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Invited Commentaries

Now Is Our Time to Act: Why Academic Medicine Must Embrace Community Collaboration as Its Fourth Mission

Alberti, Philip PhD1; Fair, Malika MD, MPH2; Skorton, David J. MD3

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doi: 10.1097/ACM.0000000000004371
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Abstract

Academic medicine’s mission of serving the nation’s health has traditionally had 3 parts: (1) medical education, (2) research, and (3) clinical care. Recent events have clearly demonstrated that these missions are no longer enough, standing on their own. Something must change—and in a significant way. In fact, in his Leadership Plenary speech at “Learn Serve Lead: The Virtual Experience,” the annual meeting of the Association of American Medical Colleges (AAMC) in November 2020, president and CEO David Skorton’s refrain was, “Now is our time to act.” This message came in the wake of the theme of his 2019 speech: “The status quo is unacceptable.”

The need for change is clear and unavoidable. Long-standing discrimination against marginalized communities has contributed to dramatic health inequities in this country. Asthma, diabetes, obesity, and hypertension, for example, are more likely to affect Black adults than White adults. 1 Native Americans are more likely to die from communicable diseases like influenza, pneumonia, and chronic lower respiratory diseases than the general population. 2 And the pernicious effects of poverty affect the current and future health and prospects of many.

We can no longer ignore these inequities. All of us are part of one big community—whether we treat each other equally or not—yet many of us are not thriving. The problem is so complex that a single intervention or solitary action by any one sector or individual will not address it. When we understand that the fundamental causes of rampant health inequities involve intricate and long-standing factors like poverty and systemic racism, we recognize that we, in academic medicine, cannot solve this problem on our own.

Instead, to inculcate effective change, academic medicine must integrate with communities, collaborating and co-creating in more in-depth, ongoing ways. We must do more than we historically have done to share expertise, resources, and responsibility for achieving shared goals with communities and across sectors through interactions built on trust, mutual respect, cultural humility, and mutual benefit. A fourth and crucial component must join academic medicine’s mission areas: community collaboration.

The University of Puerto Rico’s response to Hurricane María is one example of what can be accomplished through successful community collaboration. When Hurricane María hit, the school drew upon its existing, deeply embedded relationships and resources within the community to respond to the island’s most immediate needs. With clinical guidance from faculty and residents, students organized a supply command center staffed by interdisciplinary teams who learned from community members they already had relationships with what supplies were needed and where. 3 Such efforts ideally unite all sectors of the health ecosystem (e.g., housing, food suppliers, infrastructure, the private sector, medical care, public health) to solve problems in an integrated way. Like the University of Puerto Rico, many institutions have made some progress, but we must do more and achieve more.

It is time for academic medicine to elevate this work as a core component of our mission and to expand what we can achieve through efforts like this. We must do more because the lived experiences of our patients who have been marginalized and harmed in society and in our health care system are not emphasized adequately within the traditional tripartite mission of academic medicine. We saw this clearly as educational, income, and criminal justice inequities were forced into the national spotlight during 2020, with health inequities prominent among the headlines. Community collaborations are more vital than ever.

Why Community Collaborations Matter

Health happens outside the exam room

Evidence suggests that much of a person’s health is related to many factors other than genetics and medical care—factors sometimes called social determinants of health (or, increasingly, “vital conditions for health”). 4 These factors, like safe transportation, clean air and water, education, and job opportunities, significantly influence health. For example, Native Americans are 19 times more likely than White people to lack indoor plumbing, making handwashing as a disease prevention strategy difficult. 5

Because only roughly 20% of a person’s health can be attributed to the health care we provide, improving health equity does not end with what we can achieve through the traditional missions of academic medicine, as important as they are. 4 In fact, research shows that 50% of a person’s health is determined by a combination of socioeconomic factors and their physical environment. 6 If we wish to achieve health equity, we must ensure that no community is disadvantaged from achieving its full health potential because of social position or circumstances. 7 In the mid-1990s, Link and Phelan suggested that, if the goal of public health is to improve the health of populations, it will never be achieved by addressing 1 individual risk behavior at a time. Rather, we should focus on what puts communities at risk of risk. 8

