Training Platforms
As of 2015, 57 million people in the United States live in medically
underserved areas (MUA), or areas “having too few primary care
providers, high infant mortality, high poverty, or a high elderly
population.” While the number of MUAs in the U.S. is increasing, the
number of primary care physicians willing to work in these underserved
areas is decreasing.67 Although many reasons account
for the paucity of physicians practicing in MUA’s, a primary factor is
an approach to medical education that does not embrace a wider
understanding of the role of medicine in promoting community health,
addressing the needs of populations, or the importance of the social
determinants of health.
Beginning in 2001, we created innovative elective service-learning and
mentored community based participatory research (CBPR) education
programs and experiences, initially funded through grants and eventually
institionalized at UT Southwestern Medical Center at Dallas. The
benefits of community-based service learning experiences for medical
students include increasing knowledge of diseases prevalent in the
community around them and enhanced ability to develop clinical practice
skills in community-based settings. Furthermore, students are better
able to address health disparities through service learning in
impoverished areas and are able to cultivate essential citizenship
skills that allow them to be adept at spearheading causes for medical
justice in community and global health.68
Our training programs were designed to provide medical students and
residents with the skills needed to work together with communities to
reduce the disproportionate burden of chronic disease, and co-develop
appropriate and effective models of health improvement. The training
covers assessing the health needs of a specific population, implementing
and evaluating interventions to improve the health of that population,
and providing care for individual patients in the context of the
culture, health status, and health needs of the population. We prepare
trainees in community-oriented primary care, emphasize understanding and
addressing population-based health and interdisciplinary teamwork These
structured learning programs incorporate service learning activities,
community health interventions and scholarship under mentorship and
guidance from faculty members and community leaders familiar with the
social determinants of health, and include the following:
Community Health Fellowship Program (CHFP ): The Community
Health Fellowship Program (CHFP) introduces medical students to
community based and clinical research during the summer months between
their first and second year. A didactic curriculum introduces students
early in their training to population health, social determinants of
health, health disparities, and community based participatory research
(CBPR). Community organizations in low-income areas addressing the needs
of underserved communities, submit their health improvement needs to
program faculty, researchable projects are developed, and brief
proposals are presented to students. Students then select a specific
project of interest and collaborate with the community organization to
complete a mentored project to improve some aspect of the social
determinants of health. Community partner organizations include the
public health department, faith-based organizations, hospitals, local
nonprofit organizations, social service organizations, schools, and free
or reduced cost community clinics.69,70
Community Action Research Track (CART): after developing the
CHFP program in 2001, we identified a need for a more longitudinal
experience directed at community health improvement. Using the CHFP as
the foundational experience, we collaborated with our community partners
to secure a training grant from the U.S. Health and Resources Services
Administration to create a four-year, longitudinal experience for
medical students that includes instruction in public health and
community-based participatory research (CBPR), annual service-learning
experiences in the community, and completing a community health elective
in the fourth year of medical school. The lectures and experiential
training focus on population medicine, health promotion and disease
prevention, and social determinants of health. The program focus on
community-based participatory research (CBPR) and service-learning train
medical students how to provide patient care from a population
perspective while partnering with community organizations to determine
how to best meet their needs by building on their strengths and
integrating knowledge to meet shared goals.71
Community Action Research Track (CARE): The team also created a
training program in a family practice residency program with additional
support from the U.S. Health Services and Resources Administration.
Although family physicians are ideal candidates to improve access and
reduce health care disparities for individuals, many lack the knowledge
and skills to effectively impact community health.72We created a training model designed for family medicine residents in
community action research to equip them with the knowledge, skills, and
attitudes to care for the underserved and reduce health disparities
throughout the City of Dallas, and stimulate their interest in
practicing in community-based underserved settings after
graduation.73,74
Although many of the training programs we created during the past 20
years were optional and elective, they have been extremely popular among
medical students and have had a profound effect on changing the culture
of UT Southwestern Medical School and increasing the number and depth of
community relationships. Medical students can now complete for credit, a
4-week community medicine elective or participate in a 12-week advanced
learning experience completing a community health project with a
community partner. The Albert Schweitzer Fellowship Program has been
created in partnership with a local university where fellows receive
mentorship, leadership training, and complete a long-term project with
the underserved in their community. Students can also participate in
Student Run Free Clinics (SRFCs) where they engage with the community in
special initiatives. And, the cumulative experiences provided through
combined community-engaged programs and research experiences, as of 2018
allows interested medical students to graduate with MD with Distinction
in Community Health. These physicians are equipped to assume leadership
roles for improving populations health, through engaging medicine in
partnerships with others throughout the community who are addressing the
social determinants of health.
