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Perspectives

Putting Communities in the Driver’s Seat

The Realities of Community-Engaged Medical Education

Strasser, Roger MBBS, MClSc; Worley, Paul MBBS, PhD; Cristobal, Fortunato MD; Marsh, David C. MD; Berry, Sue MCE; Strasser, Sarah MBBS; Ellaway, Rachel PhD

Author Information
doi: 10.1097/ACM.0000000000000765
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Abstract

In 2010, the Lancet Commission on Education of Health Professionals for the 21st Century recommended that academic institutions build strong relations with communities to provide a context for education programs focused on achieving health equity.1 In this Perspective, we present community-engaged medical education (CEME) as an emerging set of philosophies and practices that addresses many of the Lancet Commission’s recommendations. In doing so, we explore the developing focus on “community” in medical education, describe CEME as a concept, present examples of the implementation and implications of CEME at three medical schools, and highlight these schools’ successes in advancing the Lancet Commission’s recommended instructional and institutional reforms.

From Community-Based to Community-Engaged Medical Education

The 1910 Flexner Report’s recommenda tions that medical schools should be university based and that their education programs should be grounded in scientific knowledge set the trend for medical education in the 20th century.2 Since then, the first half of undergraduate medical education programs has been largely classroom based with a focus on the basic sciences, whereas the second half has involved students learning clinical medicine in teaching hospitals where they are taught by physicians who use the scientific method in patient care and research. Subsequently, medical schools have become more homogeneous, following a scientific rather than a practical philosophy of medicine and focusing on biomedical rather than community dimensions of health and medical care.3 Medical schools that did not or could not conform to this standard model closed, which reduced the number of women’s and minority medical schools.4

The centenary of the Flexner Report was marked by a number of new perspectives that considered the potential directions medical education should take in the 21st century.5–7 The Lancet Commission report1 was notable among them, linking proposed new directions to achieving “health equity within and between countries” and concluding that both instructional and institutional reforms are required to produce graduates who are agents for change. By explicitly linking medical education to social change, the Lancet Commission sought to reposition medicine and medical education as responsible for health in a broader sense than had previously been considered either legitimate or desirable.8 The Lancet Commission1 also recommended that medical education programs should be “locally driven for a global workforce market,” with clinical education occurring in remote, rural, and suburban settings as well as in urban academic medical centers. The concept of “community” was central to these recommendations.

“Community” can mean many things to many people in medical education. Some view community as simply a locality or setting where patients are,9 some consider it to be everything outside the tertiary care environment,10 and others see it as an essential social construct that deserves as much attention as the individuals within it.11 It is this third concept of community as a social construct in medical education that underpins the vision of the Lancet Commission.

“Community” has featured in the discourse about medical education for over half a century. In the 1960s and 1970s, community-oriented medical education (COME) described medical students learning about community contexts and their impact on the care of patients from different cultural and social backgrounds.12 The Network: Towards Unity for Health began in 1979, at the instigation of the World Health Organization (WHO), with a group of 19 medical schools that implemented COME.13 However, over time, the term “COME” was used to describe an increasingly broad range of educational models that were related in some way to a community context but with a diminished precision as to what, specifically, COME involved.14,15

Expansion of COME concepts in the 1980s and 1990s led to what came to be called community-based medical education (CBME). This described programs that aimed to enhance students’ learning by placing students in communities, in contrast to programs in which students learned about communities from afar. CBME extended the range of potential clinical learning environments to include mental health services, long-term care facilities, and medical clinics as well as hospitals and health services in remote, rural, and urban communities.16 CBME emerged at a time when medical student numbers were increasing and there was a growing recognition that a relatively small proportion of the population was being cared for in acute care teaching hospitals.17

CBME also explored the extent to which students could benefit from prolonged community-based learning, typically in family practice settings. This approach was developed in the urban setting at Cambridge University in England,18 and it became part of the “rural tracks” established by a number of U.S. medical schools.19,20 In the 1980s, community-based education and service developed in Africa with the goal of “producing students with a sense of service and a strong inclination toward broad community care and preventive medicine.”21

CBME has been described as the “engine” of the COME “car.”14 However, medical schools tended to assume the driver’s seat in developing community-based experiences for their students, and it was unclear in many cases whether communities were even in the car at all. Extending this metaphor, communities tended to be destinations or to be passive passengers, with medical schools referring to professional standards and quality in response to any attempts at backseat driving by communities.

