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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