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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective a
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Kohar Jones , Laura M. Blinkhorn , Sarah-Anne Schumann & Shalini T. Reddy
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Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA b
Family Medicine, Swedish Medical Center, Seattle, Washington, USA
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Department of Medicine, OU School of Community Medicine, Tulsa, Oklahoma, USA
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Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA Published online: 10 Jul 2014.
To cite this article: Kohar Jones, Laura M. Blinkhorn, Sarah-Anne Schumann & Shalini T. Reddy (2014) Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective, Teaching and Learning in Medicine: An International Journal, 26:3, 296-303, DOI: 10.1080/10401334.2014.911698 To link to this article: http://dx.doi.org/10.1080/10401334.2014.911698
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Teaching and Learning in Medicine, 26(3), 296–303 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.911698
Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective Kohar Jones Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
Laura M. Blinkhorn Family Medicine, Swedish Medical Center, Seattle, Washington, USA
Sarah-Anne Schumann Downloaded by [Mount St Vincent University] at 16:47 04 October 2014
Department of Medicine, OU School of Community Medicine, Tulsa, Oklahoma, USA
Shalini T. Reddy Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
Background: To address the country’s most pressing healthcare needs, medical students must choose careers in primary care and commit to working with underserved populations. Involvement in student service organizations has been shown to strengthen leadership, empathy, and commitment to underserved health and may lead students to pursue careers in primary care. Description: In 2010, the University of Chicago Pritzker School of Medicine developed a novel 1-year longitudinal service-learning elective called SERVE (Service, Education, Reflection, Volunteerism Elective). Students earned elective credit for completing three course requirements: 10 service sessions, monthly reflections, and a servicelearning project. Evaluation: One third of the class enrolled in the course (33/99), 25 students completed the course, and 20 completed the final evaluation. Both quantitative and qualitative analyses of the final evaluations demonstrated high satisfaction with the course, and appreciation of the opportunity to volunteer, teach, and develop service projects. SERVE students reported a strong commitment to continuing community service after graduation, with 100% planning to continue volunteering and 70% strongly
The opinions expressed in this article are those of the authors alone and do not reflect the views of the University of Chicago Pritzker School of Medicine or the Department of Family Medicine. The abstract of Teens Teaching Up (Teen Ambassadors) was presented at the 2011 University of Chicago Pritzker School of Medicine Medical Education Day. We thank the Pritzker School of Medicine and the 4th-year students who were the inspiration of the course, with special thanks to Kavitha Selvaraj, M.D.’12, Sophie Shay, M.D.’12, and Sarah Horvath, M.D.’12, for sharing their “Teen Ambassadors” project for this article. We also thank Irma Hasham and Karen Sanders for their help with research, references, and formatting. Correspondence may be sent to Kohar Jones, 5841 South Maryland Avenue MC 7110, Suite M – 156, Chicago, IL 60637, USA. E-mail: [email protected]
agreeing with the statement that they would practice in an underserved community in the future. This commitment was higher than that expressed by the graduating class of 2012 (34%) and higher compared to a national average (30.9%). Conclusions: SERVE is a unique 1-year course that reengages 4th-year medical students in service to their communities in a structured educational environment. SERVE students report that the course has increased their involvement in the community, supported their growth into a teaching role, and enhanced continuity within student-run free clinics. Future directions include assessing the impact of SERVE students on the experience of preclinical medical students in student-run free clinics; community response to SERVE projects; and the impact of SERVE on volunteerism, primary care specialty choice, and future practice in underserved communities for class participants during their medical careers. Keywords
service-learning, medical education, underserved communities, public health
curriculum,
BACKGROUND The number of Americans in need of a doctor is growing as baby boomers age and the Affordable Care Act brings healthcare access to the previously uninsured.1 The Association of American Medical Colleges (AAMC) and others predict physician shortages, especially for primary care, with underserved populations suffering the most from this shortage.2,3 Fitzhugh Mullan and others have called on medical schools to live up to their social mission by training students to tackle the country’s most urgent needs.2,4–6 To address shortages and disparities in healthcare, increasing numbers of medical students will need to practice primary care and commit to serving vulnerable populations. Medical schools must find ways to introduce students to the challenges, rewards, and excitement of this work.