Solutions happen outside the exam room, too

We will never be able to ask the right research question, make the right diagnosis, fully explain the pathophysiology of disease, or develop the best treatment plan if we do not have the full story in mind. For too long, the medical community has chosen health goals for our patients, their families, and our communities. We have set standards influenced by our biases, our definitions, and our training. By default, our solutions can be 1-sided, and their salutary effects, however well intentioned, will not last.

There is a better way. When Michigan State University (MSU) College of Human Medicine built its Flint, Michigan, campus in 2014, the school recruited community stakeholders to make up half the research faculty search committee, along with representatives from the university, area hospitals, and government. Establishing partnerships with the community from the start of the school’s presence in Flint soon proved crucial when MSU researchers found alarming increases of lead levels in children’s blood and asked the state government to find a safer water source for the city. MSU continued to build on these mutually beneficial relationships with a collaborative public health program to mitigate the long-lasting health consequences of the water crisis. 9 Because MSU partnered with those who knew the on-the-ground realities best, members of the community and MSU faculty and researchers were able to navigate the most difficult obstacles together. This kind of disaster preparedness is especially crucial when our nation is faced with significant public health challenges, such as a novel coronavirus. If we approach community collaborations with a posture of humility and seek to value and appreciate the lived experiences of our patients and their families, our colleagues, and our communities, we create space for meaningful partnerships to achieve health equity.

Where Do We Go From Here?

The examples of community collaborations provided in this commentary are a step in the right direction. However, making one small impact in one individual community does not achieve health justice for our broader society as a whole. Instead, we need an expansive movement catalyzed by widespread community collaborations and framed by the local expertise and wisdom of the people we serve; those who experience health injustice are those closest to the solutions to that injustice. Because the obstacles we face are complex, those solutions must be multifaceted. We must pull together a multisector team to develop a long-term, aligned, mutually beneficial agenda to achieve lasting impact through policy and practice changes at all levels—organizational, tribal, local, state, and federal. Finally, these collaborations must embrace the reality that change is constant, and so we must remain vigilant, constantly evaluating and revising our strategies to adjust to evolving circumstances. Medicine, and academic medicine specifically, has unique and necessary, though insufficient, tools and resources to contribute to this effort. To achieve health justice, leadership is partnership.

Bridging the Gaps Across Sectors

To be successful in this effort, academic medicine must partner more, and more deeply, with public health, government, grassroots community groups, and the private sector. The medical care and public health communities have not always worked together optimally, but the AAMC and collaborating associations are beginning dialogue aimed at changing that. An ongoing, in-depth partnership is needed to fix what is broken in the U.S. health system.

AAMC efforts

The AAMC is dedicating significant resources and effort toward the community collaboration component of the mission of academic medicine. As part of the AAMC’s new strategic plan, we are prioritizing and deepening our efforts to advance this mission, committing the AAMC to national leadership in health equity and health justice. One way we are demonstrating this is by creating the AAMC Center for Health Justice to make progress on initiatives advancing the moral, financial, and societal imperative of health justice. The center will focus on community-engaged, multisector efforts to co-create solutions to health inequities and improve population and community health. In May of 2021, the center released the Principles of Trustworthiness (www.aamc.org/trustworthiness) to help organizations of all kinds demonstrate they are worthy of their community’s trust—the necessary foundation for effective collaborations and partnerships. 10

What institutions can do

Leaders of academic medical institutions can hold themselves accountable for weaving community collaborations consistently throughout the mission areas of clinical care, research, and education and for standing up the fourth mission of community collaboration. In this section, we offer recommendations to those at all levels of their institutions for incorporating community collaboration into each of the mission areas.

Clinical care.

