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Invited Commentaries

Normalizing Service Learning in Medical Education to Sustain Medical Student-Led Initiatives

Nguemeni Tiako, Max Jordan MD, MS1; Johnson, Shawn F.2; Nkinsi, Naomi Tweyo3; Landry, Adaira MD, MEd4

Author Information
doi: 10.1097/ACM.0000000000004432
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Abstract

Service learning is an education method that incorporates community outreach with didactic coursework and student reflection; this approach has been proven effective in many health professions education programs. 1 The disruptions to medical education brought on by the COVID-19 pandemic have allowed for service learning to rise to the fore of medical schools. Students have leveraged their networks and prior experiences to canvas for personal protective equipment, provide childcare for frontline workers, and engage in patient education and community outreach. 2,3 At the same time, facing one of the largest social movements in U.S. history following the murder of unarmed George Floyd by the police, 4 many medical schools have stated their renewed commitment to antiracism. 5

Before the COVID-19 pandemic, however, a debate had arisen among leaders in medicine about the role of social issues in the curriculum. Some argued that medical education should not concern itself with addressing social issues that “relate to health care only tangentially.” 6 An April 2020 article in The Wall Street Journal even posited that “doctors should learn to fight pandemics, not injustice,” as an explanation for why the United States might have been unprepared to fight the COVID-19 pandemic. 7 Yet, injustice and inequality have only made the pandemic worse. 8 For instance, a significant proportion of the COVID-19 cases in Chicago early in the pandemic were linked to jail cycling through Cook County Jail, a feature of mass incarceration. 9

Medical students’ long-standing commitment to service learning and addressing social issues has contributed tremendously to the communities they serve. In this commentary, we discuss the history of medical student-led service-learning efforts through to the present day, barriers to implementing and sustaining student-led service-learning initiatives, and solutions to prepare students for service-learning initiatives.

History of Medical Student-Led Service-Learning Initiatives

The Civil Rights Movement and antiwar efforts of the 1960s ushered in a new era of medical student advocacy that would have a lasting impact on medicine and medical education. In 1965, a group of students from medical and nursing schools across the United States formed the Student Health Organization (SHO). 10 The mission of the SHO was to redefine health in the context of the social determinants of health, rather than simply the absence of disease. The SHO grew to have a presence in 40 states, producing 60 independent newspapers and involving thousands of medical students. It also organized Summer Health Projects, which were modeled after the Student Nonviolent Coordinating Committee’s Mississippi Summer Project, in that they aimed to provide education to vulnerable communities about health issues and available resources, demonstrate the relationship between medicine and society to students, and inspire systemic changes within the health care system, as the Mississippi Summer Project did for voting rights.

Supported by federal agencies and medical schools and in collaboration with community health workers, the SHO aimed to raise health awareness within communities, help medical students gain greater insights into the relationships between medicine and society, and challenge the medical establishment to confront the failings of the U.S. health care system. 10 These students challenged curricula at their respective medical schools and fought the American Medical Association’s (AMA’s) opposition to the passage of Medicare. Members of the SHO pressured professional leaders to integrate the ideals of the Civil Rights and antiwar movements into medicine and medical education. Ultimately, the SHO’s efforts contributed to the AMA and the Association of American Medical Colleges creating minority affairs offices with a focus on community health, adding student representatives to committees, and encouraging the leadership of medical schools to undertake similar initiatives.

SHO members later joined the free clinic movement and worked at the Peoples’ Free Medical Clinics organized by the Black Panther Party. 10 These clinics, staffed by medical students, nursing students, volunteer physicians, and volunteer nurses, served as a model for contemporary student-run free clinics (SRFCs). Today’s SRFCs serve an essential role in providing health care to marginalized patient populations; the need for such services was partially created by the for-profit business models of students’ home institutions. 11 As of 2014, there were at least 106 SRFCs across 141 medical schools. 12 Patients receive a range of services, including outpatient medical care and pharmacy, laboratory, and social work services, and medical students fulfill various needs, including clinical operations, public relations, community outreach, and pharmacy management.

Besides SRFCs, medical students continue to advocate for health equity and increased health care access in other ways. One recent example is the Duke Hotspotting Initiative at Duke University School of Medicine. 13 First-year medical students act as liaisons and collaborate with patients to help them set and monitor health goals, identify and address barriers to accessing health resources, and efficiently access primary care. In addition, at the national level, medical student delegates contributed to the AMA’s adoption of an antiracism mission statement and commitment to implementing policy and organizational changes aimed at promoting health equity. 14,15 These contemporary medical student-led efforts have striking similarity to those of the 1960s, in that they include political activism, the provision of free health care, and nonmedical care work.

In contrast to criticisms that these activities are a negative divergence from traditional medical education, we argue that such advocacy efforts are essential for the development of junior trainees. Clinical opportunities that allow students to engage in advocacy and address patients’ social needs have the potential to produce better physicians. For example, a recent study of medical students suggested that volunteering with an SRFC sustained empathy. 16 In addition, medical students participating in the Duke Hotspotting Initiative indicated a significant increase in comfort with communication and patient advising, managing common chronic diseases, using interview skills, and assuming clinical responsibilities. 13

Barriers to Implementing and Sustaining Service-Learning Initiatives

The role of medical students as agents of change is evolving. Still, students often face barriers to implementing and sustaining service-learning initiatives despite the presupposed benefits of such work.