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Service-learning curricula may help to achieve this social mission of medical education. Service-learning courses provide richness and depth to the medical education experience. Students who participate in service organizations have strengthened commitment to underserved health,7 leadership skills,8,9 and increased empathy.10 Studies on involvement in service and future specialty choice have been less clear.7,11 The goal of service-learning is to create a mutually beneficial balance of community service and student learning.12 In response to community-defined health needs, students create projects and partnerships in underserved communities and reflect critically on the experience. Inspired by John Dewey and David A. Kolb’s writings on experiential education, servicelearning courses help students practice medicine more thoughtfully through service and reflection.13,14 Ideally, students engage in community service throughout their time in medical school and apply the lessons they learn in formal curricular activities to the care of underserved communities. In designing service-learning curricula, each medical school must examine the needs of its students and surrounding community. The University of Chicago Pritzker School of Medicine is a private medical school located in a culturally rich but socioeconomically disadvantaged urban community. Many students choose to come to Pritzker because of the opportunity to engage with the neighboring community on Chicago’s South Side. In the 2011 AAMC graduation questionnaire, 85.6% of graduating Pritzker students reported that they had some involvement in student-run free clinics (SRFCs) during their time in medical school, with 32.4% reporting participation in a structured service-learning experience (2011 data as reported in the AAMC 2012 Medical School graduation questionnaire, Question 12 [SRFC] and Question 11 [service-learning]).3 Although this level of involvement is laudable, engagement in community service had previously occurred almost exclusively during the first 2 years of medical school and generally without formal academic guidance. Rather, underclass students participate in student-run outreach organizations and clinics. Participation in service activities decreases dramatically during subsequent years of medical school due to the increasing complexity and quantity of coursework, board preparation, clinical rotations, and ultimately the residency application process. This drop-off in student participation has led to discontinuity in clinic leadership; loss of mentorship opportunities for underclassmen and missed opportunities for 4th-year students to reengage in service activities after they have had meaningful clinical experiences through their clerkships. Many Pritkzer 4th-year students want to resume community service activities but identified several barriers. These barriers include the need to fulfill graduation requirements and time constraints imposed by the residency application process. Students noted that providing course credit for service-learning would facilitate participation in volunteer activities. At the same time that students were identifying a desire to reengage in community service, there has been a growing
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national recognition of the importance of service-learning in medical education. In 2008, the Liaison Committee for Medical Education (LCME) issued the following standard regarding service learning: IS-14-A. Medical schools should make available sufficient opportunities for medical students to participate in service-learning activities, and should encourage and support student participation.15
Many innovative service-learning curricula have been developed in response to this standard.16–19 Many service electives target preclinical medical students, though a few address the particular needs of 4th-year students.20 We present a description and evaluation of a unique 1-year service-learning elective for 4th-year students, established in response to 4th-year student requests to obtain needed credits for graduation while returning to work in student service organizations, in compliance with new LCME service-learning objectives. SERVE provides students the opportunity to increase their knowledge of underserved medicine, teach underclassmen, and develop and implement service projects in the Pritzker community. The course also guarantees stability in student-run clinics and enhances interstudent communication between the preclinical and clinical years. Long term, the goal of the course is to nurture an ongoing commitment to underserved medicine, regardless of students’ specialty choice, while building the skills to confidently practice as primary care physicians in the future. DESCRIPTION One of the authors (SAS) piloted a yearlong 4th-year ServiceLearning Elective in 2010–2011. The objective of the course was to provide structured educational opportunities that would allow 4th-year students to learn by serving community-defined health needs. The course, renamed the Service, Education, Reflection, and Volunteerism Elective (SERVE), has continued to operate under the direction of two of the authors (KJ and STR) as an expanded elective. The course was specifically designed to accommodate 4th-year schedules, including flexibility around the residency application process. We hypothesize that the elective would benefit 4th-year students by allowing them to explore their interest in community service, work with and teach underclassmen in a community setting, and solidify their commitment to vulnerable populations before the beginning of residency. We also hypothesize that this elective would strengthen existing student-led service groups by creating more stability in leadership and allowing for the implementation of projects. COURSE DESIGN SERVE is a 1-year longitudinal elective course that is available to interested 4th-year students who have completed their core clinical rotations. The 2011–2012 course consisted of three main components: (a) monthly reflection assignments, (b) participation in 10 direct service sessions, and (c) the completion
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TABLE 1 Reflection topics for SERVE course Didactic Session Title
Date
Course Overview & Expectations “What is Service-Learning?”
