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Community-Based Education


Using Service-Learning to Teach Community
Health: The Morehouse School of Medicine
Community Health Course
Ayanna V. Buckner, MD, MPH, Yassa D. Ndjakani, MD, MPH, Bahati Banks, MBA,
and Daniel S. Blumenthal, MD, MPH



Abstract
Medical education is evolving to include               Health Course (CHC) that entails                The authors describe the course and
more community-based training                          conducting a community health needs             offer data from the course’s past 11
opportunities. Most frequently, third-                 assessment and developing,                      years. Data include the types of
and fourth-year medical students have                  implementing, and evaluating a                  collaborating community sites, the
access to these opportunities. However,                community health promotion                      community health issues addressed, and
introducing community-based learning to                intervention. In teams, students conduct        the interventions implemented and
medical students earlier in their training             health needs assessments in the fall, and       evaluated. The MSM CHC has provided
may provide a more formative experience                in the spring they develop interventions        students with an opportunity to obtain
that guides their perspectives as they                 in response to the problems they                hands-on experience in collaborating
enter clinical clerkships. Few known                   identified through the needs                    with diverse communities to address
courses of this type exist for first-year              assessments. At the end of each                 community health. Students gain insight
medical students.                                      semester, students present their findings,      into how health promotion interventions
                                                       outcomes, and policy recommendations            and community partnerships can improve
Since 1998, the Morehouse School of                    at a session attended by other students,        health disparities. The MSM CHC is a
Medicine (MSM) has required first-year                 course faculty, and community                   model that other medical schools across
students to take a yearlong Community                  stakeholders.                                   the country can use to train students.



Medical school curricula are                           incorporate community concerns into             engaging in risky behaviors.9 The changes
constantly evolving to prepare young                   health care delivery. In recent years,          in the provider occur through the
physicians-in-training to be able to                   medical educators have placed more              combination of service tasks and structured
provide high-quality health care within                attention on equipping medical students         opportunities that link the service task to
dynamic medical systems that often                     and residents with the tools to                 self-reflection, self-discovery, and the
struggle to balance care for poor and                  incorporate the community in their              acquisition and comprehension of values,
underserved communities with economic                  delivery of primary health care.1–5             skills, and knowledge content.
solvency. In this context, teaching                    However, medical curricula are still not
medical students community medicine                    fully adequate for preparing students to        Recognizing the significance of service-
means teaching them to employ public                   meet the demands that they will face in         learning in medical education, the Liaison
health approaches while caring for                     serving poor, underserved communities.          Committee on Medical Education (LCME)
individuals. Students do not learn                                                                     revised its accreditation standards in July
through traditional curricula to                                                                       2008 to include a new standard on service-
                                                       One approach to teaching future clinicians
                                                                                                       learning, stating that medical schools
                                                       the skills they need to serve communities is
                                                                                                       should not only make available sufficient
                                                       “service-learning.”6,7 Service-learning is a
Dr. Buckner is assistant professor, Department of                                                      opportunities for medical students to
                                                       teaching and learning strategy that
Community Health and Preventive Medicine,                                                              participate in service-learning activities but
Morehouse School of Medicine, Atlanta, Georgia.        integrates meaningful community service
                                                                                                       also encourage and support student
                                                       with instruction and reflection to enrich
Dr. Ndjakani is assistant professor, Department of                                                     participation.10 The LCME suggests that
Community Health and Preventive Medicine,              the learning experience, teach civic
                                                                                                       medical schools provide information about
Morehouse School of Medicine, Atlanta, Georgia.        responsibility, and strengthen
                                                                                                       available service-learning opportunities,
Ms. Banks is a staff member, Office of Institutional
                                                       communities. Service-learning combines          develop service-learning opportunities in
Advancement & Marketing and Communications,            service objectives and learning objectives      partnership with relevant communities,
Morehouse School of Medicine, Atlanta, Georgia.        with the intent that the activity will change   offer students credit for participating in
Dr. Blumenthal is professor, Department of             both the recipient and the provider of the      service-oriented activities and courses, and
Community Health and Preventive Medicine,              service. Research has shown that students       hold presentations or public forums to
Morehouse School of Medicine, Atlanta, Georgia.
                                                       engaged in service-learning showed an           highlight and recognize service-learning
Correspondence should be addressed to Dr.              increase in the degree to which they felt
Buckner, Morehouse School of Medicine, 720                                                             activities.
Westview Drive, SW, NCPC Suite 335-C, Atlanta, GA
                                                       aware of community needs, believed they
30310-1495; telephone: (404) 752-1517; fax: (404)      could make a difference, and were               Learning the tools of community health
752-1160; e-mail: abuckner@msm.edu.                    committed to service in the future,8 and        needs assessment and health promotion
Acad Med. 2010;85:1645–1651.                           communities involved in service-learning        and having an opportunity to exercise
doi: 10.1097/ACM.0b013e3181f08348                      have shown decreased numbers of people          these skills can prepare students to


Academic Medicine, Vol. 85, No. 10 / October 2010                                                                                              1645
Community-Based Education


deliver care to communities as well as          populations in Georgia and across the                  and evaluating a health promotion
individual patients.2 Community health          nation and to address primary health care              intervention. Spring lectures also address
needs assessments are used to identify the      needs through programs in education,                   the relationship between public health and
strengths and needs of the community, to        research, and service. MSM requires the                public policy.
establish community health priorities,          Community Health Course (CHC) for all
and to facilitate collaborative action          first-year medical students. Originally                Groups of 10 to 14 students and two
planning directed at improving                  taught as a series of individual, discrete             faculty facilitators are assigned to
community health status and quality of          classroom lectures, it became a                        community sites at the start of each
life.11 Some examples of community              community-based service-learning course                academic year. Classes occur at
health needs assessment tools include           in 1998.16 The course engages first-year               community sites that the faculty
focus groups and surveys. Health                medical students, faculty members, and                 facilitators of each small group have
promotion is the process of enabling            community-based organizations in                       selected either through their own prior
people to increase their control over and       service-learning and community service.                experiences or through referrals from
improve their own health.12 We believe                                                                 other faculty members or community
that educating physicians early in their                                                               contacts. Faculty select sites on the basis
training and giving them an opportunity         The CHC at MSM                                         of each site’s involvement with and
to practice their skills in a service           The CHC is a two-semester course that                  commitment to low-income and
environment may be one factor leading           provides students with the opportunity to              underserved populations, the site’s
to the greater incorporation of public          analyze the health, health problems,                   geographic location (located in
health in health care delivery. Whereas         and the delivery of health services in                 metropolitan Atlanta), the site
students learn primary care medicine in         underserved communities. The course’s                  administration’s willingness to facilitate
medical school, exposure to community           topics of study comprise community health              involving its staff and the community it
settings is often sparse in the first two       analysis, health-related behavior, and                 serves in the health needs assessment and
years of medical education, which are           community health promotion.                            intervention, the availability of a
largely focused on the basic sciences. We       Instructional methods include hands-on                 community liaison who can serve as a
feel that early exposure to or familiarity      community activities in a small-group                  primary contact for the course faculty
with community medicine may inspire             setting, group discussions, reading and                and students, and the availability of on-
more physicians to specialize in primary        writing assignments, and introductory                  site weekly meeting space for the course
care or community medicine or to                lectures. Students receive classroom                   faculty and students. Each site’s
integrate community-based medicine              instruction in two 3-hour sessions at the              community liaison agrees to work with
principles into their chosen specialty.         beginning of each semester. As a                       the faculty facilitators and students for
                                                foundation for the health promotion                    the entire year. These community liaisons
Some medical trainees have the                  activities in the course, the two fall lectures        may be, for example, a school principal
opportunity to participate in community         focus on viewing the community as a                    or guidance counselor or the director or
experiences in their clinical clerkships, in    patient (“Clinical Community Health”)                  program manager of a community
electives during the third and fourth           and review theory on how the physician                 organization. The faculty facilitators are
years of medical school, or through             will diagnose and treat the patient, that is,          health professionals with experience in
residency programs.13–15 However, few           the community. This CHC conceptual                     community health. At least one facilitator
courses of this type exist for preclinical      framework is the converse of the well-                 in each group has an MD degree, and the
medical students, and studies that              known “community-oriented primary                      other has a PhD or a master’s degree in
document the immersion of medical               care” model, which uses public health                  public health or a related discipline.
students in the community during the            concepts to guide the actions of
first two years of their training are lacking   clinicians.17,18 In the CHC clinical concepts          Small-group instruction emphasizes
in the literature. The purpose of this          guide the actions of students engaged in the           access and barriers to health services,
article is to describe a novel course that      practice of public health. That is, students           team collaboration, project evaluation,
both uses the service-learning construct        gather subjective and objective data,                  community service, health promotion,
to expose preclinical medical students to       compile a problem list, and formulate and              and disease prevention. Each week,
the community setting and allows                carry out a therapeutic plan, all in the               students meet for a three-hour session
students to analyze the health problems         manner of a clinician treating a patient.16            at their assigned community sites to
of the community and to design and              To prepare students to adapt evidence-                 complete course objectives. The course
implement an intervention to address            based health promotion activities for their            meetings are factored into the students’
identified community problems.                  communities, fall lecture topics also include          curriculum schedule and do not interfere
                                                performing searches of the medical                     with the time that students spend in their
Morehouse School of Medicine (MSM)              literature and instruction on critiquing               other required courses. Students are
was founded to train students for careers       articles. For the remainder of the fall                responsible for arranging and organizing
as primary care physicians who will             semester, students use a team-based                    their weekly course activities (course
practice in medically underserved areas         approach for the community assessments                 activities described below), while faculty
among populations of minorities and/or          and the required presentations (Table 1). In           leaders serve as group facilitators, guiding
populations with low socioeconomic              the spring semester, students receive                  groups toward completion of weekly
status. MSM’s curriculum reflects the           instruction on writing program objectives,             tasks. In addition to completing the
institution’s commitment both to                on constructing and understanding logic                actual assessment activities in the fall
support the underserved urban and rural         models, and on designing, implementing,                semester and implementing the