If you work on the clinical side, take the time to really listen to community residents and patients describe their experiences with the medical center. Find out what patients and their families truly need and want and use that information to train all those involved in clinical care. Familiarize yourself with relevant and granular data to understand the communities you serve and the upstream factors affecting their health.

Education.

The medical students and residents at your institution should align their community health outreach or service-learning projects with the institution’s community health needs assessment and should partner with community-based organizations that have a sustainable commitment to eliminating health inequities. You can also partner with local schools and colleges to encourage health careers for students who are underrepresented in medicine and from marginalized communities, which will ultimately increase diversity and inclusion in the health workforce.

Research.

To increase the relevance and impact of research discoveries for your larger community, think about the following questions:

  • What makes patients, their families, and communities from marginalized groups concerned about participating in clinical trials?
  • How deeply are community members and patients involved in the development of your research—from the development of the research question to the implementation, analysis, and dissemination of the study?
  • Are you sharing study results with the community and engaging in a back-and-forth dialogue about what the results mean for them?

Community collaborations.

You can work with community residents and organizations to advocate for policies that improve health and health equity locally. You can also integrate community collaboration into leadership-level decisions, as MSU did in Flint by involving community members on the research faculty search committee. Examine hiring practices, procurement, and investments according to community priorities and partner with community organizations to address the social determinants of health (e.g., invest in transportation infrastructure).

For example, the University of Wisconsin School of Medicine and Public Health integrates public health into its mission. Its Wisconsin Alzheimer’s Institute has spent years building relationships, engaging the community, and focusing on developing trust as its priority. It has since reaped the benefits of these efforts, now having grown the number of African Americans participating in the Institute’s Alzheimer’s disease research from 2% to 10%. 11 As another example, Henry Ford Health System partnered with several institutions to revitalize local neighborhoods by improving transportation, updating façades, and rehabilitating housing developments for Detroit residents. 12 Programs like these prove the power of genuine partnership.

Consider how you can collaborate more with those outside the walls of your institution and beyond its traditional boundaries. How can your organization build a strong network of collaborators across sectors? How will you seek out diverse insights and translate them into concrete, measurable actions that make a difference?

Taking Action to Achieve Change

Embracing community collaborations as academic medicine’s fourth mission provides an opportunity to reimagine what optimal health can be—together. Doing so is the only way to comprehensively fix what is broken in the U.S. health system and make meaningful progress toward achieving health justice for all.

Now is our time to act.

Acknowledgments:

The authors thank Sarah Burstyn, copy editor, Association of American Medical Colleges, and Kristin Zipay, lead writer for executive communications, Association of American Medical Colleges, for their editorial support for this piece.

References

1. Gould E, Wilson V. Black workers face two of the most lethal preexisting conditions for coronavirus—Racism and economic inequality. Economic Policy Institute. www.epi.org/publication/black-workers-covid. Published June 1, 2020. Accessed August 6, 2021.
2. Indian Health Service. Disparities. www.ihs.gov/newsroom/factsheets/disparities. Published October 2019. Accessed August 6, 2021.
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7. Centers for Disease Control and Prevention. Health equity. www.cdc.gov/chronicdisease/healthequity/index.htm. Accessed August 6, 2021.
8. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94.
9. Association of American Medical Colleges. 2016 Spencer Foreman Award for Outstanding Community Service. www.aamc.org/what-we-do/aamc-awards/spencer-foreman/2016-michigan-state-university-chm. Accessed August 6, 2021.
10. Association of American Medical Colleges. The principles of trustworthiness. www.aamc.org/trustworthiness. Accessed August 6, 2021.
11. Wisconsin Alzheimer’s Institute, University of Wisconsin School of Medicine and Public Health. WAI Regional Milwaukee Office. https://wai.wisc.edu/wp-content/uploads/sites/1129/2020/01/Milw-Office-handout-Overview.pdf. Accessed August 6, 2021.
12. National Academies of Sciences, Engineering, and Medicine. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017;399.
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