June
Introduction
July
1) What is service-learning? Seifer SD. “Service-learning: 2) What are its promises? Community-campus 3) What are the perils? partnerships for health 4) What aspect of service-learning will professions education.” Acad you be engaging in? Med. 1998 5 5) What are your goals for your servicelearning experience? Begin thinking about what project you will want to do. What community will you serve? What health needs do you want to address? 1) Describe the 5 microskills for Neher JO, et al. A five-step teaching “Microskills” model of clinical 2) How will you apply these techniques teaching.” J Am Board Fam in your precepting of first and second Pract.6 year students? Meet with community/organizational leaders—what are their concerns? Do they have a project they want you to work on? Do you have a project you will bring to them? 1) Describe an ethical dilemma you Buchanan D, Witlen R. “Balancing faced while engaged in serviceservice and education: Ethical learning. management of student-run clinics.” J Healthcare Poor Underserved. 2006 7 Decide on your project; identify community and faculty mentors. 1) What challenges does your Caines LC, et al. “The revolving student-run organization face with door of resident continuity transitions of leadership and student practice: Identifying gaps in involvement each year? transitions of care.” J Gen Intern 2) What could be done to make this Med. 20118, 9 easier and improve patient care? 3) What can you do to improve leadership transitions? 1) Project description 2) Reflect challenges/supports Project, context, specifics, outcome, broader impact, future What went well? Challenges? Quality Improvement for course
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Project Milestone
Your Impact on Students “Five Microskills for Clinical Teaching”
August
Project Milestone
“The Ethics of Service-Learning”
September
Project Milestone “Leadership Transitions in Student-Run Free Clinics”
Project Reflections Project Presentations End-of-Year Reflection
October
November December January–April
Trigger Questions for Reflection
of a project that applies the principles of service-learning.21 Students have flexibility in how and when to complete the course requirements to allow them to travel for away rotations and residency interviews. Reflection sessions can be completed either
Reading —
in person via a small-group didactic session or through online journaling. Both didactic and journaling exercises are anchored by a reading in a relevant topic. Four special topics are covered and are shown in Table 1. Faculty who have expertise in the
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TABLE 2 Specialty choice
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Choice of Specialty Anesthesiology Dermatology Emergency Medicine Family Medicine General Surgery Internal Medicine Internal Medicine/Pediatrics Neurology Obstetrics and Gynecology Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Plastic Surgery Psychiatry Radiology Radiation Oncology Urology Primary Care Specialties (Family Medicine, Internal Medicine, Pediatrics) No. of Responses
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TABLE 3 Final course evaluation results
SERVE Class of Participants (%) 2012 (%) 0 0 8 20 4 36 4 0 4 4 0 4 0 4 0 4 4 0 4 60
25
7 1 5 4 6 28 3 4 4 2 7 3 3 4 2 5 5 2 3 36
99
topics are guest lecturers for the class meetings. The remaining monthly assignments ask that students reflect on their experiences with volunteerism and provide updates on their projects. In the first 2 years the course was offered, students were required to volunteer in 10 outreach sessions for a student-run free clinic or neighborhood school outreach program. Students are also made aware of opportunities to volunteer in one-time events such as student organized health fairs or days of service. The service sessions involve providing not only direct service to the community but also mentorship and teaching to underclassmen at the clinics and organizations. The requirement was reduced to eight outreach sessions in the 2012–2013 year in response to course evaluations. Before beginning their project, students are introduced to the service-learning model.12 They are encouraged to identify a need in an existing student service organization and develop a project to improve care, efficacy, or quality. For example, one student found that there was inadequate and ineffective screening for depression at a student-run clinic. This student developed a worksheet explaining how to administer a validated depression screening questionnaire and a list of resources for patients who had a positive screen. Students are given the option
Questiona
M (SD)
How much prior exposure did you have to the content covered in this course?b The course is meeting the objectives stated in the syllabus. The course is well organized. The course provides me with useful knowledge, skills, or insights. The course material is presented at an appropriate level. The content material is well paced, so the workload is spread evenly. The content material is constructively challenging. The effort required to learn the material is reasonable. The assigned readings are valuable adjuncts to the course. The clinical relevance of the course material is made apparent. I am planning to practice in an underserved community in the future. I am planning to volunteer in the future. Overall, this is an outstanding course to date.