CEME emerged as a third-wave model during the first decade of the 21st century. The CEME concept stresses the importance of interdependent and reciprocally beneficial partnerships between medical schools and the communities they serve.22 In CEME, community involvement is a fundamental part of setting a medical school’s education, research, and community development missions. CEME seeks to address power inequities between academies and their community partners by supporting the alignment of students’ learning objectives and activities with communities’ health care needs and by encouraging students to develop the skills and motivation to practice in specific community settings. CEME also requires communities to contribute directly to students’ learning about the local social determinants of health. The CEME agenda is broadly consistent with the WHO model of social accountability in medical education23,24 and the Lancet Commission’s recommendations.1

CEME in Practice

We have described the emerging discourse around the intersection between medical education and communities. With COME, the medical school considered a community’s needs at a distance. It described and measured the community’s needs, defined their causes, and critically appraised measures to address them. In CBME, the medical school coexisted with the local health care system, with communities acting as the passive hosts of the school’s students. In CEME, the community (including but not limited to the local health care system) is actively involved in the medical school’s activities and co-creates the school’s missions, priorities, and outcomes. This represents a higher level of accountability for medical education to society (in the form of specific communities), as well as a framework for medical schools and communities to identify and pursue shared goals.

CEME is not just an aspirational concept, however; it is a reality in a growing number of medical schools. The following examples illustrate CEME in action in three countries.

Flinders University School of Medicine (Australia)

Flinders University School of Medicine, in the city of Adelaide in the state of South Australia, was founded in 1974 on the academic health science center model. In the context of chronic shortages of rural practitioners, Flinders pioneered a form of rural CEME in South Australia in the mid-1990s. Students participating in the Parallel Rural Community Curriculum (PRCC) undertake the entire third year of the four-year medical education program living in one rural community where they are based in the family practice setting (with other specialists as consultants in the education process).25 The learning objectives for the PRCC are the same as those for students undertaking their third year in the urban teaching hospital (Flinders Medical Centre in Adelaide).

The PRCC has been shown to provide learning experiences and outcomes that are equivalent to, if not better than, those in the metropolitan teaching hospital. For example, PRCC students consistently outperform their teaching-hospital-based colleagues in end-of-year examinations.26 They are also five times more likely than their peers to choose careers in rural practice (both in primary care and hospital-based specialties), an outcome highly valued by underserved rural communities.27

The success of the PRCC led Flinders to expand its CEME programs to cover the entire 2,000-mile north–south central corridor of Australia. This expansion includes establishing a major presence at a community health center in the underserved outer-suburban areas of southern Adelaide and teaching the entire four-year medical education program in Darwin, the capital city of the remote Northern Territory. CEME in the Northern Territory has emphasized working with Indigenous people to recruit higher numbers of Indigenous students into the medical education program and to ensure that graduates are equipped to contribute to closing the gap in Indigenous health outcomes in Australia.28 The PRCC’s rural CEME philosophy is the model underpinning clinical teaching in the Northern Territory and outer-suburban Adelaide. At Flinders, CEME began with 8 third-year students per year in the 1990s; now, in 2015, CEME involves 32 students in rural South Australia, 24 students in Adelaide, and 32 students in the Northern Territory.

Research into the PRCC has shown that the success of students learning medicine in communities is based on student–teacher, student–student, and student–community relationships that have clinical, institutional, social, and personal dimensions.29 The community plays a pivotal role in these relationships by motivating and giving meaning to students’ learning and career choices. Examples of community involvement include community participation in selection of students, community mentors who volunteer to provide students with local orientation and insights, and community liaison committees which provide local oversight of the academic program.