1646                                                                                              Academic Medicine, Vol. 85, No. 10 / October 2010
Community-Based Education


                                                                                                                                                                                                            measurable, achievable, relevant, and
Table 1                                                                                                                                                                                                     time bound. As with the needs
Timeline of the Community Health Course at the Morehouse School of Medicine                                                                                                                                 assessments, creativity is paramount in
                                                                                                                                                                                                            designing interventions at sites that have
Timing                                                     Activity or activities—Students…
                                                                                                                                                                                                            been long-standing community partners.
Fall semester
.........................................................................................................................................................................................................
                                                                                                                                                                                                            Because students must design a
Weeks 1–3                                                  ѧ attend lectures                                                                                                                                community intervention based on their
.........................................................................................................................................................................................................
Weeks 4–5                                                  ѧ begin meeting at community site and conduct key informant                                                                                      needs assessment, they may not merely
                                                             interviews                                                                                                                                     continue the work of previous students.
.........................................................................................................................................................................................................
Weeks 6–8                                                  ѧ conduct focus group interviews and plan surveys                                                                                                If the needs assessment dictates an
.........................................................................................................................................................................................................
Week 7                                                     ѧ submit their journal critiques                                                                                                                 expansion on previous students’ work,
.........................................................................................................................................................................................................   the faculty facilitators challenge the
Weeks 8–9                                                  ѧ conduct their surveys and start their community engagement
                                                              activities                                                                                                                                    students to be creative in designing an
.........................................................................................................................................................................................................
Weeks 10–11                                                ѧ conduct their data analyses and share the results of their needs
                                                                                                                                                                                                            intervention that is unique yet effective in
                                                              assessment with community liaisons and leaders                                                                                                meeting the community’s needs. Students
.........................................................................................................................................................................................................
Weeks 12–13                                                ѧ prepare their presentations and papers                                                                                                         also design an evaluation of their
.........................................................................................................................................................................................................   intervention. In most instances, they
Week 13                                                    ѧ submit their papers
.........................................................................................................................................................................................................   use brief pretest and posttest surveys to
Week 14                                                    ѧ give their presentations to course faculty, community stakeholders,
                                                                                                                                                                                                            assess knowledge change, but faculty
                                                             and other students
                                                                                                                                                                                                            encourage students to also collect
Spring semester                                                                                                                                                                                             satisfaction and/or process data.
.........................................................................................................................................................................................................
Week 1                                                     ѧ attend lectures                                                                                                                                Chart 1 provides a sample student
.........................................................................................................................................................................................................
Weeks 2–12                                                 ѧ plan and revise their interventions                                                                                                            needs assessment and intervention
.........................................................................................................................................................................................................
Weeks 2–13                                                 ѧ conduct community engagement activities                                                                                                        from the MSM CHC.
.........................................................................................................................................................................................................
Weeks 6–13                                                 ѧ conduct their community interventions
.........................................................................................................................................................................................................
Weeks 14–16                                                ѧ conduct their data analyses and prepare their final papers and                                                                                 Student Assessment
                                                              presentations
.........................................................................................................................................................................................................
Week 16                                                    ѧ submit their final papers and give their presentations to course                                                                               Faculty facilitators assess student learning
                                                              faculty, community stakeholders, and other students                                                                                           and service through multiple-choice
                                                                                                                                                                                                            examinations, fall and spring semester
intervention activities in the spring                                                                    them the opportunity to make subjective                                                            group papers, fall and spring semester
semester, the students spend weekly                                                                      and objective evaluations that include                                                             presentations, class participation, and
course time planning these activities.                                                                   descriptions of the community and any                                                              completion of a reflection journal. All
During the weeks of planning, dedicated                                                                  evidence of trends, stability, or changes                                                          students in the group receive the same
course time also allows the students to                                                                  that may contribute to the health of the                                                           grade for the group papers and
interact with community representatives                                                                  population. Other fall semester activities                                                         presentations, but students receive
and provide community service. In the                                                                    include student-conducted key informant                                                            individual grades for class participation,
CHC, we refer to these interactions with                                                                 interviews, (i.e., interviews with integral                                                        journal entries, and their performance on
the community and/or community                                                                           community stakeholders) and, usually                                                               examinations. Students complete three
representatives as “community                                                                            following these, focus groups and                                                                  reflection journal entries each semester;
engagement activities.” As a group, the                                                                  community surveys. Although all                                                                    in each journal entry, they answer
students determine the focus of their                                                                    students in the course must complete                                                               predetermined questions (e.g., “Describe
community engagement activities; the                                                                     the same components of the needs                                                                   your experience at your community site,”
focus is largely site dependent. For                                                                     assessment, faculty facilitators encourage                                                         “What were your initial perceptions?”,
example, groups assigned to schools or                                                                   them to be creative in their approach to                                                           “What are some of the general
after-school programs frequently                                                                         doing so. Sometimes students collect                                                               stereotypes or misconceptions you’ve
participate in tutoring. In keeping with                                                                 other information—for instance,                                                                    had?”, and “Has your experience at your
the principles of service-learning,6 the                                                                 anthropometric (i.e., height and weight)                                                           site supported or refuted these
students reflect on their experiences                                                                    data on elementary school children.                                                                stereotypes?”). Faculty facilitators read
through scheduled journal entries and                                                                                                                                                                       the reflection journals of the students in
group discussions.                                                                                       Students continue working in their small                                                           their group. Although the students do
                                                                                                         groups at community sites during the                                                               not receive subjective comments on their
Table 1 provides a timeline of course                                                                    spring semester, planning, implementing,                                                           responses, they do receive a grade
activities. During the fall semester, faculty                                                            and evaluating a health promotion                                                                  (complete or incomplete) for answering
facilitators guide students through                                                                      intervention that addresses one or more                                                            the questions. The multiple-choice
the community needs assessment                                                                           of the community health issues identified                                                          examinations take place once per
methodology by engaging the students in                                                                  during the fall semester. The students                                                             semester and are based on the
a variety of assessment activities. The                                                                  begin by revisiting the needs assessment                                                           introductory lectures that students
assessment begins with a “windshield                                                                     to determine components for their spring                                                           receive at the start of each semester.
survey”—that is, the students conduct a                                                                  intervention. They write objectives for                                                            Lecturers submit three to four questions
visual assessment while they drive                                                                       the intervention, using the SMART                                                                  per lecture. The two faculty facilitators
through the community. The drive allows                                                                  model: Their objectives must be specific,                                                          assigned to each group decide their