3.40 (1.05) 4.65 (0.49) 4.10 (0.91) 4.55 (0.60) 4.55 (0.69) 4.55 (0.60) 4.60 (0.60) 4.80 (0.41) 4.47 (0.77) 4.70 (0.47) 4.50 (0.83) 4.85 (0.37) 4.60 (0.60)
a Unless otherwise specified, questions utilized Likert scale of 1 (strongly disagree) to 5 (strongly agree). b 1 = no exposure at all; 5 = a great deal of exposure.
of working independently or in small groups of two to five under the guidance of a faculty mentor. Almost all student projects involve close interactions with the underclass students who run the service organizations and clinics. The projects are presented to the class in the latter half of the year. Several projects have been continued over the 3 years that the course has been offered. EVALUATION During the 2011–2012 school year, 33 students enrolled in the course from a class of 99 (33.3%). A total of 25 students completed the course, 16 women and nine men. The SERVE students matched in a broad range of future specialties (see Table 2), but the potential primary care specialties (as defined by the AAMC—internal medicine, pediatrics, family medicine) had a larger proportion than in the graduating class (60% vs. 36%). For comparison, the AAMC 2012 medical school graduate questionnaire Question 21a showed 22.9% in IM, 6.0% peds, and 2.4% in FM for a total of 31.3% of medical school graduates entering potential primary care specialities.22
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TABLE 4 Qualitative analysis Themes
No. of Comments
Representative Quote
1) How, if at all, did SERVE shape your future plans? “SERVE inspired me to dedicate my future practice to underserved communities.” 4 “It gave me a chance to try teaching, which was fun.” 5 “I did gain helpful insight into organizational management and institutional transitions that will be helpful to me in the future.” d) self-efficacy 5 “I learned a lot about the pros and cons of service learning and how to create a service learning project in my community.” 2) What can we do differently next year to make the class go even better?
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a) commitment to underserved patients b) joy of teaching c) practical experience
4
a) logistics b) flexibility
8 5
c) fewer required service sessions d) increased involvement of 1st-year students
4
“regular class meeting times” “I think it was really helpful that you expanded the volunteer requirement to include service outside of the student-run clinics, as it was challenging at times to arrange to work in the clinics.” “fewer number of volunteering sessions”
2
“more communication for the first-year students”
3) What went well with the SERVE elective? a) teaching 4
“The interactions with underclassmen were great . . . . it kept me clinically engaged and also put me in a position to teach on the go.” b) service 7 “The service experiences themselves were very valuable.” c) projects 7 “The project mostly ran smoothly.” d) flexibility 4 “flexibility of attending a class or writing a reflection.” e) theory 3 “Great balance of volunteer requirements mixed with helpful lectures.” 4) What were the challenges with the SERVE elective? a) scheduling b) clinic cancellation
12 2
c) group work
2
“Some scheduling difficulties.” “The volunteer days I signed up for were frequently cancelled due to the lack of a physician.” “Group organization. Needed more intervention from instructors.”
Quantitative Data The SERVE 2011–2012 course was well received by 4th-year students. At the end of the year, students rated the course using a standard evaluation form that consisted of a 5-point Likert scale. Eighty percent (20/25) of the SERVE students enrolled in the class at the end of the year responded to the final evaluation. Quantitative results are shown in Table 3. On average, students reported moderate prior exposure to the course content (3.40, SD = 1.05; 1 = no exposure, 5 = a great deal of exposure). Students strongly endorsed the statement that SERVE was an outstanding course (4.60, SD = 0.60; 1 = strongly disagree, 5 = strongly agree). They found the material to be clinically relevant (4.70, SD = 0.47) and rated the readings as valuable (4.47, SD = 0.77).
SERVE students reported a strong commitment to continuing community service after graduation. All students plan to continue volunteering, with 85% of students (17/20) in strong agreement and 15% (3/20) in agreement with the statement that they would volunteer in the future. Seventy percent (14/20) strongly agreed with the statement that they would practice in an underserved community in the future. This commitment to working with underserved patients was higher than that expressed by their peers in the graduating class of 2012 (41.5%; 35% excluding SERVE participants) and much higher compared to a national average (30.9%; AAMC 2012 Question 25). On the 2012 AAMC Questionnaire, 35.1% of graduating Pritzker students reported plans to care for a primarily underserved population compared to a national average of 27.8% (AAMC 2012 Question 26).