Northern Ontario School of Medicine (Canada)

Northern Ontario, a geographically vast region (> 300,000 square miles), is known for its resource-based economy and socioeconomic characteristics which differ markedly from those of the rest of Ontario province. Forty percent of Northern Ontarians live in rural and remote areas in diverse communities and cultural groups, including Aboriginal and Francophone communities. The overall health status of Northern Ontario communities is below that of communities in the province as a whole—a problem that has been exacerbated by a chronic shortage of trained health professionals in the region. The Northern Ontario School of Medicine (NOSM) was established in 2002 with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario.30 NOSM views the whole of Northern Ontario as its campus. It serves as the Faculty of Medicine of Lakehead University in Thunder Bay, Ontario, and of Laurentian University in Sudbury, Ontario, which is 700 miles from Thunder Bay.

NOSM engaged Northern Ontario communities in the development of its academic programs from the outset, starting with a three-day curriculum workshop attended by over 300 participants drawn from communities across the region. Community-engaged consultations have continued through regular workshops involving a wide range of community partners, including members of the local Aboriginal and Francophone communities. Community members play a vital role in selecting students for the four-year MD program, participate in students’ training by serving as standardized patients, and provide local support for students during their community placements. During the eight-month Comprehensive Community Clerkship (CCC), each third-year student is placed in 1 of 15 communities to learn core clinical medicine from a family practice and community perspective. Students follow patients and their families encountered in the primary care setting over an extended period of time, engaging with a range of community medical specialists and health professionals, so as to experience continuity of care in family practice while also studying different clinical specialty disciplines. Much of the CCC program is devised by and in partnership with the host communities.31

The success of the CCC approach is reflected in many ways.32 NOSM students perform above the national average in national licensing exams, and in most years all graduating students have been matched to residency programs in the first round of the Canadian Resident Matching Service. Between 2009 and 2014, 62% of NOSM graduates chose family medicine (and predominantly rural) training, almost double the Canadian average. Since 2009, 70% of NOSM residents (both NOSM graduates and those from other medical schools) have chosen to practice in Northern Ontario after completing their training (including 22% choosing small rural communities), and some have become NOSM faculty members. As indicated above, CEME has been a part of the NOSM curriculum from the start; it has contributed to the quality of medical education, helped ensure the sustainability of the program, and provided benefits to the many participating communities.

Ateneo de Zamboanga University School of Medicine (Philippines)

The Ateneo de Zamboanga University School of Medicine (ADZU SOM) in Zamboanga City in the Philippines operates CEME on principles similar to those of Flinders and NOSM but does so with much greater resource constraints. ADZU SOM is the regional health care center for Western Mindanao and the Sulu Archipelago, which is one of the most underserved areas in the South Pacific and has poor health statistics and chronic health workforce shortages. At ADZU SOM, biomedical aspects of the treatment of disease are taught within the social, cultural, political, and community environments. Students learn that whereas the treatment of immediate medical symptoms is biomedical, the production and ongoing integrity of individual health and community health status are inextricably linked to broader social conditions. The medical education program is driven by a social determinants of health model with a view to ensuring that students learn to be responsive to community health care needs.33

Community engagement occurs throughout the four-year program. Commencing in the first year, students develop community projects and do much of their clinical learning in small rural communities. This engagement culminates with students living in these same small communities for the entire fourth year while they implement the community projects they started developing in their first year. The student-initiated projects are intended to solve major community health issues, drawing heavily on the social capital available in the community. Examples include building pit latrines, improving access to potable water, developing solid waste management policies for local governments, increasing immunization rates, determining risk factors for tuberculosis, developing cottage industries to generate income, and creating home vegetable gardens.

ADZU SOM admitted its first students in 1994, and students’ performance on national board exams has been consistently above the national average.33 Over 90% of the school’s graduates continue their training and clinical practice within the region.34 This is remarkable in the Philippines—the majority of graduates of the other 37 Philippine medical schools leave to work abroad as soon as they graduate.33 In addition, the infant mortality rate in this region has declined (from 75 per 1,000 in 1995 to 8.2 per 1,000 in 2008) and shows significantly greater improvement than national improvement figures, which is attributable in part to the medical school.34 However, CEME is challenging in this politically unstable region. For six weeks in 2013, ADZU SOM was situated in the cross fire between Moro National Liberation Front rebel factions and government forces. Equipped with a population health care perspective, the faculty and students weathered the crisis while treating the sick and injured.