Academic Medicine, Vol. 85, No. 10 / October 2010                                                                                                                                                                                                 1647
Community-Based Education


                                                                                                                       first-year medical students that included
 Chart 1                                                                                                               a focus on biostatistics, epidemiology,
 Sample Student Needs Assessment and Intervention From the Morehouse                                                   and health disparities. It included lectures
 School of Medicine Community Health Course                                                                            given by MSM faculty and faculty from
                                                                                                                       the Centers for Disease Control and
    Needs assessment                                                                                                   Prevention. In 1991, MSM received a
    Community site:                                                                                                    grant from the W.K. Kellogg Foundation
    Local church                                                                                                       to expand this course. The grant proposal
    Windshield survey*:                                                                                                was written based on the Area Health
    Conducted in a 10-mile radius of the church
                                                                                                                       Education Centers (AHEC) program
    Key informant for key informant interviews:
                                                                                                                       model, which included partnerships
       • Priest
                                                                                                                       between medical schools and
         •   Health ministry leaders                                                                                   communities. AHEC’s mission is to
                                                                                                                       enhance access to quality health care,
         •   Teen group advisors                                                                                       particularly primary and preventive care,
         •   Deacon
                                                                                                                       by improving the supply and distribution
                                                                                                                       of health care professionals through
         •   Lay members (e.g., president of the church parish council, president of the men’s                         community/academic educational
             group, member of the committee that developed the church’s strategic vision,                              partnerships.19 The U.S. Congress
             member of the senior citizen’s group)                                                                     developed the AHEC program to recruit,
                                                                                                                       train, and retain a health professions
    Focus group:
    Two conducted: One group with adults and one group with teens
                                                                                                                       workforce committed to underserved
    Survey:                                                                                                            populations.20 With the support of the
    Distributed to all parishioners at morning church service and midday church service                                W.K. Kellogg Foundation grant, the
                                                                                                                       course designers created the original
    Intervention                                                                                                       iteration in conjunction with faculty and
    Wellness initiative:                                                                                               students from local nursing schools, a
    Entitled “A New Year, A New You”                                                                                   theological center, and a school of social
        • Nutrition and exercise intervention: Part 1—focused on healthy cooking and                                   work. Although its interdisciplinary
        exercise demonstrations (conducted at Week 7)                                                                  nature was a strength, the course
         • Teen conference focused on coping with stress and healthy communication                                     experienced several challenges, including
         (conducted at Week 9)                                                                                         the difficulties of identifying community
                                                                                                                       faculty who could design educational
         • Nutrition and exercise intervention: Part 2—focused on the spiritual basis of                               lectures of graduate school quality,
         healthy eating, a healthy promotion scavenger hunt, and a healthy food potluck                                coordinating multiple presentations
         (conducted at Week 10)                                                                                        while avoiding redundant material, and
                                                                                                                       identifying community presenters who
                                                                                                                       understood the course’s relevance to
* A windshield survey is an activity during which students drive through the community whose needs they plan to        medical school education. In 1998,
  assess in order to observe and do an initial observation-only-based assessment.
                                                                                                                       the course coordinator and faculty
                                                                                                                       redesigned the course using the service-
 students’ participation grades through                    • a summary of the leading health-related                   learning construct and emphasizing the
 consensus. Participation grades are based                   community concerns including the                          training of only medical students. The
 on weekly attendance, contribution to                       consequences of these public health                       redesigned course received funding
 weekly discussions and course activities,                   concerns and the local resources                          from the Corporation for National and
 and interaction with colleagues and                         available to the community                                Community Service. Group leaders are
 community partners. All 10 to 14                                                                                      primarily faculty from the Department of
 students in a group contribute to the                                                                                 Community Health and Preventive
                                                           The spring semester papers and
 group papers, but they are divided into                                                                               Medicine. Over the years, the course
                                                           presentations offer descriptions and
 smaller subgroups of two or three                                                                                     faculty has expanded to include one
                                                           evaluations of the student-conducted
 students for the presentations. The                                                                                   faculty member from the MSM
                                                           interventions. Each semester, the students
 papers are limited to 3,000 to 3,750                                                                                  Department of Pediatrics who has
                                                           give their presentations (of 20 minutes,
 words, excluding tables, figures, and                                                                                 extensive community-based experience
                                                           followed by a 5- to 10-minute question-
 appendices. All of the fall papers and                                                                                and several staff members from public
                                                           and-answer period) to an audience
 presentations include a description of the                                                                            health organizations such as the Centers
                                                           composed of other students, course faculty,
 community needs assessment and detail                                                                                 for Disease Control and Prevention.
                                                           and community stakeholders.
 • community demographics and assets,
                                                                                                                       A Review of the Community
 • morbidity and mortality data,                           Development of the Program                                  Projects
 • socioeconomic factors that impact                       As in most U.S. medical schools, MSM                        In the first 11 years of the CHC (1999 –
   health, and                                             had a required lecture-based course for                     2010), over 500 students conducted 56


 1648                                                                                                             Academic Medicine, Vol. 85, No. 10 / October 2010
Community-Based Education