COMMUNITY SERVICE IN MEDICAL SCHOOL YEAR 4
TABLE 5 Service-learning projects 2011—2012
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Pritzker Day of Service
5 course participants organized quarterly days of service in the fall, winter, and spring semesters. Students partnered with 3 neighborhood sites to do various projects, including gardening, tutoring, and organization. In the fall 62 students participated, 55 participated in the winter, and 45 in the spring. Teen Ambassadors 3 course participants worked with neighborhood teenagers to create a curriculum to teach physicians how to communicate effectively with teenagers. Depression 2 course participants translated the PHQ-9 Screening into dozens of East Asian languages and taught clinic volunteers how to utilize the instrument. Clinic Teaching 5 course participants developed a Curriculum curriculum for 1st- and 2nd-year medical students who volunteered in a student-run free clinic (Community Health Clinic Curriculum). Education 2 course participants formalized a teaching Curriculum for curriculum for a substance abuse School-Based prevention educational program Education (Adolescent Substance Abuse Program). Clinic Leadership 2 course participants oversaw the creation Transitions of manuals to improve clinic handoffs at all clinic sites. Healthcare for 2 course participants organized sessions Vulnerable for a year-long lecture series attended by Populations medical students, residents, and attendings on primary care for vulnerable and underserved populations. Physician 1 course participant reached out to faculty Recruitment in primary care specialties to recruit potential physician volunteers. Preclinical 1 course participant designed the Correlation curriculum for several small group, Lectures 15-minute didactic sessions to be taught before clinics opened. Topics included common primary care complaints such as low back pain, hypertension, and mood disorders. Qualitative Data In their final evaluations, students also submitted comments to open-ended prompts addressing their future plans and their assessment of the SERVE elective. Qualitative results are shown in Table 4. Data were analyzed using the constant comparative method, consistent with a grounded theory approach, to analyze student course evaluations.23 Three authors (KJ, STR, LMB)
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independently identified themes in the responses to each question prompt. The themes were compared and chosen for each question prompt. Then two coders (KJ, LMB) independently assigned themes to each comment and met to compare and reconcile the analysis. Prompts used to gather comments were as follows: (a) How, if at all, did SERVE shape your future plans? (b) What can we do differently next year to make the class go even better? (c) What went well with the SERVE elective? (d) What were the challenges with the SERVE elective? A total of 54 comments were analyzed. Data are presented next by questions. 1. How, if at all, did SERVE shape your future plans? (11 responses). We identified four themes from 11 unique responses. Students found that the course strengthened commitment to underserved patients (“Re-affirmed my desire to work with underserved communities”), introduced them to the joy of teaching (“It gave me a chance to try teaching, which was fun”), offered insight into the practical aspects of community work (“I learned . . . how to create a service-learning project in my community”), and enhanced self-efficacy (“SERVE gave me the space to grow as a servant of the surrounding community”). 2. What can we do differently next year to make the class go even better? (14 responses). The four themes that emerged as suggestions to improve the course were better logistics, increased flexibility, fewer service requirements, and more integration of 1st-year students. Student suggestions included “Having a pre-planned schedule for SERVE meetings” and “Getting first years even more involved in the course.” 3. What went well with the SERVE elective? (15 responses). The five most frequent themes that arose in the qualitative comments about what went well in the course were: pleasure of teaching (“Terrific to work with first-years in the clinic”), appreciation of the opportunity to re-engage in community service (“Loved working in the clinic as an M4!!!”), enjoyment of the projects (“I really enjoyed learning about other people’s projects”), and appreciation both of the flexibility of the class (“Having the freedom to create and implement a communitybased project”) and the theory grounding the service (“Great balance of volunteer requirements and helpful lectures”). 4. What were the challenges with the SERVE elective? (14 response). Students identified a number of challenges that they encountered with the course, primarily related to the logistics of scheduling service sessions during the busy 4th year of medical school. Other students had difficulty fitting in to the clinic schedule, working in groups on projects and accommodating clinic cancellations. One student noted, “Scheduling—sometimes difficult to get into assigned clinic, either because of limited numbers of spaces or because of other scheduling conflicts.”
