While I always held my profession to be my vocation, still I was interested in other fields of activity … I was an active member of the Moravian Church … I was elected and served two terms (four years) on the Board of County Commissioners … I was instrumental in organizing the Forsyth County Medical Society.
—Edward F. Strickland, MD, Meditations and Memoirs of an Old-Time Family Physician
In the late 1940s and early 1950s, physicians’ engagements with their communities, such as Dr. Stickland's stated above,1 were natural extensions of the profession. Physicians often took care of patients in their own homes and were generally connected to the beliefs and desires of their patients. In turn, these patients typically deeply respected the care and commitment they received. Today, although more isolated in sterile offices and serving populations that are often more culturally diverse than before, physicians still seek connections with their communities. For example, in a recent study of community service in North Carolina, physicians were found to regularly participate in health fairs, serve on boards of community organizations, coach children's sport teams, give talks to schools, lobby government officials, and perform many other activities that go beyond the one-on-one interaction with patients in the office or the hospital. The great majority of both faculty and private practice family physicians participated in one or more dimensions of volunteer community service.2
Some health care and academic leaders, in fact, see community service as one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. In public surveys over a 30-year period, U.S. medicine went from being perhaps the most trusted to being one of the least trusted social institutions.3 Guen et al.4 recently called for physicians to become more actively involved in community issues as a way to regain public trust in medicine that has been eroded. In their article in this issue of Academic Medicine, Calleson et al.5 argue that physicians in academic health centers (AHCs) should have a particular interest in working directly with local communities as a way to maintain local and state support crucial to the long-term success of AHCs. The term scholarship of community engagement describes the involvement by academicians in community service.6 While many physicians are philosophically attracted to community service, financial pressures and time constraints create barriers for community engagement. For physicians in AHCs, these barriers are particularly salient, as work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. In most AHCs, faculty roles and reward policies are heavily geared towards clinical concerns and grants, thus limiting AHCs’ involvement with local communities.5
If there is interest in increasing the attention that AHCs and their physicians devote to community service, administrative leaders need to evaluate models in which the scholarship of community engagement is found alongside the more traditional areas of patient care and research. Unfortunately, few precedents and little literature exist to help clinical departments incorporate work with local communities into their academic mission and promotion and tenure guidelines. In this article we describe how one department in an AHC has begun to incorporate the scholarship of community engagement into its mission and structure.
One Department's Approach
In 1971, the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine was formed to address the serious shortage of primary care physicians in the state. Two years later, the residency was approved, with the stated mission of training excellent community-based physicians, creating new knowledge in family medicine, and promoting the discipline of family medicine among medical students. The department also became an essential component in building a consortium of family medicine residencies across the state as part of the Area Health Education Center (AHEC) system. In the beginning, all department faculty had previously worked as community-based physicians in the United States and the United Kingdom.
As members of the AHC (even though some worked in distant community hospitals), it was essential for faculty to become successful in research and publishing. But this new generalist discipline's immediate challenge was to train clinician–teachers who could create an efficient and effective educational pipeline to solve the medical workforce problems of the state. Another challenge to the academic performance of faculty in family medicine was the lack of clear theoretical underpinnings and a research agenda for this new discipline.7 At that time, research in the delivery of health services, the relevance of the doctor–patient relationship, the effect of family and community issues on health, and the management of comorbid conditions over time (areas at which generalists excelled) created little interest in the biomedically oriented AHC.8,9
While the pressure continued for faculty to compete on the AHC's traditional playing field and publish, the inclination and background of these pioneering faculty pulled them more towards engaging with local communities. These clinician–teachers, through their previous community experience and interests, developed local voluntary service activities in the communities in which the residencies were located, usually with residents and medical students as assistants and learners. For an example, the department faculty became the sponsors and clinical preceptors for the Student Health Action Coalition (SHAC), now the longest running student-led health clinic serving indigent patients in the United States. But because of the attitudes and requirements of the AHC, these activities were expected to occur in faculty members’ “spare time.” Thus, although family medicine professed to be a community-based discipline, community work was not included as a central part of the department's mission.10
This tension between the formal roles of academic faculty and their unrecognized work with communities persisted until the late 1980s and early 1990s. At that time an increasing number of departmental faculty became interested and involved in community service, including both clinical faculty and faculty trained in public health, educational policy, and sociology. Faculty and residents became team physicians providing care at different local elementary and high schools and working with local and state activist groups to improve health care access, reduce gun violence, prevent adolescent tobacco use, and reduce drunk driving. The department institutionalized its role in SHAC by making precepting in that clinic a formal part of the call system. The department also began working with midwives and alternative birthing groups and established the first local hospice program, began forums on alternative medicine, and established multiple relationships with the local county health department.11
Including community service in the department's mission
By 1998, the department had fully evolved into a statewide organization, consisting of six residency sites, five of which were not affiliated with a university medical center. Throughout the departments’ affiliated AHEC residencies, community-based activities had expanded from voluntary service to leadership activities, access interventions, funded projects, and publications. The department, recognizing that it needed to simultaneously serve the interests of its faculty and those of the AHC, chose to reexamine its mission statement. Recognizing changes within the department, a newly elected department chair made a commitment to more fully engage with local communities and helped to craft a mission statement.* that featured service prominently. The mission statement became a central point for long-term planning, and it was publicized broadly and prominently throughout the Department.