community interventions—all in                  community partners to improve their             both integral parts of the CHC—also
metropolitan Atlanta, Georgia. The              health.                                         address the Healthy People Curriculum
students established partnerships with the                                                      Task Force’s Community Aspects of
Atlanta Housing Authority, the Boys and         A CHC can also expose medical students          Practice component,22 which is designed
Girls Club of Metro Atlanta, Atlanta            to the common health issues (e.g., poor         to reflect both clinical prevention and
Public Schools (grades K–12), Headstart,        nutrition/obesity, substance abuse, and a       population health.
and other smaller grassroots organizations      lack of sexual health education/resources)
(e.g., churches and neighborhood                experienced by adults, adolescents, and         Service-learning opportunities for
groups). The two leading health                 children in various communities. Many           medical students are becoming more
problems the students identified through        of the problems the students diagnose           common; as mentioned, the LCME now
their health needs assessments were the         each semester also mirror the leading           mandates that they be made available for
prevalence of violence and substance            health indicators associated with Healthy       students who wish to experience them.
abuse (usually identified as comorbid by        People 2010.1,21 These indicators reflect       MSM’s CHC differs from most of these
the community and thus considered a             the major health concerns in the United         in that it is required of all first-year
single problem in this analysis [12             States at the beginning of the 21st             students (rather than offered as an
assessments]) and the lack of community         century. These concerns are important           elective) and thus introduces all students,
development (including unemployment,            public health issues, and their significance    including those who would not have
deteriorating housing, and lack of              as relevant health disparities is reflected     pursued it otherwise, to a community
security [12 assessments]). Other leading       by the fact that the students ascertained       health experience. Further, where
health problems identified in the health        the necessity for interventions for similar     required courses or clerkships do exist,
needs assessments included low literacy         problems each year.                             either they focus on “community
rates (10 assessments), obesity and                                                             diagnosis” alone24 (or conversely, they
nutrition (8 assessments), chronic              Several organizations, including the            require a community project without the
diseases such as asthma (8 assessments)         Association of American Medical                 needs assessment component25) or they are
and hypertension (3 assessments), and           Colleges (AAMC), the Healthy People             classroom-based courses that are closely
adolescent sexual health (3 assessments).       Curriculum Task Force convened by the           tied to epidemiology and traditional
Interventions included educational              Association for Prevention Teaching and         population health experiences.26 We are not
programs, health fairs, and policy              Research (formerly the Association of           aware of any other required course in a U.S.
initiatives. Some examples of                   Teachers of Preventive Medicine), and           or Canadian medical school that provides
interventions include dental, physical          the Association of Academic Health              the full spectrum of community
fitness, and parent education workshops,        Centers, have delineated standards for          assessment, intervention, and evaluation
tutoring sessions to address the low            integrating population health into the          for first-year medical students.
literacy levels, and sexual health              training of health professions students.22,23
education workshops for teenagers. No           The AAMC has asserted that physicians           Over the span of the CHC, the
data are available regarding the effect of      must collaborate with other health              partnerships with the community have
the CHC on student perceptions during           professionals and individuals                   enabled us to mobilize more than 500
clinical preceptorships or after graduation;    representing a wide variety of community        medical students to address the health
however, anecdotal experience and               agencies to use systematic approaches           disparities of underserved youth and
informal feedback suggest that students         for promoting, maintaining, and                 adults by providing responsive health
refer to their CHC experience if/when they      improving the health of individuals and         promotion intervention projects
choose primary care residencies and that        populations.23 Through participating in         throughout metropolitan Atlanta.
many graduates integrate community              the CHC, MSM students collaborate both          Each year, the community sites have
service into their practice.                    with peers and with community members           responded very favorably to the students.
                                                and work with a team. We feel that              Community sites typically return each
                                                through the course they learn skills that       year to participate in the program, even
The Significance of Preclinical                 ease their transition into clinical rotations   though none of the sites, community
Community Health Training                       as upper-level medical students and             members, or administrators receive
This description of the CHC and review          residents, and we hope they will gain           compensation or honoraria for
of the first 11 years of CHC data suggest       proficiencies that may help them                participating. Existing organizations (i.e.,
that a medical school course focused on         function better as physicians as the            parent auxiliaries and parent–teacher
community health and service-learning           medical model moves toward                      organizations at schools) at the
can expose students to community needs          multidisciplinary approaches to patient         community sites have sought
assessments and health promotion                management. By performing needs                 opportunities to collaborate with the
interventions in a variety of community         assessments and designing interventions         students, frequently scheduling their
settings. When incorporated into the            for underserved communities, students           activities to coincide with the student-
medical school curriculum, a CHC can            in the CHC address the AAMC’s                   planned interventions. The community
provide an opportunity for medical              objective that medical students                 sites receive, at no cost, the results of the
students to obtain hands-on community           understand the economic, social, and            community needs assessments, and they
engagement experiences. These courses           cultural factors that contribute to the         benefit from an intervention designed by
can provide medical students with the           conditions that impact health.23 The            students in response to that assessment,
knowledge and skills to assess the health       assessments of community needs and              but they receive no financial benefits
of the community and to collaborate with        strengths as well as the interventions—         other than the nominal budget ($500 –


Academic Medicine, Vol. 85, No. 10 / October 2010                                                                                       1649
Community-Based Education


$600) that each group uses to support the       consideration. Although effective and                      5 Carney JK, Hackett R. Community–academic
assessments and interventions.                  easily implemented educational programs                      partnerships: A “community-first” model to
                                                                                                             teach public health. Education for Health.
                                                such as this course may contribute to                        2008;21(1). Available at: http://www.education
We feel that MSM students and faculty           improving the education of future                            forhealth.net/publishedarticles/article_print_
serve as role models to the youth and           physicians, further study is needed to                       166.pdf. Accessed June 10, 2010.
young adults in the community; for              assess student and community                               6 Seifer SD. Service-learning: Community–
example, for more than four years,              perceptions of the course as well as its                     campus partnerships for health professions
                                                                                                             education. Acad Med. 1998;73:273–277.
students in the CHC have implemented a          long-term effectiveness. Additional                        7 Mohan CP, Mohan A. HealthSTAT: A
series of life skills, substance abuse, and     research is also needed to investigate the                   student approach to building skills needed to
sexual health education workshops for           impact that the CHC has on community                         serve poor communities. J Health Care Poor
youth who live in public housing.               health status, the continuity or                             Underserved. 2007;18:523–531.
Following the end of the course, some of        sustainability of student interventions,                   8 Melchior A. Summary Report: National
                                                                                                             Evaluation of Learn and Serve America.
the medical students have continued             the specialties chosen by CHC medical                        Waltham, Mass: Brandeis University, Center
their relationships with the youth whom         students, the types of communities in                        for Human Resources; 1999. Available at:
they mentored. We also hope that                which they choose eventually to practice,                    http://www.learnandserve.gov/pdf/lsa_
community partners feel more                    and the degree to which they use the                         evaluation.pdf. Accessed July 6, 2010.
empowered to make health decisions and          knowledge and skills gained from their                     9 Kirby D. Emerging Answers: Research
                                                                                                             Findings on Programs to Reduce Teen
to become advocates for their own health.       CHC experiences.                                             Pregnancy. Washington, DC: National
Evaluations from student interventions          Acknowledgments: The authors wish to thank Dr.               Campaign to Prevent Teen Pregnancy; 2001.
reveal short-tem behavior changes such          Meryl McNeal and the staff of the Center for              10 Liaison Committee on Medical Education.
as increased physical activity and making       Community Health and Service-Learning at the                 LCME Accreditation Standards. IS-14-A.
                                                                                                             Available at: http://www.lcme.org/functionslist.
healthier food choices. We hope that            Morehouse School of Medicine. The authors also
                                                                                                             htm. Accessed June 10, 2010.
these behaviors continue in the long            wish to thank Dr. George Rust and the staff in the
                                                                                                          11 Manitoba Health. Community Health Needs
term. Through the course, MSM has               Faculty Development Program at the Morehouse
                                                                                                             Assessment Guidelines. Available at: http://
                                                School of Medicine.
strengthened its partnerships with                                                                           www.chssn.org/En/pdf/networking/
Atlanta community organizations and             Funding/Support: The Morehouse School of                     community%20health%20assessment.pdf.
                                                Medicine Community Health Course has been                    Accessed July 2, 2010.
remains poised to respond to the                                                                          12 World Health Organization. Ottawa Charter
                                                funded in part by the W.K. Kellogg Foundation
developing needs of the community.              and the Corporation for National and                         for Health Promotion. First International
                                                Community Service.                                           Conference on Health Promotion. Ottawa, 21
                                                                                                             November 1986 –WHO/HPR/HEP/95.1.
CHC Funding and Support                         Other disclosures: Dr. Blumenthal serves on the              Available at: http://www.who.int/hpr/NPH/
                                                board of directors of the Southeastern Primary               docs/ottawa_charter_hp.pdf. Accessed July 2,
The course is faculty-intensive; at least       Care Consortium/Atlanta Area Health Education                2010.
eight faculty members devote a half-day         Center, which provided some financial support             13 Andrus NC, Bennett NM. Developing an
nearly every week to it. Institutional (i.e.,   for the course. He receives no compensation for              interdisciplinary, community-based
MSM) support has been important, and            serving on this board.                                       education program for health professions
                                                                                                             students: The Rochester experience. Acad
grant funding from the Corporation for          Ethical approval: The Community Health Course                Med. 2006;81:326 –331.
National and Community Service and the          was not evaluated in this manuscript, so IRB              14 Mareck DG, Uden DL, Larson TA, Shepard
U.S. Health Resources and Services              approval was not obtained.                                   MF, Reinert RJ. Rural interprofessional
Administration (HRSA) has provided              Previous presentations: The authors (A.B., Y.N.,             service-learning: The Minnesota experience.
additional support. HRSA funds the              and D.B.) gave a poster presentation with                    Acad Med. 2004;79:672–676.
                                                information about the Morehouse School of                 15 McIntosh S, Block RC, Kapsak G, Pearson
AHEC program; the MSM AHEC                                                                                   TA. Training medical students in community
program is 1 of 54 nationally. The Atlanta      Medicine Community Health Course on
                                                                                                             health: A novel required fourth-year clerkship
                                                February 22, 2007, at the American College of
AHEC program has helped implement                                                                            at the University of Rochester. Acad Med.
                                                Preventive Medicine “Preventive Medicine 2007”
the course through support of                                                                                2008;83:357–364.
                                                meeting in Miami, Florida.
community sites and by offering student                                                                   16 Blumenthal DS, Jones A, McNeal M.
                                                                                                             Evaluating a community-based
travel (mileage) reimbursement.                                                                              multiprofessional course in community
                                                References                                                   health. Educ Health (Abingdon). 2001;14:
                                                 1 Magill MK, Quinn R, Babitz M, Saffel-Shrier               251–255.
Opportunities for Enhancement                      S, Shomaker S. Integrating public health into          17 Kark SL. The Practice of Community-
                                                   medical education: Community health                       Oriented Primary Health Care. New York,
Opportunities for enhancing the MSM
                                                   projects in a primary care preceptorship.                 NY: Appleton-Century-Crofts; 1981.
CHC include improving the small-group              Acad Med. 2001;76:1076 –1079.                          18 Art B, De Roo L, De Maeseneer J. Towards
dynamic by increasing the number of              2 Nickens H. It’s about time. The medicine/                 unity for health utilising community-oriented
faculty and decreasing the number of               public health initiative. Am J Prev Med. 1999;            primary care in education and practice.
students in each group. This would                 16(3 suppl):20 –21.                                       Education for Health. 2007;20(2). Available
                                                 3 Cashman SB, Anderson RJ, Weisbuch JB,                     at: http://www.educationforhealth.net/
allow students a more individualized                                                                         publishedarticles/article_print_74.pdf.
                                                   Schwarz MR, Fulmer HS. Carrying out the
experience. However, the current                   medicine/public health initiative: The roles of           Accessed June 10, 2010.
economic climate makes this difficult. As          preventive medicine and community-                     19 National AHEC Organization. AHEC
mentioned, grant funding has supported             responsive care. Acad Med. 1999;74:473–483.               Mission. Available at: http://www.nationalahec.
the course since its inception, but              4 Paterniti DA, Pan RJ, Smith LF, Horan NM,                 org/About/AHECMission.asp. Accessed June
                                                   West DL. From physician-centered to                       30, 2010.
funding opportunities are becoming                 community-oriented perspectives on health              20 National AHEC Organization. About Us.
scarcer, and greater institutional financial       care: Assessing the efficacy of community-                Available at: http://www.nationalahec.org/
commitment has become a necessary                  based training. Acad Med. 2006;81:347–353.                About/AboutUs.asp. Accessed June 30, 2010.



