicians who will actively incorporate community health principles and practice in their future careers as health care leaders. We also hope for improved health in underserved, underrepresented populations, enhanced multidisciplinary collaboration in health prevention, and an increased number of medical students who decide to pursue careers that formally integrate population health research and practice.
Creating the Community Health Improvement Clerkship
In 1998, URSMD completely revised and updated its curriculum, creating the Double Helix curriculum, a practice-based, learning-oriented educational program that emphasizes integration of basic science and clinical medicine across the spectrum of Engel's17 Biopsychosocial Model. As part of this integrated approach, previous courses in epidemiology, biostatistics, and community medicine in years one and two were replaced by a single four-week course in epidemiology, biostatistics, and evidence-based medicine (titled Mastering Medical Information) that initiates year one. Although this course was designed to improve preventive medicine and epidemiology knowledge in URSMD students, additional preventive medicine instruction was required as part of the ambulatory medicine curriculum. Yet, after two years or so, it was clear that the principles and practice of community health were lacking in the curriculum, despite the Biopsychosocial Model's inclusion of community, culture, society, and biosphere as important determinants of the patient's health.17 Several models to rectify this deficiency were considered, including an elective community health improvement course offered to undergraduate nursing and medical students that emphasized experimental learning.18 However, the few medical students who participated in the elective course chose to do so before their fourth year, before their primary clinical experiences in which they would have the opportunity to apply this knowledge in a practical setting. A multidisciplinary curriculum design team then set out to create a medical student clerkship which emphasized interactions in social groups rather than between individuals through supervised experiences in community agencies supported by didactic learning sessions.19,20 The Community Health Improvement Clerkship (CHIC) was created for fourth-year medical students, and for its first two years (2002, 2003) it was offered as an elective. It has, since 2004, been required for the MD degree at URSMD.
The overarching goal of CHIC is for students to learn how to improve the health of a target community through community-based interventions directed at a significant health issue. The specific learning objectives of the clerkship are community health assessment, community risk behavior change, assurance of personal health services, environmental change, health disparities and cultural determinants of health, community organization and partnership building, advocacy and policy change, and program evaluation (Table 1).
CHIC, after two years as an elective, is now a required fourth-year clerkship at URSMD. Students can take this clerkship either as a four-week intensive experience or as a culminating longitudinal experience with community health improvement activities across all four years. By January of their first year, students must declare their intention to pursue this longitudinal track. The longitudinal track helps to structure and focus the community-health-related activities of the students who choose this option. In addition to participating in community-health-related activities across the four years of medical school, students who choose this track also receive didactic instruction and resources through online modules. Although the instruction provided in the online modules is not as intensive as the didactic instruction they receive in the four-week clerkship during their fourth year (which they attend along with the rest of the fourth-year students), the students on the longitudinal track are prepared with the requisite knowledge, attitudes, and skills necessary to assume the role of the physician as more than a practitioner in a one-to-one patient–physician relationship. Rather, they develop skills that allow them to assume the role of a population-based health facilitator focusing on the one-to-many physician–group relationship, to help effect positive changes in health on a broader scale.21 Students in the longitudinal track complete evaluations of the online modules along the way (allowing us to track their mastery of the material), and we track all students during the fourth-year CHIC through attendance at lectures, progress notes, module evaluations, and final papers. Students who complete the longitudinal track are considered for receiving the honor of Distinction in Community Service, which is explained below.
During the fourth year, four-week CHIC, students participate in didactic and interactive lectures delivered by faculty from a variety of disciplines and representatives from local agencies for the first three days of the clerkship, read through supplemental online didactic modules, and then spend the rest of their four weeks developing and implementing community health projects. Students are encouraged to build off of projects previously begun by past or current CHIC students, encouraging the ongoing sustainability of projects and partnerships that are beneficial to a target community. The CHIC project is meant to challenge students to think beyond the comfort zone of their perception of the world of health care to see how community-level approaches can affect health on a larger scale than what they have typically encountered in one-to-one care.