Concluding Comments and Discussion
From 2000-2020, our team of health care professors, researchers,
clinicians, social scientists, and community members, developed and
tested means for improving health outcomes and providing training in
mostly low-income, underserved, minority communities. Our approach
combined community-based participatory research (CBPR), asset-based
community development, social determinants of health, and
community-based primary care (COPC) principles. Our model community
health science program combined clinical practice, population health,
and community organization components, with the goal of promoting health
equity and reducing health disparities. We also developed means for
training the next generation of physicians in this approach. In the
U.S., university faculty members who are motivated to offer
experiential, cross-sectoral, and interprofessional educational
opportunities with community partners to their students confront
significant barriers to acquiring the training necessary to provide
these opportunities. There are few faculty development opportunities for
obtaining the relevant competencies and skills, and few career pathways
and rewards from academic leadership. Our approach has been to integrate
training into medical student and resident curriculum from the outset,
as a means for overcoming these barriers.75-78
Much of our work was and continues to be developed in response to the
deficiencies of the American health care system, which eschews primary
health care and universal health care. The U.S. health care system falls
far short of the World Health Organization standards for a
well-functioning health care system and is often considered a non-system
of health care.14,79 Despite spending more per capita
on health care than any other developed country, it consistently ranks
last in overall performance, access to quality care, administrative
efficiency, health equity, and health care outcomes.80During the last two decades, little has changed regarding the U.S.
approach to reducing health disparities or initiating the types of
reforms needed to produce a more equitable system of care. Research
consistently reveals significant differences in chronic disease
prevalence, levels of health and wellbeing, access to quality care,
average length of life, and rates of uninsurance and untreated disease
based on race, ethnicity, and income.81-84 As Donald
M. Berwick, President Emeritus of the Institute for Healthcare
Improvement observed recently, except for a few clinical preventive
services, most hospitals and physician offices continue to be “repair
shops,” trying to correct the damage caused by the upstream social
determinants of health.85
Our approach of advocating for and supporting community organizations
addressing the determinants of health and training the next generation
of physicians to understand the upstream causes of health, is only now
becoming understood in more mainstream areas of
medicine.86 A consensus is evolving in many parts of
medicine that we must take action to reduce health disparities by
addressing the full range of health determinants.2,87Researchers and clinicians in the U.S. are beginning to understand that
living in conditions of poverty creates chronic disease, and that
minorities are at greatest risk since they are disproportionately
represented in low-SES communities.88-91 Poverty also
helps explain why research during the past 20 years focused on merely
increasing access to health care has not been successful, since health
disparities result from the conditions faced by residents in low-SES
communities.92
Ten years ago appeals for medicine to more thoroughly engage the
community in order to reduce inequities were often met with puzzled
looks or indifference. However, today the evidence supporting the need
to reform health care in the United States is overwhelming; most in the
health professions recognize that the status quo is inequitable and does
little to curb epidemic levels of persistent chronic disease, especially
among those living in poverty.20 Survey data indicate
that hospital staff believe that clinical and administrative leaders are
becoming more committed to systematically addressing patients’ social
needs as part of clinical care, and some hospitals are beginning to
partner with community organizations to address other health-related
needs. However, while these well-intentioned efforts no doubt reflect
movement in the right direction, these small steps are by no means
universal across health care systems and very little information exists
about their effectiveness.86
Although we presented mostly our community-health related activities in
the present paper, the success of these activities has been promoted and
facilitated through our many longstanding partnerships with community
leaders in housing, education, food security, and economic
stability.20 Our approach assumes that the factors
contributing to health can only be addressed by working directly with
and in affected communities to co-develop health care solutions across
the broad range of causal factors. Perhaps the greatest error that U.S.
health care systems could make in trying to better address population
health and the social determinants of health, would be ignoring the
important community initiatives that are already underway in most local
communities. Understanding the value of combining the resources and
expertise of health professionals and community leaders been the
greatest lesson of our approach, has provided the foundation for our
community health science approach, and accounts for whatever success we
have achieved during these past two decades.
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