SERVE PROJECTS The SERVE student projects were designed by the students in response to community defined needs and were diverse in their scope and execution. There were nine separate
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individual or group projects including an effort to improve referral mechanisms in free clinics, the creation of educational tools for 1st-year medical student volunteers at free clinics, and the implementation of language specific screening tools for depression. Table 5 summarizes the student projects for the 2011–2012 academic year. An example of a project that was created using the service-learning model is “Teen Ambassadors,” which partnered medical students with high school students in a youth program to create a workshop to teach healthcare professionals how to communicate effectively with adolescents. This is detailed in the appendix.
CONCLUSION SERVE is a successful 1-year longitudinal 4th-year elective for medical students, which provides structure and credit for engagement in service-learning. The course is well received and has encouraged the development of novel community-based projects. At the conclusion of the course, students rated the elective highly, and demonstrated a strong commitment to future volunteerism and practice in underserved communities. We conclude that SERVE is a feasible model for incorporating structured service-learning into the medical school curriculum, reengaging 4th-years in service activities, and strengthening student organizations. All of these goals can be accomplished while improving teaching skills and student commitment to underserved communities. These skills will serve students well in their transition to residency. In response to student requests, we have decreased the number of service sessions to eight, and provided the full year’s class schedule at our first meeting. A by-product of SERVE has been a shift in the structure of student-run organizations, with increasing involvement in leadership over the 4 years of medical school. This, in turn, has strengthened organizational memory and provided opportunities for the 1st- and 2nd-year student leaders to learn from 4th-year SERVE students. Before the SERVE elective, few 4th-year students independently volunteered. Because the service-learning elective was formalized, Pritzker 4th-year students have returned to the organizations they volunteered and led in their preclinical years. They have valuable clinical experience to share with underclass students and can see the evolution of the student organizations and suggest new directions and improvements. Future directions for SERVE include formalizing the integration of 1st- and 2nd-year medical students into the SERVE elective, and identifying additional service-learning opportunities for 4th-year medical students. Limitations to our study include the level at which the success of the course was evaluated. Although the data thus far are almost exclusively from student reactions (Kirkpatrick’s first level), it is reassuring to learn from the qualitative comments that students’ desire to work with the underserved was strengthened by the course. The course remains popular with more than one
fourth of 4th-year students (23/82) enrolled for the 2012–2013 school year. Future studies will assess the underclassmen’s response to 4th-year involvement, evaluate community reactions to SERVE supported projects, and track prior SERVE students’ future dedication to underserved communities and primary care during residency and beyond. This latter goal is difficult to assess in the short term,24 so we will continue to follow the career trajectory of SERVE participants and observe the number who volunteer, go on to practice in underserved settings, choose to enter primary care from internal medicine and pediatric residencies, engage in teaching, and return to the communities they served as medical students to teach the next generation, supporting the social mission of medicine. FUNDING This course was established with a grant from the Academy of Distinguished Medical Educators: “Developing and Implementing a Scholarly Track in Community Health and ServiceLearning for Pritzker Students,” with ongoing support from the Department of Family Medicine at the University of Chicago. REFERENCES 1. Schwartz M. health care reform and the primary care workforce bottleneck. Journal of General Internal Medicine 2012;27:469–72. 2. West CP, Dupras DM. General medicine vs. subspecialty career plans among internal medicine residents. Journal of the American Medical Association 2012;308:2241–7. 3. AAMC 2012 Physican specialty data book: Center for Workforce Studies. Available at: https://members.aamc.org/eweb/upload/12039%20Specialty%20Databook final2.pdf. Accessed March 27, 2014. 4. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: Ranking the schools. Annals of Internal Medicine 2010;152:804–11. [Erratum appears in Ann Intern Med 2010;153:212]. 5. Markuns J, Culpepper L, Halpin WJ. Commentary: A need for leadership in primary care for the underserved: a call to action. Academic Medicine 2009;84:1325–7. 6. Foreman S. Social responsibility and the academic medical center: Building community-based systems for the nation’s health. Academic Medicine 1994;69:97–102. 7. Campos-Outcalt D, Chang S, Pust R, Johnson L. Commitment to the underserved: Evaluating the effect of an extracurricular medical student program on career choice. Teaching & Learning in Medicine 1997;9:276–81. 8. Veronesi MC, Gunderman RB. Perspective: The potential of student organizations for developing leadership: one school’s experience. Academic Medicine 2012;87:226–9. 9. Long JA, Lee RS, Federico S, Battaglia C, Wong S, Earnest M. Developing leadership and advocacy skills in medical students through service learning. Journal of Public Health Management & Practice 2011;17: 369–72. 10. Brazeau CM, Schroeder R, Rovi S, Boyd L. Relationship between medical student service and empathy. Academic Medicine 2011;86:S42–5. 11. Tong ST, Phillips RL, Berman R. Is exposure to a student-run clinic associated with future primary care practice? Family Medicine 2012;44:579–81. 12. Seifer SD. Service-learning: Community-campus partnerships for health professions education. Academic Medicine 1998;73:273–7. 13. Dewey J. Experience and education. New York, NY: Macmillan, 1963.