1650                                                                                                 Academic Medicine, Vol. 85, No. 10 / October 2010
Community-Based Education


21 Leading health indicators? In: U.S.                Curriculum framework for health professions.   25 Chamberlain LJ, Wang NE, Ho ET, Banchoff
   Department of Health and Human Services.           Am J Prev Med. 2004;27:471–476.                   AW, Braddock CH, Gesundheit N.
   Healthy People 2010: Understanding and          23 The Medical School Objectives Writing             Integrating collaborative population health
   Improving Health. 2nd ed. Washington, DC:          Group. Learning objectives for medical            projects into a medical student curriculum at
   U.S. Government Printing Office; November          student education—Guidelines for medical          Stanford. Acad Med. 2008;83:338 –344.
   2000. Available at: http://www.healthypeople.      schools: Report I of the Medical School        26 Finkelstein JA, McMahon GT, Peters A,
   gov/document/html/uih/uih_4.htm. Accessed          Objectives Project. Acad Med. 1999;74:13–18.      Cadigan R, Biddinger P, Simon SR. Teaching
   June 10, 2010.                                  24 Blacklow RS, Boex JR, Keck CW. A required         population health as a basic science at
22 Allan J, Barwick TA, Cashman S, et al.             clerkship in community medicine. Acad Med.        Harvard Medical School. Acad Med. 2008;83:
   Clinical prevention and population health:         1995;70:449 –450.                                 332–337.




Academic Medicine, Vol. 85, No. 10 / October 2010                                                                                              1651