To focus the students' projects appropriately, we encourage them to use a model for conceptualizing community interventions that requires them to identify three dimensions: (1) behaviors targeted for change, (2) community settings for interventions, and (3) interventions (services) to change behaviors. Framing their projects around these three dimensions helps students identify the specific behaviors which are important determinants of a health problem of interest, such as cardiovascular health (Figure 1). Because an interventionist can become quickly overwhelmed by the complexity of issues that are a threat to community health, it is helpful to focus project efforts on one behavior, one community setting, and one intervention. A community service project can then be quickly conceptualized on such a three-dimensional “grid.” A cardiovascular health project, for example, could include reducing smoking among teens (the target behavior for change) in local schools (the community setting) by offering free smoking-cessation classes (the actual intervention).
Students engaging in local community-based projects have access to office space and computers (provided by our Department of Community and Preventive Medicine) which are located within a specific target community in the inner city of Rochester. Although this target community is only one of many of our sites in the metropolitan area, this office space was chosen for its accessibility to key community partners. The office space is located within the same building as an elementary school, a neighborhood action coalition, a dental center, and a community health center. Information on these agencies and their relation to CHIC are provided to the students to consider during their project planning. Although students can engage with projects in other local, national, and global communities, this unique setting facilitates ample opportunities for a wide variety of projects and allows for the “sustainability” of long-term projects.19 It also fosters long-term relationships between URSMD and specific community agencies and members.
CHIC has approximately 10 organized lectures (the didactic component of the clerkship) given by faculty, organization representatives, and guest lecturers during the first three days of the clerkship (Table 2). Some of the content refreshes information from year one and two courses, but most is new material.
Several novel lectures and workshops have been successfully introduced. One example is a session about advocacy and policy change. An online module was developed and published22 that describes advocacy and policy change as they relate to the roles physicians could play in affecting public health policy. A workshop during the didactic portion of the clerkship brings in a local policy maker (e.g., county legislative representative, health department director, city mayor) for an interactive role-play. In the lecture, the students are taught specific “lobbying” techniques, and a fictional health policy issue is presented (e.g., state law regarding mandatory colorectal cancer screening, indoor-air tobacco-control, laws etc.). After strategizing, students are taken to another room where they play various roles (doctor, cancer survivor, stakeholder, etc.) in a mock legislative lobbying activity with the guest policy maker. After the role-play, a debriefing with the policy maker reviews how “successful” the students' lobbying event was (i.e., how well they used persuasive tactics, medical information, surveillance data, etc.) and incorporates real-life examples to further emphasize the roles that physicians can play in affecting policy changes.
Faculty from a variety of academic departments contribute to the lectures, serve as ad hoc preceptors for specific projects, and are generally available to serve as mentors. In this way, one-on-one expertise is available from a wide variety of disciplines, such as medicine, preventive medicine, epidemiology, psychology, psychiatry, anthropology, environmental health, biostatistics, and ethics.
Since its inception in 2002, CHIC has resulted in more than 190 unique community health improvement projects. Through development and implementation of feasible short- and long-term projects (sustainable by involving new students across time), students learn how to assess and address common community health problems including, but not limited to, lead poisoning, pediatric obesity, smoking, disparities in access to health care, violence and conflict, cancer, cardiovascular disease, diabetes, and injury risks (Table 3).
Projects that are longitudinal (carried out over time by one or more students and/or picked up by subsequent students where previous students have left off) are seen as “sustainable” and, therefore, beneficial to a target community because of the multiple opportunities over time to address a particular issue, and the additional opportunities for evaluating the intervention's long-term impact on health behaviors. These benefits may not always be evident when there are gaps of months or years between student projects addressing a specific intervention, but our goal is at least to have the curriculum structure in place to encourage and carry out such sustainable projects. For example, a series of students developed and implemented, in a specific urban area of Rochester, conflict-resolution workshops, which identified youth violence as an ongoing determinant of injuries and accidental death. The notion of “sustainability” may not have been evident to the target community, who experienced these interventions at unpredictable times over a period of several years. However, subsequent students were able to carefully review and build on previous student projects to improve the workshops each time in terms of faster connection with key community contacts, refined needs assessments, improved workshop content, and increasingly successful community-outreach strategies. The result is a developed intervention that is an ongoing resource available to our local target community.
Project one (one-month clerkship).