Including community service in promotion and tenure guidelines
When the department's leaders modified its mission statement to include community service, they also decided to modify the department's promotion and tenure guidelines. This decision was driven by two primary forces: the AHC's need to increase clinical productivity and the department's need for clinician–teachers, especially at its community-based programs. The old promotion and tenure guidelines were no longer relevant or realistic for many faculty. The reexamination of the guidelines presented the opportunity to more explicitly include service to local communities. In addition to the traditional areas to be considered for promotion and tenure (clinical care, teaching, research, and administration), the department adopted community service as an aspect of faculty accomplishments, and defined these as “contributing to the public good, helping the department respond to local health care problems, and facilitating the use of faculty expertise outside the realm of their primary clinical responsibilities.”12
To further clarify this definition, examples of community service and their academic value were added to the promotion and tenure guidelines. Faculty could engage in service activities rated to be of higher, medium, and lower academic value (see List 1). For example, faculty engaging in community service activities labeled “higher value” would likely have community service recognized as an area of excellence in their promotion process.
In 2003, one department faculty member became the first in our school of medicine to be promoted largely on her work with local communities. Over many years, that faculty member had built strong relationships with Hispanic groups in a nearby town (Siler City, North Carolina). She had obtained federal money to create a health education program and develop support services for pregnant women. Her work helped Hispanic families obtain better health care and eased tensions with the local community. The faculty member engaged health profession students in these service activities, and helped create a class on rural and underserved care. In addition to writing and obtaining grants, she presented her service work at conferences and published relevant articles in peer-reviewed journals. She was promoted with an area of excellence in community service and scholarship in research.
In 2004, the school of medicine revised its tenure and promotion guidelines for all departments, using a template similar to the one created by the Department of Family Medicine. Community professional service has been added to the list of areas in which faculty members may demonstrate excellence and productivity to be promoted on the fixed-term (nontenure) track. These revised guidelines do not mandate that all departments allow promotion for excellence in community professional service; rather, they permit departments to recognize this dimension. Individual departments are given leeway in how to define professional community service. Also these revisions do not apply to tenure track promotion, where the more rigid criteria of the university apply. Despite these caveats, these changes signal a formal recognition throughout the school of medicine of the importance of community service.
The department's involvement with community service continues to evolve, particularly as it seeks ongoing ways to incorporate service activities across its program activities. For example, the predoctoral section, supported by Title VII funding, established a program with multidisciplinary faculty called Education for Lifelong Service, with a mission to help medical students acquire the skills needed to effectively provide service to underserved communities. (More information about this program may be found at 〈www.fammed.unc.edu/service〉.) Two faculty members recently initiated a service–learning leadership elective in the medical school whereby student leaders in service organizations learned advanced leadership concepts through lectures, discussions, guest lecturers, reflection, and application of the concepts. The department's faculty advisors to SHAC also recently worked with students to develop a partnership with Habitat for Humanity via a four-year grant from the Association of American Medical Colleges’ community service program. This partnership has built four Health for Habitat houses in an underserved rural community, has involved over 200 interdisciplinary health affairs students in community service, and has inspired the creation of an endowment of over $100,000 in less than two years. Finally, an ad-hoc service research group has evolved in the department. The group meets monthly and has designed several research studies with multiple articles submitted for publication. From a measurement perspective, most of these successful activities have been process measures. As discussed further below, it takes longer to measure the success of community involvement by depending solely on outcome measures. Institutionalizing a commitment to service would not have been possible had the departmental leadership not been willing to recognize process measures such as grant procurement, community partnership building, and course development. Nevertheless, it will be important to attempt to measure long-term outcomes such as community relationships with the department as well as health outcomes in the community.
As we reflect on the process that led our department to recognize community service as an explicit part of its mission, we see a number of important lessons that we learned. Understanding these lessons might help other academic departments as they attempt to make their activities more community responsive.
Lesson 1: If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures.
Although many individual faculty may be devoted to the concept of community service, until there are organizational structures in place to support service, many faculty will be discouraged from engaging with their communities. For departments desiring to increase their involvement with community service, creating a mission statement that reflects a focus on service is crucial. As pointed out by Bhat-Shelbert et al.,13 mission statements help define the organization's purpose and basic philosophy. Changing a mission statement is the work of more than one or two people, but as was the case in our department, a commitment to service often becomes apparent only when consciousness is raised on the topic. One or two members in a department can uncover and promote much latent interest in this area and thus build a critical mass that works to change the mission statement.
In addition, incorporating community service explicitly into the reward system for faculty can remove obstacles to service. By incorporating community service into promotion and tenure guidelines, we allowed faculty who were already performing a significant amount of service to be recognized for their activities and encouraged others who might be so inclined to make community service a more central part of their work. Recognizing specific community service activities as a routine part of faculty members’ responsibilities, such as our department did with SHAC, can also increase faculty members’ ability to engage with the community.
