Commentary - (2016) Volume 13, Issue 6
Division of General Internal Medicine, Emory University School of Medicine, Atlanta, USA
Submitted date: September 03, 2016; Accepted date: October 22, 2016; Published date: October 29, 2016
Service learning is defined as “a form of experiential education in which [learners] engage in activities that address human and community needs together, with structured opportunities for reflection designed to achieve desired learning outcomes1.” Service learning is a core, but under-practiced component of physicians’ professional responsibility, yet likely contributes to improved physician engagement in advocacy for “social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.Service learning can be expected to increase physicians’ awareness of social determinants of health – defined as the complex social structures and economic systems which impact conditions of daily life3 including the social and physical environment in which people live, as well as their access tohealthy food, water, resources and health services4. Because social determinants of health “are shaped by the distribution of money, power and resources throughout local communities,” these non-biological determinants of health contribute to the perpetuation of disease and health disparities
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Service learning can be expected to increase physicians’ awareness of social determinants of health – defined as the complex social structures and economic systems which impact conditions of daily life[3] including the social and physical environment in which people live, as well as their access to healthy food, water, resources and health services[4]. Because social determinants of health “are shaped by the distribution of money, power and resources throughout local communities,” these non-biological determinants of health contribute to the perpetuation of disease and health disparities[5,6].
While more than 90% of physicians believe that addressing social determinants of health is a core professional responsibility, only 65% have participated in a community-based activity or collective advocacy in the last three years[7]. An unpublished 2007 survey of Emory Internal Medicine trainees, for example, found that 91% of residents reported an interest in volunteering, but only 10% acted on their interest.
Medical education largely fails to provide students with the knowledge and skills to address the social determinants of health and may even worsen their attitudes toward the underserved.
A critical missing element in most physicians training is the preparation of learners for engagement in social issues that affect health[8]. In fact, studies consistently show that students’ attitudes toward the underserved and medically indigent actually become more negative throughout medical school[6,9]. What remains unknown are the personal characteristics and training experiences that may foster resilience against negative forces in medical culture. In addition, there is limited information regarding specific educational interventions and teaching techniques that effectively address social determinants of health.
Educational interventions grounded in service-learning may increase physician engagement in communities.
Service-learning is a pedagogical strategy that integrates community service with instruction and reflection to enrich learning, inspire civic responsibility, and engage communities[10]. This strategy has been successfully used in undergraduate environments, with studies showing that participants have increased reflective judgment, leadership skills and compassion and decreased racism[11]. These strategies have been utilized less in medical education. In the wake of ongoing efforts to transform health care in ways that add value – improving health outcomes at lower cost—understanding and impacting health “beyond the office visit” will be critically important.
To this end, we have found that a robust and engaging social medicine curriculum should include the following elements: (1) exposure to a vast array of experiential exercises that encompass social determinants; (2) engagement with the community in a respectful and mutually beneficial way; (3) reflection; and (4) exposure to advocacy training, under the guidance of experienced faculty. We have had success providing the learners autonomy to engage in exercises they are most passionate about and implementing large and small group reflective discussions as well as reflective writing exercises.
At our institution, we developed curricula aimed at promoting experiential activities that help learners embrace social determinants of health from a personal standpoint. Exercises include asking students to visit the neighborhoods of patients under their care, and to submit a reflective summary of their experience. These activities have yielded an appreciation for the vast differences in resources available to high income versus low income neighborhoods. Learners are also encouraged to visit local nursing homes and sub-acute rehabilitation centers to which their patients are frequently transferred. Planned visits to our state capital for health related advocacy is another part of the educational experience. While some activities are prescribed, we also encourage learners to select from a menu of activities, thereby promoting engagement and involvement in topics of individual interest as it relates to social determinants and health advocacy. Finally, there are ample opportunities for written and verbal reflection on these activities.
It is our opinion that this type of service-learning increases cultural competency through a better understanding of communities and its members. Service learning may lead to increase practice and community outreach in underserved areas with great need. For example, one resident described their experiential exercise as impacting their practice through the following written reflection:
I was planning to identify and visit a senior center and/ or local pool…[to] see how hard it is to get to these places and find out what activities they have. The idea came about because I recently had a patient with bad knee OA in the clinic…and she was asking where to look, to which of course I really had no clue. Turns out that even finding these places and learning when they are open, cost, etc. was quite difficult for me (I looked online). I ended up emailing the [local] Coordinator for Senior & Volunteer Services with [our City’s] parks and recreation department, to see if they had anything we could hand out in the clinics. She actually got back to me today and is excited to help out. She is going to [meet and] give us a little more information…
Exposing trainees to service learning in primary care may lead to increase practice in underserved areas with great need. Caring for diverse and underserved populations will be increasingly important as the demographics of the US population continue to evolve.
Finally, service learning may improve future providers’ ability to perform population management and value-based care. We acknowledge that even a well-trained physician providing evidenced based medical care does not assure quality patient outcomes and health. Understanding the impact of culture and other social determinants and how to advocate for change at the community and system level, is a great tool for future clinicians who will be increasingly expected to meet health metrics collaboratively with their patients.
In conclusion, well-planned service learning curricular content gives learners an insight into the context within which they will practice medicine. Such curricula could be designed to support participants in scholarly activity that both achieves high standards of academic rigor and benefits a specific community, organization or public interest.
Further, the skills acquired through service learning may prove applicable to physicians beyond their training years. As exemplified by the resident reflection quoted above, a background in service learning may provide the confidence and tools necessary to understand the needs of the community physicians will serve as they move beyond training and into their practice of medicine. Importantly, it can be anticipated that the concepts and skills gained through this education will equip the future physicians to practice medicine in a socially complex world. When physicians are better able to understand and cooperatively address the problems facing many of their patients and communities, they are empowered to provide patientcentered care rooted in an understanding of the environmental and cultural circumstances that impact patients’ health.