A recent student (in 2007) developed an educational video for lay audiences in target populations at risk for head injury. By partnering with various medical departments, a local public television station, and community-based groups, the student created a high-quality video education program for the prevention of traumatic brain injury. The half-hour program highlights a case example of a young boy with traumatic brain injury suffered while riding his skateboard without a helmet. Interviews with the family and members of the health care team who worked with the child present a strong message about the importance of, and strategies for, preventing head injuries. The video is available for local and national broadcasting and for Internet-based presentations. Of greater impact than one specific educational video was the student's development of the infrastructure and partnerships necessary for future students to create such programs as part of a digital library for use by both the partnering agencies and the medical school. The benefits of this project included successful partnerships within and outside the medical school, and well-developed strategies for sustainability (involvement of first- and second-year medical students, and grant applications for continuous funding). Through an impressive array of activities and contacts, this project met several key learning objectives: sustainable partnership building; risk behavior change; decreasing barriers to access to health care; program evaluation; and advocacy.
Project two (longitudinal clerkship).
Two students participated as investigators in a pilot study using a personalized educational intervention targeting socioeconomically disadvantaged inner-city youth with obesity and metabolic syndrome and their families.19 During their second, third, and fourth years of medical school, as part of the longitudinal experience, these students accomplished several objectives for the project, including organizing and directing study meetings, partnering with community physicians, contacting referred families, obtaining IRB-approved informed consent, administering a questionnaire, and educating families, using an innovative approach that included educational sessions, strategies for in-home meal preparation, and a grocery shopping trip. The students experienced a variety of barriers and facilitators firsthand, including language barriers, the complex cultural and environmental issues that contribute to obesity, and the challenges of recidivism and study recruitment. Through this longitudinal health project experience, the students met their learning goals, confirmed their plans for careers in primary care, and devised constructive ideas for project improvement. The students met the following key learning objectives: sustainable partnership building, risk behavior change, environmental change, community health assessment, program evaluation, and decreasing barriers to access to health care.
The CHIC clerkship directors (who are from the Department of Community and Preventive Medicine) have direct responsibility for supervising and teaching the students. They also have the primary responsibility for providing frequent and timely feedback, including midclerkship feedback on progress reported through regular progress notes, direct communications by phone and e-mail, and direct observations, and for postclerkship evaluation of the students. Preceptors (community partners and/or faculty mentors) and clerkship coordinators are responsible for guiding and assisting the clerkship directors and students.
Students who have participated in community service activities in their first three years document all such activities with the medical school's community service outreach director as well as with the fourth-year clerkship director when the students are involved in sustainable projects as part of the longitudinal track. Students in the fourth-year clerkship month are responsible for presenting progress reports for their projects to preceptors and directors throughout the four-week program. Students write and submit progress notes weekly. The didactic lectures in the fourth-year clerkship are mandatory for all students, including those who have been involved in the longitudinal track. The lectures are presented in the first three days of the four-week experience, so that students are presented with specific knowledge, skills, and attitudes as early as possible in their experiential month, and to preserve the remainder of the time for project development, implementation, and evaluation. Even longitudinal students, for whom the bulk of community contact has occurred during two or three years, are encouraged to work more intensively in their target communities during the four-week clerkship time to implement specific changes (e.g., more intensive interventions), to elicit feedback, and/or to evaluate impact.
Students are required to spend their nondidactic time at their community sites, creating and sustaining partnership relationships, performing project-related tasks, and implementing their projects. Their required final paper is a description of their intervention, and their documentation of measurable progress during the four-week time period (e.g., impact on community site, impact on student, data collected and analyzed, number of persons who participated in the intervention, etc.). Longitudinal students also spend these four weeks at their community sites during nondidactic time and, as part of their required final paper, additionally report on their community health work throughout their four years. These students are also required to present their projects to a community health advisory board as part of their evaluation for consideration of Distinction in Community Service.
Students who pursue the longitudinal track are eligible to receive the honor of Distinction in Community Service on their MD diploma if they complete the following required elements:
* 40 hours of community service in each of years one and two, and 60 hours of community service across years three and four with a recognized community outreach agency approved by a community service outreach director in the medical school;
* registration of intent to pursue the longitudinal experience with the outreach director by January of their first year;
* a grade of high pass or honors in the fourth-year CHIC; and
* recommendation from the community health advisory board based on their review of the required final paper and project presentation, considering both effort and impact.