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Academic Medicine

  • 1. Community-Based Education Using Service-Learning to Teach Community Health: The Morehouse School of Medicine Community Health Course Ayanna V. Buckner, MD, MPH, Yassa D. Ndjakani, MD, MPH, Bahati Banks, MBA, and Daniel S. Blumenthal, MD, MPH Abstract Medical education is evolving to include Health Course (CHC) that entails The authors describe the course and more community-based training conducting a community health needs offer data from the course’s past 11 opportunities. Most frequently, third- assessment and developing, years. Data include the types of and fourth-year medical students have implementing, and evaluating a collaborating community sites, the access to these opportunities. However, community health promotion community health issues addressed, and introducing community-based learning to intervention. In teams, students conduct the interventions implemented and medical students earlier in their training health needs assessments in the fall, and evaluated. The MSM CHC has provided may provide a more formative experience in the spring they develop interventions students with an opportunity to obtain that guides their perspectives as they in response to the problems they hands-on experience in collaborating enter clinical clerkships. Few known identified through the needs with diverse communities to address courses of this type exist for first-year assessments. At the end of each community health. Students gain insight medical students. semester, students present their findings, into how health promotion interventions outcomes, and policy recommendations and community partnerships can improve Since 1998, the Morehouse School of at a session attended by other students, health disparities. The MSM CHC is a Medicine (MSM) has required first-year course faculty, and community model that other medical schools across students to take a yearlong Community stakeholders. the country can use to train students. Medical school curricula are incorporate community concerns into engaging in risky behaviors.9 The changes constantly evolving to prepare young health care delivery. In recent years, in the provider occur through the physicians-in-training to be able to medical educators have placed more combination of service tasks and structured provide high-quality health care within attention on equipping medical students opportunities that link the service task to dynamic medical systems that often and residents with the tools to self-reflection, self-discovery, and the struggle to balance care for poor and incorporate the community in their acquisition and comprehension of values, underserved communities with economic delivery of primary health care.1–5 skills, and knowledge content. solvency. In this context, teaching However, medical curricula are still not medical students community medicine fully adequate for preparing students to Recognizing the significance of service- means teaching them to employ public meet the demands that they will face in learning in medical education, the Liaison health approaches while caring for serving poor, underserved communities. Committee on Medical Education (LCME) individuals. Students do not learn revised its accreditation standards in July through traditional curricula to 2008 to include a new standard on service- One approach to teaching future clinicians learning, stating that medical schools the skills they need to serve communities is should not only make available sufficient “service-learning.”6,7 Service-learning is a Dr. Buckner is assistant professor, Department of opportunities for medical students to teaching and learning strategy that Community Health and Preventive Medicine, participate in service-learning activities but Morehouse School of Medicine, Atlanta, Georgia. integrates meaningful community service also encourage and support student with instruction and reflection to enrich Dr. Ndjakani is assistant professor, Department of participation.10 The LCME suggests that Community Health and Preventive Medicine, the learning experience, teach civic medical schools provide information about Morehouse School of Medicine, Atlanta, Georgia. responsibility, and strengthen available service-learning opportunities, Ms. Banks is a staff member, Office of Institutional communities. Service-learning combines develop service-learning opportunities in Advancement & Marketing and Communications, service objectives and learning objectives partnership with relevant communities, Morehouse School of Medicine, Atlanta, Georgia. with the intent that the activity will change offer students credit for participating in Dr. Blumenthal is professor, Department of both the recipient and the provider of the service-oriented activities and courses, and Community Health and Preventive Medicine, service. Research has shown that students hold presentations or public forums to Morehouse School of Medicine, Atlanta, Georgia. engaged in service-learning showed an highlight and recognize service-learning Correspondence should be addressed to Dr. increase in the degree to which they felt Buckner, Morehouse School of Medicine, 720 activities. Westview Drive, SW, NCPC Suite 335-C, Atlanta, GA aware of community needs, believed they 30310-1495; telephone: (404) 752-1517; fax: (404) could make a difference, and were Learning the tools of community health 752-1160; e-mail: abuckner@msm.edu. committed to service in the future,8 and needs assessment and health promotion Acad Med. 2010;85:1645–1651. communities involved in service-learning and having an opportunity to exercise doi: 10.1097/ACM.0b013e3181f08348 have shown decreased numbers of people these skills can prepare students to Academic Medicine, Vol. 85, No. 10 / October 2010 1645
  • 2. Community-Based Education deliver care to communities as well as populations in Georgia and across the and evaluating a health promotion individual patients.2 Community health nation and to address primary health care intervention. Spring lectures also address needs assessments are used to identify the needs through programs in education, the relationship between public health and strengths and needs of the community, to research, and service. MSM requires the public policy. establish community health priorities, Community Health Course (CHC) for all and to facilitate collaborative action first-year medical students. Originally Groups of 10 to 14 students and two planning directed at improving taught as a series of individual, discrete faculty facilitators are assigned to community health status and quality of classroom lectures, it became a community sites at the start of each life.11 Some examples of community community-based service-learning course academic year. Classes occur at health needs assessment tools include in 1998.16 The course engages first-year community sites that the faculty focus groups and surveys. Health medical students, faculty members, and facilitators of each small group have promotion is the process of enabling community-based organizations in selected either through their own prior people to increase their control over and service-learning and community service. experiences or through referrals from improve their own health.12 We believe other faculty members or community that educating physicians early in their contacts. Faculty select sites on the basis training and giving them an opportunity The CHC at MSM of each site’s involvement with and to practice their skills in a service The CHC is a two-semester course that commitment to low-income and environment may be one factor leading provides students with the opportunity to underserved populations, the site’s to the greater incorporation of public analyze the health, health problems, geographic location (located in health in health care delivery. Whereas and the delivery of health services in metropolitan Atlanta), the site students learn primary care medicine in underserved communities. The course’s administration’s willingness to facilitate medical school, exposure to community topics of study comprise community health involving its staff and the community it settings is often sparse in the first two analysis, health-related behavior, and serves in the health needs assessment and years of medical education, which are community health promotion. intervention, the availability of a largely focused on the basic sciences. We Instructional methods include hands-on community liaison who can serve as a feel that early exposure to or familiarity community activities in a small-group primary contact for the course faculty with community medicine may inspire setting, group discussions, reading and and students, and the availability of on- more physicians to specialize in primary writing assignments, and introductory site weekly meeting space for the course care or community medicine or to lectures. Students receive classroom faculty and students. Each site’s integrate community-based medicine instruction in two 3-hour sessions at the community liaison agrees to work with principles into their chosen specialty. beginning of each semester. As a the faculty facilitators and students for foundation for the health promotion the entire year. These community liaisons Some medical trainees have the activities in the course, the two fall lectures may be, for example, a school principal opportunity to participate in community focus on viewing the community as a or guidance counselor or the director or experiences in their clinical clerkships, in patient (“Clinical Community Health”) program manager of a community electives during the third and fourth and review theory on how the physician organization. The faculty facilitators are years of medical school, or through will diagnose and treat the patient, that is, health professionals with experience in residency programs.13–15 However, few the community. This CHC conceptual community health. At least one facilitator courses of this type exist for preclinical framework is the converse of the well- in each group has an MD degree, and the medical students, and studies that known “community-oriented primary other has a PhD or a master’s degree in document the immersion of medical care” model, which uses public health public health or a related discipline. students in the community during the concepts to guide the actions of first two years of their training are lacking clinicians.17,18 In the CHC clinical concepts Small-group instruction emphasizes in the literature. The purpose of this guide the actions of students engaged in the access and barriers to health services, article is to describe a novel course that practice of public health. That is, students team collaboration, project evaluation, both uses the service-learning construct gather subjective and objective data, community service, health promotion, to expose preclinical medical students to compile a problem list, and formulate and and disease prevention. Each week, the community setting and allows carry out a therapeutic plan, all in the students meet for a three-hour session students to analyze the health problems manner of a clinician treating a patient.16 at their assigned community sites to of the community and to design and To prepare students to adapt evidence- complete course objectives. The course implement an intervention to address based health promotion activities for their meetings are factored into the students’ identified community problems. communities, fall lecture topics also include curriculum schedule and do not interfere performing searches of the medical with the time that students spend in their Morehouse School of Medicine (MSM) literature and instruction on critiquing other required courses. Students are was founded to train students for careers articles. For the remainder of the fall responsible for arranging and organizing as primary care physicians who will semester, students use a team-based their weekly course activities (course practice in medically underserved areas approach for the community assessments activities described below), while faculty among populations of minorities and/or and the required presentations (Table 1). In leaders serve as group facilitators, guiding populations with low socioeconomic the spring semester, students receive groups toward completion of weekly status. MSM’s curriculum reflects the instruction on writing program objectives, tasks. In addition to completing the institution’s commitment both to on constructing and understanding logic actual assessment activities in the fall support the underserved urban and rural models, and on designing, implementing, semester and implementing the 1646 Academic Medicine, Vol. 85, No. 10 / October 2010