Medical school curricula

The incorporation of evidence-based service-learning content into medical school curricula would enhance students’ ability to cultivate an understanding of the core principles of this area of work. Service-learning content could focus on strategies of community engagement, program sustainability, and impact measurement. Specific topics could include political advocacy, quality improvement efforts, and grassroots community health. Medical students represent a national collective of young professionals with diverse prior experiences and insights. Yet, from our experience as students, mentors, and advisors, we recognize that students might feel restricted regarding their ability to effect change in the health care system. Building their interest and confidence in program development and advocacy is a useful strategy to create student leaders.

Consider a group of first-year medical students who want to launch a local diabetes screening program. They likely will have numerous questions. How do they conduct an initial needs assessment, engage with key community partners, ensure longitudinal implementation, and determine meaningful outcomes? Implementing such advocacy efforts, as well as developing the requisite leadership and organizing skills, should not depend on the resourcefulness of untrained students. Incorporating service-learning content into the curriculum would help these students develop and implement their program and measure its success.

Funding

Implementing new programs requires funding and partnering with organizations, such as local community groups, which often operate on limited budgets. In addition, health disparities research is significantly underfunded compared with other work. 17 Thus, student-led service-learning efforts and community collaborations often rely on charity funds or seed grants from various donors. 18,19

Measuring the effectiveness of these efforts is also important and requires time and allocation of funds. In a resource-limited setting, students may be inclined to prioritize securing funding for the program itself, while neglecting the important task of program evaluation, which requires human capital and expertise. Additionally, lack of funding limits potential opportunities to scale local student-led efforts. 12

Academic incentives

There can be discordance between what medical students are encouraged and required to do in preparation for residency applications and what is most effective in terms of longitudinal program development and community engagement. In addition, difficulty can arise when promising student-proposed or student-led work fails to get the recognition it deserves. For example, participating in a vaccination campaign that delivers preventative medicine to low-resource communities requires time and dedication, as does writing a scholarly paper. However, volunteering and publishing are not always regarded similarly by residency program directors. 20

Much of the work at SRFCs is important but not necessarily novel or associated with a titled position. The prioritization of students with publications over students with community engagement experience during the residency application review process 20 risks encouraging students to participate in novel programs that offer opportunities for scholarship rather than contributing to longitudinal community service programs, such as SRFCs. Further, projects related to advocacy and policy may receive fewer awards than projects related to other areas. 21 This barrier can have the greatest impact for students pursing specialties that expect applicants to have numerous publications and recognitions. Students applying to these specialties may worry about the impact on their application, specifically their letters of recommendation from prominent faculty and publications related to their research.

Furthermore, there is a direct conflict between the expectation that residency applicants will have high Step 1 scores, which are most valued by program directors in many specialties, 20 and the amount of time required to pursue service-learning endeavors that benefit the health of the local community. Indeed, medical students report spending a tremendous amount of time and resources studying for the United States Medical Licensing Examination and report that they would otherwise spend that time and effort on research and volunteering. 22

Solutions to Prepare Students for Service-Learning Initiatives

Curricular development

A standardized service-learning curriculum within medical schools would ensure that students have consistent and sustained exposure to such education. We advocate for service learning to be a required component of medical education, rather than having students opt in to such coursework. This approach would allow schools to implement structured mentoring in parallel to service-learning initiatives. From our experience, we have observed that students are often expected to create their own support networks if they want to engage in service learning. Integrated service-learning curricula would also create institutional memory and a sense of responsibility among administrators to support such programs long term.

As students transition to their clinical years, the time required to lead service-learning initiatives can be overwhelming and impossible to secure. This challenge can lead to program abandonment. Creating protected space and time in the curriculum could ensure that students not only see their projects to completion but also are able to pass them on to others for continuity.

Certainly, in mandating leadership and service experience for students, those who are uninterested in this work may struggle to meet requirements. As initiatives such as SRFCs often serve marginalized populations, having students participate who are indifferent to the impact of their work can certainly be harmful. Therefore, careful consideration is warranted before instituting comprehensive training programs and engagement requirements.

Internal funding

Medical schools and affiliated hospitals could financially support relevant student-led initiatives to mitigate difficulty securing funding and to streamline the process of launching and maintaining such programs. Funds could be awarded as grants, stipends, fellowships, or scholarships from internal offices related to scholarly engagement, social justice, community outreach, or curricular development. To maintain sustainability, funding should be budgeted as an annual expense. Adequate and ongoing funding would allow students to expand and maintain their projects despite the human capital required.

Academic acknowledgment

Service-learning initiatives should not be conducted for the sake of achieving an honor. However, rewarding students for their work creates a balanced landscape of recognition. Special designations at graduation, such as public service or health justice distinctions, would demonstrate the value of the emotional and intellectual labor students put into this work.

To ensure that projects are high quality, service-learning curricula should include quality improvement and learning system principles. 23 Formalizing program evaluation, such as collecting project effectiveness metrics and objective measures of skill acquisition, ensures that student-led service-learning initiatives can demonstrate their value through measurable outcomes, similar to student-led research in other domains. Finally, programmatic review boards—akin to research review boards—can conduct systematic reviews of service-learning project proposals to ensure that ethical standards are met, projects are feasible, and impact is measured.

Conclusions

Student-led service-learning initiatives allow medical students to shape the future of medicine. As new members of the medical community, students bring a fresh perspective to improve health and influence the greater health care system. However, students face challenges when implementing service-learning projects, which require training, funding, and recognition. Medical schools can support student-led initiatives through remodeling the curriculum to include service-learning content, instituting adequate internal funding opportunities, and providing recognition and credit for meaningful work.

References

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