Throughout the entire CHIC, a level of ethical behavior and professionalism is expected of the students. The community partners are a resource for our students, but the inverse is also true: students are providing valuable health care resources for the community, and the community's needs come first. Emphasizing the sustainability of a project with the students and the community partners helps address the common suspicions and fears associated with a community–medical institution partnership—namely, that the community will be seen as a short-term site for the benefit of education or research, rather than as a long-term beneficiary.
Evaluation of the Clerkship
All students are asked to complete evaluations of CHIC at the end of their four-week experience by using standardized online evaluation methods common to all our required courses and clerkships. Students are able to provide feedback anonymously to the medical school about their experience overall in the clerkship, as well as about the faculty, lectures, and structural elements of the clerkship. For specific modules of interest to us, for which we want feedback more specific than that which is available from standardized evaluation requirements, we ask the students to complete surveys anonymously, or to provide us with online feedback (not anonymously) related to some of the online didactic modules.
From the standardized evaluation feedback in a recent academic year, we learned that most respondents who provided ratings as to how well their project improved the health of the social group or community with which they interacted (n = 27) rated this positively overall (23% said a little, 40% said a moderate amount, and 17% said a lot). Only 20% stated not at all. Of those who provided remarks on their project's impact on their career (n = 30), 94% reported that their clerkship project has impacted their future career favorably (27% said a little, 40% said a moderate amount, and 27% said a lot). Only 6 felt their project had no impact on their future career.
One of the novel features of the clerkship is the use of an interactive Web site to provide links to scheduling, didactic lectures, online educational modules, partnership contact information, possible clerkship project ideas, evidence-based “toolbox” resources (surveys, audit tools, scientific papers), and uploaded versions of all past clerkship student papers. We wanted to know how these online resources were perceived by the students. Standardized anonymous evaluation data from the past two academic years (n = 102) reveals that 91% of the students found this Web site somewhat helpful (34%), very helpful (44%), or extremely helpful (13%). Only 9% felt it was not helpful.
Despite progress in reducing disparities in some health conditions within some ethnic/racial groups, the magnitude of these disparities has remained fairly constant overall and is actually increasing in certain important areas.23 Such issues are addressed throughout our medical school curriculum and are specifically presented in our community-health-related clerkship as important considerations for any intervention at the community level. Students often report specific project outcomes related to how a marginalized or underserved group (e.g., inner-city population) was able to have health care needs met as a result of a student project. To evaluate the impact of teaching students about disparities, 102 students were routinely and anonymously surveyed after the clerkship's didactic lecture on “cultural determinants of health,” which demonstrated how any minority population (in our guest lecturer's example, the lesbian, gay, bisexual, transgendered, and intersexed populations) can experience disparities in health care at the personal, provider, and health care system levels (e.g., prejudice, fear, ignorance). When asked, “How relevant was the information covered in this training to your role at work/role as a medical provider?” 92.9% responded in the positive direction (3 or 4 on a 4-point Likert-type scale, where 4 indicated very relevant).
Finally, to elicit qualitative feedback from students on the overall clerkship experience, we conducted an IRB-approved focus-group study with a convenience sample of fourth-year medical students during a recent academic year (2006–2007) near the end of the students' four-week experience. The focus-group comments revealed that students view the clerkship positively and that they find it to be valuable to their respective career paths.
The Double Helix curriculum, introduced as a new structure to the curriculum at URSMD in 1999, is an effort to better integrate clinical training with basic science across all four years of medical school. Our medical students are expected to be able to translate scientific evidence into practice in a timely manner, and this curriculum structure was designed to facilitate the translation between science and practice by integrating basic science and clinical work from the beginning of the first year of medical school.20 Consonant with this model, learning objectives that are applicable to community health are also introduced in years one and two in the curriculum and are applied in CHIC in the fourth year. Learning objectives are interwoven across the four years as students gain skills in creating, delivering, and evaluating evidence-based public health approaches at the community level.