  • 3. Community-Based Education measurable, achievable, relevant, and Table 1 time bound. As with the needs Timeline of the Community Health Course at the Morehouse School of Medicine assessments, creativity is paramount in designing interventions at sites that have Timing Activity or activities—Students… been long-standing community partners. Fall semester ......................................................................................................................................................................................................... Because students must design a Weeks 1–3 ѧ attend lectures community intervention based on their ......................................................................................................................................................................................................... Weeks 4–5 ѧ begin meeting at community site and conduct key informant needs assessment, they may not merely interviews continue the work of previous students. ......................................................................................................................................................................................................... Weeks 6–8 ѧ conduct focus group interviews and plan surveys If the needs assessment dictates an ......................................................................................................................................................................................................... Week 7 ѧ submit their journal critiques expansion on previous students’ work, ......................................................................................................................................................................................................... the faculty facilitators challenge the Weeks 8–9 ѧ conduct their surveys and start their community engagement activities students to be creative in designing an ......................................................................................................................................................................................................... Weeks 10–11 ѧ conduct their data analyses and share the results of their needs intervention that is unique yet effective in assessment with community liaisons and leaders meeting the community’s needs. Students ......................................................................................................................................................................................................... Weeks 12–13 ѧ prepare their presentations and papers also design an evaluation of their ......................................................................................................................................................................................................... intervention. In most instances, they Week 13 ѧ submit their papers ......................................................................................................................................................................................................... use brief pretest and posttest surveys to Week 14 ѧ give their presentations to course faculty, community stakeholders, assess knowledge change, but faculty and other students encourage students to also collect Spring semester satisfaction and/or process data. ......................................................................................................................................................................................................... Week 1 ѧ attend lectures Chart 1 provides a sample student ......................................................................................................................................................................................................... Weeks 2–12 ѧ plan and revise their interventions needs assessment and intervention ......................................................................................................................................................................................................... Weeks 2–13 ѧ conduct community engagement activities from the MSM CHC. ......................................................................................................................................................................................................... Weeks 6–13 ѧ conduct their community interventions ......................................................................................................................................................................................................... Weeks 14–16 ѧ conduct their data analyses and prepare their final papers and Student Assessment presentations ......................................................................................................................................................................................................... Week 16 ѧ submit their final papers and give their presentations to course Faculty facilitators assess student learning faculty, community stakeholders, and other students and service through multiple-choice examinations, fall and spring semester intervention activities in the spring them the opportunity to make subjective group papers, fall and spring semester semester, the students spend weekly and objective evaluations that include presentations, class participation, and course time planning these activities. descriptions of the community and any completion of a reflection journal. All During the weeks of planning, dedicated evidence of trends, stability, or changes students in the group receive the same course time also allows the students to that may contribute to the health of the grade for the group papers and interact with community representatives population. Other fall semester activities presentations, but students receive and provide community service. In the include student-conducted key informant individual grades for class participation, CHC, we refer to these interactions with interviews, (i.e., interviews with integral journal entries, and their performance on the community and/or community community stakeholders) and, usually examinations. Students complete three representatives as “community following these, focus groups and reflection journal entries each semester; engagement activities.” As a group, the community surveys. Although all in each journal entry, they answer students determine the focus of their students in the course must complete predetermined questions (e.g., “Describe community engagement activities; the the same components of the needs your experience at your community site,” focus is largely site dependent. For assessment, faculty facilitators encourage “What were your initial perceptions?”, example, groups assigned to schools or them to be creative in their approach to “What are some of the general after-school programs frequently doing so. Sometimes students collect stereotypes or misconceptions you’ve participate in tutoring. In keeping with other information—for instance, had?”, and “Has your experience at your the principles of service-learning,6 the anthropometric (i.e., height and weight) site supported or refuted these students reflect on their experiences data on elementary school children. stereotypes?”). Faculty facilitators read through scheduled journal entries and the reflection journals of the students in group discussions. Students continue working in their small their group. Although the students do groups at community sites during the not receive subjective comments on their Table 1 provides a timeline of course spring semester, planning, implementing, responses, they do receive a grade activities. During the fall semester, faculty and evaluating a health promotion (complete or incomplete) for answering facilitators guide students through intervention that addresses one or more the questions. The multiple-choice the community needs assessment of the community health issues identified examinations take place once per methodology by engaging the students in during the fall semester. The students semester and are based on the a variety of assessment activities. The begin by revisiting the needs assessment introductory lectures that students assessment begins with a “windshield to determine components for their spring receive at the start of each semester. survey”—that is, the students conduct a intervention. They write objectives for Lecturers submit three to four questions visual assessment while they drive the intervention, using the SMART per lecture. The two faculty facilitators through the community. The drive allows model: Their objectives must be specific, assigned to each group decide their Academic Medicine, Vol. 85, No. 10 / October 2010 1647
  • 4. Community-Based Education first-year medical students that included Chart 1 a focus on biostatistics, epidemiology, Sample Student Needs Assessment and Intervention From the Morehouse and health disparities. It included lectures School of Medicine Community Health Course given by MSM faculty and faculty from the Centers for Disease Control and Needs assessment Prevention. In 1991, MSM received a Community site: grant from the W.K. Kellogg Foundation Local church to expand this course. The grant proposal Windshield survey*: was written based on the Area Health Conducted in a 10-mile radius of the church Education Centers (AHEC) program Key informant for key informant interviews: model, which included partnerships • Priest between medical schools and • Health ministry leaders communities. AHEC’s mission is to enhance access to quality health care, • Teen group advisors particularly primary and preventive care, • Deacon by improving the supply and distribution of health care professionals through • Lay members (e.g., president of the church parish council, president of the men’s community/academic educational group, member of the committee that developed the church’s strategic vision, partnerships.19 The U.S. Congress member of the senior citizen’s group) developed the AHEC program to recruit, train, and retain a health professions Focus group: Two conducted: One group with adults and one group with teens workforce committed to underserved Survey: populations.20 With the support of the Distributed to all parishioners at morning church service and midday church service W.K. Kellogg Foundation grant, the course designers created the original Intervention iteration in conjunction with faculty and Wellness initiative: students from local nursing schools, a Entitled “A New Year, A New You” theological center, and a school of social • Nutrition and exercise intervention: Part 1—focused on healthy cooking and work. Although its interdisciplinary exercise demonstrations (conducted at Week 7) nature was a strength, the course • Teen conference focused on coping with stress and healthy communication experienced several challenges, including (conducted at Week 9) the difficulties of identifying community faculty who could design educational • Nutrition and exercise intervention: Part 2—focused on the spiritual basis of lectures of graduate school quality, healthy eating, a healthy promotion scavenger hunt, and a healthy food potluck coordinating multiple presentations (conducted at Week 10) while avoiding redundant material, and identifying community presenters who understood the course’s relevance to * A windshield survey is an activity during which students drive through the community whose needs they plan to medical school education. In 1998, assess in order to observe and do an initial observation-only-based assessment. the course coordinator and faculty redesigned the course using the service- students’ participation grades through • a summary of the leading health-related learning construct and emphasizing the consensus. Participation grades are based community concerns including the training of only medical students. The on weekly attendance, contribution to consequences of these public health redesigned course received funding weekly discussions and course activities, concerns and the local resources from the Corporation for National and and interaction with colleagues and available to the community Community Service. Group leaders are community partners. All 10 to 14 primarily faculty from the Department of students in a group contribute to the Community Health and Preventive The spring semester papers and group papers, but they are divided into Medicine. Over the years, the course presentations offer descriptions and smaller subgroups of two or three faculty has expanded to include one evaluations of the student-conducted students for the presentations. The faculty member from the MSM interventions. Each semester, the students papers are limited to 3,000 to 3,750 Department of Pediatrics who has give their presentations (of 20 minutes, words, excluding tables, figures, and extensive community-based experience followed by a 5- to 10-minute question- appendices. All of the fall papers and and several staff members from public and-answer period) to an audience presentations include a description of the health organizations such as the Centers composed of other students, course faculty, community needs assessment and detail for Disease Control and Prevention. and community stakeholders. • community demographics and assets, A Review of the Community • morbidity and mortality data, Development of the Program Projects • socioeconomic factors that impact As in most U.S. medical schools, MSM In the first 11 years of the CHC (1999 – health, and had a required lecture-based course for 2010), over 500 students conducted 56 1648 Academic Medicine, Vol. 85, No. 10 / October 2010