Challenges of Community Engagement

Despite the many advantages of community engagement, implementing CEME has its challenges. The development of relationships with host communities is complex and context dependent. For instance, all three medical schools described in this Perspective developed their approaches to CEME in and for distributed and rural contexts where the geography of a community is that community’s key identifying characteristic. For medical schools in urban centers, community may be more a matter of culture or ethnicity than geography. Communities also have different needs and values. The criteria for community engagement must therefore be sensitive to local variations in academic and medical cultures, as well as the nature of the social contract in different settings.

Community leaders and members need to be persuaded that the medical school is serious about building meaningful relationships and partnerships. This requires considerable discussion, during which all stakeholders must be free to ask questions and challenge assumptions so that they can come to understand each other’s perspectives. In this process, geographic, social, and cultural diversity should be viewed as strengths and opportunities rather than as impediments or barriers to cooperation and collaboration.

Successful CEME depends on medical schools engaging communities as genuine contributors and as shared decision makers. This is facilitated by formal affiliation agreements, as well as open and frequent discussions and regular face-to-face contact between medical school representatives and community members. CEME also needs to be adaptable to accommodate situations in which a community (or, for that matter, a medical school) is not a coherent and uncomplicated whole. In such situations, dissent and division should be understood as strengths rather than weaknesses, as they can enhance students’ understanding of the social realities of the communities they will serve.

Both existing schools that move to become more community engaged (e.g., Flinders) and new schools that are established with a community-engagement mandate from the outset (e.g., NOSM and ADZU SOM) face challenges because physicians, hospitals, and communities are comfortable with historical norms and may resist the changed relationships inherent in CEME. For example, Flinders experienced opposition from specialist departments in Flinders Medical Centre that were concerned about losing status and resources. In the case of NOSM, many of the specialists in the larger Northern Ontario population centers had chosen their practice locations because they did not want to be in an academic health center.35 All three schools faced major difficulties in achieving national accreditation for their disparate and unconventional models of education.

We recognize that tremendous effort is required for an existing medical school to change its culture to be more community engaged. There are resources available to schools seeking to move in this direction. For instance, the Training for Health Equity network (THEnet) has developed, piloted, and published an Evaluation Framework for Socially Accountable Health Professional Education,36 which articulates many CEME principles in a practical way, and provides the core content of a Global Consensus for Social Accountability of Medical Schools.37 Flinders, NOSM, and ADZU SOM are among the founding members of THEnet.

Conclusion

The three examples presented in this Perspective demonstrate that CEME occurs in very different sociocultural settings and is effective in producing physicians who choose to practice in rural and underserved areas. Further research is required to demonstrate that CEME contributes to improved health, and ultimately health equity, for the populations served by the medical school. For ADZU, there is evidence of improved health status33; however, this has yet to be demonstrated for either Flinders or NOSM.

Although we focused on the Lancet Commission report1 as a particular catalyst for change, we acknowledge that it represents one of many initiatives seeking to establish more substantial connections between medical schools and communities. For instance, the U.S.-based Association of Academic Health Centers’ Social Determinants of Health initiative encourages its members to adopt a community focus in their programs.38 Health Canada has also set out a vision for the community responsibilities of Canadian medical schools.39

CEME is an ethical stance, both in terms of social accountability and of modeling the values of community engagement to successive generations of health professionals. CEME has the potential to address the challenges and opportunities of the social contract between the medical profession and society as a whole through genuine collaboration between communities and academic institutions around education, research, and service toward the goal of achieving health equity. Whether CEME will become a required part of the missions of medical schools is beyond the scope of this article. However, an institutional commitment seems to be a key success factor for CEME as there have been many CEME-like initiatives40,41 that have not translated into an institution-wide approach to community engagement.

In this Perspective, we have shown that CEME can be a practical means by which medical education is socially accountable, communities are served, and national and international health equity agendas can be advanced. We have also demonstrated that CEME can redefine student learning as taking place at the center of partnerships between communities and medical schools.

Acknowledgments: The authors wish to acknowledge the relationships with all of their many community partners, without whom their work and the successes reported in this article would not have been possible.

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