Lesson 2: Community engagement can be scholarly.
There are natural connections between community engagement and the traditional academic missions of teaching, research, and clinical care, as articulated by Calleson and colleagues in their article in this issue of Academic Medicine.5 Teaching related to community service is frequently referred to as service–learning. Service–learning is a structured learning experience that combines community service with preparation and reflection.14 Community engagement related to the research mission is called community-based participatory research. This type of research is a collaborative approach to research that equitably involves members of the community and academic researchers.15 Community engagement that relates to the clinical mission is referred to a community-responsive clinical practice. This type of clinical care truly engages the community and exemplifies an awareness of and responsiveness to the needs of the local community.
In retrospect, we realize that we now enjoy multiple linkages and connections between community service and our academic work, including service–learning teaching, community-based participatory research, and community-responsive clinical practice. It is also clear that our biggest step towards engaging with local communities was made when we understood that such work was not “unacademic” after all.
Lesson 3: If faculty are to be recognized for their service activities, measures are necessary to determine what constitutes “excellence” and “scholarship” in community service.
This lesson emphasizes that it is important to ensure that engagement with local communities is appropriately scholarly for an academic department and extends in quality beyond the service activity that might be expected of all faculty. While most of the UNC Department of Family Medicine's community service initiatives would not be rewarded or academically validated in traditional AHCs, the revision of promotion and tenure guidelines has allowed such work to be recognized under “excellence in service.”
But there is a lack of clarity on how academic efforts should be judged as successful by peers and how the scholarship of community engagement differs from more traditional academic scholarship. This lack of clarity has been a barrier to some faculty members’ pursuing scholarship in this area. To ameliorate this difficulty, Calleson et al.5 emphasize the importance of adding process measures to the traditional scholarly outcome measures when assessing the performance of community engagement. An example of a process measure might be how effectively relationships were built with the community. Community leaders can be surveyed on their views of project progress and how conflicts were resolved. Community focus groups can elicit perception of the project by the broader community. Other examples of process measures might be the way in which input was solicited from the community and how resources were shared with the community. How were community suggestions incorporated into the project design? What portion of grant monies went to support community members? This is a shift from the traditional model of tenure and promotion evaluation, which largely emphasize the importance of end-products, such as the number of published peer-reviewed journal articles, national presentations, and a funding track record—and pay little attention to the process required to get there.
Such a shift stems, in part, from necessity. The result of community engagement can often take many years to complete, and these delays do not easily respond to the administrative need to include accomplishments and productivity in the usual tenure cycle. But perhaps more important, process measures in scholarship of community engagement have their own direct relevance. As mentioned in the beginning of the article, the profession seeks to regain public trust through greater community involvement. Measuring public perception of scholarly work in communities is a very direct proxy of this public trust. The faculty member who skillfully and respectfully builds community partnerships is building local goodwill, fostering empowerment, and potentially creating new methodologies, regardless of that eventual project's outcome. The future challenge is to arrive at process measures that reflect the wide range of community engagement activities. Process measures used by our department, such as securing grants, creating community partnerships, and developing service–learning courses, are a step in that direction. We hope that other departments around the country will develop new ways to measure the process of developing community relationships.
Lesson 4. Scholarship of community engagement goes beyond performing service activities in the community.
To truly engage with communities, academic departments should not be contented with faculty achieving “excellence in service.” Examining the impact of this work and sharing it with colleagues in a peer-reviewed setting constitutes the scholarly work that is at the core of academic departments and should be promoted for the area of service as well.5 According to Diamond and Adam,16 scholarship requires a high level of discipline-related expertise, breaks new ground or is innovative, can be replicated, documented, peer-reviewed, and has significant impact. Using this definition, many activities related to community engagement would be scholarly. We are currently working with faculty who have excelled in service to promote this concept. For an example, one faculty member has excelled by volunteering in her community in many capacities, such as starting an Albert Schweitzer chapter in our area. With her grant writing skills, she has raised substantial amounts of money for the community. Though she excelled in her work, she had difficulty developing scholarly projects within the AHC. Only recently did she begin to understand that she need look no further than her work with communities to find recognition as a scholar.
It Can Be Done
Community service can be made an integral part of any academic department. Some faculty may pursue excellence in service as others pursue excellence in teaching without making this an area of scholarship. But as we have pointed out in this article, most aspects of community service also have scholarly potential. Our case report shows that the institutional changes required to integrate service into the academic mission of a department are not necessarily difficult and can be initiated by tapping into the latent interest in service that may already exist among the faculty.
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16 Diamond RM, Adam BE. Recognizing Faculty Work: Reward Systems for the Year 2000. San Francisco: Jossey-Bass Publishers, 2000.
*The mission of the Department of Family Medicine is to promote the health of the people of North Carolina and the nation through leadership and innovation in clinical practice, medical education, research, and community service. As an instrument of the State of North Carolina, we are concerned with both the current needs and future generations and have a special commitment to the underserved, mothers and children, the elderly, and other populations at risk in a time of rapid changes in the organization of health care.