  • 5. Community-Based Education community interventions—all in community partners to improve their both integral parts of the CHC—also metropolitan Atlanta, Georgia. The health. address the Healthy People Curriculum students established partnerships with the Task Force’s Community Aspects of Atlanta Housing Authority, the Boys and A CHC can also expose medical students Practice component,22 which is designed Girls Club of Metro Atlanta, Atlanta to the common health issues (e.g., poor to reflect both clinical prevention and Public Schools (grades K–12), Headstart, nutrition/obesity, substance abuse, and a population health. and other smaller grassroots organizations lack of sexual health education/resources) (e.g., churches and neighborhood experienced by adults, adolescents, and Service-learning opportunities for groups). The two leading health children in various communities. Many medical students are becoming more problems the students identified through of the problems the students diagnose common; as mentioned, the LCME now their health needs assessments were the each semester also mirror the leading mandates that they be made available for prevalence of violence and substance health indicators associated with Healthy students who wish to experience them. abuse (usually identified as comorbid by People 2010.1,21 These indicators reflect MSM’s CHC differs from most of these the community and thus considered a the major health concerns in the United in that it is required of all first-year single problem in this analysis [12 States at the beginning of the 21st students (rather than offered as an assessments]) and the lack of community century. These concerns are important elective) and thus introduces all students, development (including unemployment, public health issues, and their significance including those who would not have deteriorating housing, and lack of as relevant health disparities is reflected pursued it otherwise, to a community security [12 assessments]). Other leading by the fact that the students ascertained health experience. Further, where health problems identified in the health the necessity for interventions for similar required courses or clerkships do exist, needs assessments included low literacy problems each year. either they focus on “community rates (10 assessments), obesity and diagnosis” alone24 (or conversely, they nutrition (8 assessments), chronic Several organizations, including the require a community project without the diseases such as asthma (8 assessments) Association of American Medical needs assessment component25) or they are and hypertension (3 assessments), and Colleges (AAMC), the Healthy People classroom-based courses that are closely adolescent sexual health (3 assessments). Curriculum Task Force convened by the tied to epidemiology and traditional Interventions included educational Association for Prevention Teaching and population health experiences.26 We are not programs, health fairs, and policy Research (formerly the Association of aware of any other required course in a U.S. initiatives. Some examples of Teachers of Preventive Medicine), and or Canadian medical school that provides interventions include dental, physical the Association of Academic Health the full spectrum of community fitness, and parent education workshops, Centers, have delineated standards for assessment, intervention, and evaluation tutoring sessions to address the low integrating population health into the for first-year medical students. literacy levels, and sexual health training of health professions students.22,23 education workshops for teenagers. No The AAMC has asserted that physicians Over the span of the CHC, the data are available regarding the effect of must collaborate with other health partnerships with the community have the CHC on student perceptions during professionals and individuals enabled us to mobilize more than 500 clinical preceptorships or after graduation; representing a wide variety of community medical students to address the health however, anecdotal experience and agencies to use systematic approaches disparities of underserved youth and informal feedback suggest that students for promoting, maintaining, and adults by providing responsive health refer to their CHC experience if/when they improving the health of individuals and promotion intervention projects choose primary care residencies and that populations.23 Through participating in throughout metropolitan Atlanta. many graduates integrate community the CHC, MSM students collaborate both Each year, the community sites have service into their practice. with peers and with community members responded very favorably to the students. and work with a team. We feel that Community sites typically return each through the course they learn skills that year to participate in the program, even The Significance of Preclinical ease their transition into clinical rotations though none of the sites, community Community Health Training as upper-level medical students and members, or administrators receive This description of the CHC and review residents, and we hope they will gain compensation or honoraria for of the first 11 years of CHC data suggest proficiencies that may help them participating. Existing organizations (i.e., that a medical school course focused on function better as physicians as the parent auxiliaries and parent–teacher community health and service-learning medical model moves toward organizations at schools) at the can expose students to community needs multidisciplinary approaches to patient community sites have sought assessments and health promotion management. By performing needs opportunities to collaborate with the interventions in a variety of community assessments and designing interventions students, frequently scheduling their settings. When incorporated into the for underserved communities, students activities to coincide with the student- medical school curriculum, a CHC can in the CHC address the AAMC’s planned interventions. The community provide an opportunity for medical objective that medical students sites receive, at no cost, the results of the students to obtain hands-on community understand the economic, social, and community needs assessments, and they engagement experiences. These courses cultural factors that contribute to the benefit from an intervention designed by can provide medical students with the conditions that impact health.23 The students in response to that assessment, knowledge and skills to assess the health assessments of community needs and but they receive no financial benefits of the community and to collaborate with strengths as well as the interventions— other than the nominal budget ($500 – Academic Medicine, Vol. 85, No. 10 / October 2010 1649
  • 6. Community-Based Education $600) that each group uses to support the consideration. Although effective and 5 Carney JK, Hackett R. Community–academic assessments and interventions. easily implemented educational programs partnerships: A “community-first” model to teach public health. Education for Health. such as this course may contribute to 2008;21(1). Available at: http://www.education We feel that MSM students and faculty improving the education of future forhealth.net/publishedarticles/article_print_ serve as role models to the youth and physicians, further study is needed to 166.pdf. Accessed June 10, 2010. young adults in the community; for assess student and community 6 Seifer SD. Service-learning: Community– example, for more than four years, perceptions of the course as well as its campus partnerships for health professions education. Acad Med. 1998;73:273–277. students in the CHC have implemented a long-term effectiveness. Additional 7 Mohan CP, Mohan A. HealthSTAT: A series of life skills, substance abuse, and research is also needed to investigate the student approach to building skills needed to sexual health education workshops for impact that the CHC has on community serve poor communities. J Health Care Poor youth who live in public housing. health status, the continuity or Underserved. 2007;18:523–531. Following the end of the course, some of sustainability of student interventions, 8 Melchior A. Summary Report: National Evaluation of Learn and Serve America. the medical students have continued the specialties chosen by CHC medical Waltham, Mass: Brandeis University, Center their relationships with the youth whom students, the types of communities in for Human Resources; 1999. Available at: they mentored. We also hope that which they choose eventually to practice, http://www.learnandserve.gov/pdf/lsa_ community partners feel more and the degree to which they use the evaluation.pdf. Accessed July 6, 2010. empowered to make health decisions and knowledge and skills gained from their 9 Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen to become advocates for their own health. CHC experiences. Pregnancy. Washington, DC: National Evaluations from student interventions Acknowledgments: The authors wish to thank Dr. Campaign to Prevent Teen Pregnancy; 2001. reveal short-tem behavior changes such Meryl McNeal and the staff of the Center for 10 Liaison Committee on Medical Education. as increased physical activity and making Community Health and Service-Learning at the LCME Accreditation Standards. IS-14-A. Available at: http://www.lcme.org/functionslist. healthier food choices. We hope that Morehouse School of Medicine. The authors also htm. Accessed June 10, 2010. these behaviors continue in the long wish to thank Dr. George Rust and the staff in the 11 Manitoba Health. Community Health Needs term. Through the course, MSM has Faculty Development Program at the Morehouse Assessment Guidelines. Available at: http:// School of Medicine. strengthened its partnerships with www.chssn.org/En/pdf/networking/ Atlanta community organizations and Funding/Support: The Morehouse School of community%20health%20assessment.pdf. Medicine Community Health Course has been Accessed July 2, 2010. remains poised to respond to the 12 World Health Organization. Ottawa Charter funded in part by the W.K. Kellogg Foundation developing needs of the community. and the Corporation for National and for Health Promotion. First International Community Service. Conference on Health Promotion. Ottawa, 21 November 1986 –WHO/HPR/HEP/95.1. CHC Funding and Support Other disclosures: Dr. Blumenthal serves on the Available at: http://www.who.int/hpr/NPH/ board of directors of the Southeastern Primary docs/ottawa_charter_hp.pdf. Accessed July 2, The course is faculty-intensive; at least Care Consortium/Atlanta Area Health Education 2010. eight faculty members devote a half-day Center, which provided some financial support 13 Andrus NC, Bennett NM. Developing an nearly every week to it. Institutional (i.e., for the course. He receives no compensation for interdisciplinary, community-based MSM) support has been important, and serving on this board. education program for health professions students: The Rochester experience. Acad grant funding from the Corporation for Ethical approval: The Community Health Course Med. 2006;81:326 –331. National and Community Service and the was not evaluated in this manuscript, so IRB 14 Mareck DG, Uden DL, Larson TA, Shepard U.S. Health Resources and Services approval was not obtained. MF, Reinert RJ. Rural interprofessional Administration (HRSA) has provided Previous presentations: The authors (A.B., Y.N., service-learning: The Minnesota experience. additional support. HRSA funds the and D.B.) gave a poster presentation with Acad Med. 2004;79:672–676. information about the Morehouse School of 15 McIntosh S, Block RC, Kapsak G, Pearson AHEC program; the MSM AHEC TA. Training medical students in community program is 1 of 54 nationally. The Atlanta Medicine Community Health Course on health: A novel required fourth-year clerkship February 22, 2007, at the American College of AHEC program has helped implement at the University of Rochester. Acad Med. Preventive Medicine “Preventive Medicine 2007” the course through support of 2008;83:357–364. meeting in Miami, Florida. community sites and by offering student 16 Blumenthal DS, Jones A, McNeal M. Evaluating a community-based travel (mileage) reimbursement. multiprofessional course in community References health. Educ Health (Abingdon). 2001;14: 1 Magill MK, Quinn R, Babitz M, Saffel-Shrier 251–255. Opportunities for Enhancement S, Shomaker S. Integrating public health into 17 Kark SL. 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