At URSMD, CHIC has provided an innovative solution to the need to introduce future medical practitioners to community-based approaches to health promotion. This clerkship has demonstrated its feasibility, its ability to create partnerships between an academic center and community organizations, and its ability to consistently engage faculty from a variety of departments (e.g., community and preventive medicine, pediatrics, family medicine, orthopedics, environmental health, nursing, emergency medicine, neurology, etc.). Through their participation, students and faculty members have had positive experiences while generating projects that have been sustainable in the community. In addition, the clerkship has served as a catalyst for educational innovation by introducing medical students to public health research methods and practical experience through hands-on projects; creating sustainable partnerships which are already attracting future clerkship students; and expanding career goal paradigms for future medical practitioners. Moreover, the clerkship has provided the students with an opportunity to integrate basic skills in public health research and practice with a meaningful and potentially sustainable project. Such projects have generated professional relationships between the University of Rochester Medical Center and community partners that will have impacts beyond the medical school curriculum. These outcomes fit very well with the community health mission of the medical center and those of Healthy People 2010,24 and this type of hands-on education is in accord with the recommendations from the Medicare Payment Advisory Commission, which has stressed the importance of experiential learning and teaching systems-based medicine.25
The innovative aspects of our clerkship will be explored further as we compare the educational outcomes resulting from this clerkship with those of more traditional preventive medicine courses, and consider whether the longitudinal track is superior to the one-month experience at achieving educational and health impact goals. Although the one-month format in the fourth year is more easily integrated into the curriculum, and students have the luxury of focusing their learning on the topic for a short period of time, the longitudinal experience has tended to create a more involved leadership role and immersion experience for students while challenging them to incorporate community service into their other curricular responsibilities. Given the heterogeneous nature of medical student preferences and interests as well as our responsibility to the mission of community health, we intend to continue to offer both formats.
Room exists for us to improve the format of CHIC. A challenge in this process is the broad nature of the competencies involved in community health improvement, particularly for students without prior experience. Coordination of student projects with the expertise of public health graduate students, postdoctoral fellows, and faculty from preventive medicine and other specialties with an interest in community health improvement projects would be beneficial, and we plan to pursue this. Opportunities for growth and dissemination are underway, and we will continue to pursue evaluation strategies. Elements of the clerkship, such as the online Advocacy Module, are available to other medical schools23 and will continue to be evaluated and improved.
To our knowledge, this is one of few required U.S. medical school clerkships in which advanced (fourth-year) medical students develop their own community-based health prevention projects while engaging faculty from a variety of disciplines. The full-time format during their fourth year permits these clinically trained students to focus their attention on a wide variety of required tasks while participating in an intensive experiential learning process. The longitudinal track spanning all four years of medical school permits a more in-depth learning experience for the small but growing number of students who choose this format.
Required clerkships such as ours, with integrated features throughout the curriculum and across all four years, proactively involve all students in preventive medicine and population health. We feel this successfully meets the recommended changes in medical education by the World Health Organization and the Pew Health Professions Commission to ensure that all students are competent in community-based care, while at the same time facilitating a long-term impact on the health of our community.
The authors would like to acknowledge the invaluable contributions of past and present codirectors and key contributors (Nancy Bennett, MD, MPH; Richard Kennedy, MD; Noelle Andrus, PhD; Adrienne Morgan; John McCarthy; Erik Libey), guest lecturers, course content developers, community agencies, participating departments (community and preventive medicine, pediatrics, family medicine, orthopedics, and the center for community health), and the members of the many target populations who contributed with their cooperation and their expertise.
The clerkship has received financial support from a grant from the New York State Department of Health (W. Varade, PI) and the Regional Medicine–Public Health Education Centers Program of the Association of American Medical Colleges and Centers for Disease Control and Prevention (T. Pearson, PI).
As a current grantee of the Association of American Medical Colleges and the Centers for Disease Control and Prevention's Regional Medicine–Public Health Education Centers initiative, the University of Rochester has integrated several of its programs with regional medicine–public health education centers by supporting the efforts of several faculty to participate in this clerkship and in grand rounds presentations on several related issues. The supported faculty include Ralph Spezio; Nancy Bennett, MD, MPH; Noelle Andrus, PhD; and Scott McIntosh, PhD.