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COMMUNITY SERVICE IN MEDICAL SCHOOL YEAR 4 14. Kolb D. Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall, 1984. 15. Liaison Committee on Medical Education Standards and Publications. Available at: http://www.lcme.org/standard.htm. Accessed February 17, 2012. 16. Averill NJ, Sallee JM, Robinson JT, McFarlin JM, Montgomery AA, Burkhardt GA, et al. A first-year community-based service learning elective: Design, implementation, and reflection. Teaching & Learning in Medicine 2007;19:47–54. 17. McNeal MS, Buckner AV. Using mini-grants and service-learning projects to prepare students to serve underserved populations. Journal of Healthcare for the Poor & Underserved 2012;23:20–6. 18. Packer CD, Carnell RC, Tomcho PM, Scott JG. Development of a fourday service-learning rotation for third-year medical students. Teaching & Learning in Medicine 2010;22:224–8. 19. Elam CL, Sauer MJ, Stratton TD, Skelton J, Crocker D, Musick DW. Service learning in the medical curriculum: Developing and evaluating an elective experience. Teaching & Learning in Medicine 2003;15:194–203. 20. Wolff M, Young S, Maurana C. A senior elective: Promoting health in underserved communities. Family Medicine 2001;33:732–3. 21. Seifer SD, Connors K, O’Neil EH. Combining service and learning in partnership with communities. Academic Medicine 1996;71:527. 22. AAMC Physician Workforce Policy Recommendations September 2012. Available at: https://www.aamc.org/download/304026/data/2012aamcwork forcepolicyrecommendations.pdf. Accessed March 27, 2014. 23. Harris I. What does “The discovery of grounded theory” have to say to medical education? Advances in Health Sciences Education 2003;8:49–61. 24. Eckenfels EJ. The purpose of service learning. Family Medicine 2009;41:659–62.
APPENDIX Service-Learning Course Example Project: Teen Ambassadors
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To promote urban adolescent health, three SERVE students partnered with eight teenagers from “Children Teaching Children” in the after-school Chicago Youth Program, housed in the same building as a preexisting student run free pediatric clinic. Under medical student guidance, the teenagers created then led a 45-minute workshop to teach doctors and medical students how to communicate with adolescents about sensitive health issues. By clarifying physician misconceptions of the needs of urban youth, and speaking across large differences in age, race, subcultural idiom, and socioeconomic background, the Teen Ambassadors seek to improve communication to improve the doctor–patient relationship and increase adolescent utilization of healthcare. From July through September 2011 the SERVE medical students worked with the community to brainstorm and plan the curriculum. Teen Ambassadors were recruited in October. From October through January the medical students guided the high school students to develop the presentations. This included assistance with preparing workshop material, coaching the teens on presentation skills, and empowering them to speak for their own needs. In February 2012 the Teen Ambassadors first led the workshop for health professionals in a special SERVE class session opened to all medical students and select faculty. The Teen Ambassadors will lead their workshop at annual board meetings of the Washington Park Clinic. Each year an evolving group of newly recruited Teen Ambassadors will renew the curriculum on adolescent health for medical students and physicians.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective a
b
c
Kohar Jones , Laura M. Blinkhorn , Sarah-Anne Schumann & Shalini T. Reddy
d
a
Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA b
Family Medicine, Swedish Medical Center, Seattle, Washington, USA
c
Department of Medicine, OU School of Community Medicine, Tulsa, Oklahoma, USA
d
Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA Published online: 10 Jul 2014.
To cite this article: Kohar Jones, Laura M. Blinkhorn, Sarah-Anne Schumann & Shalini T. Reddy (2014) Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective, Teaching and Learning in Medicine: An International Journal, 26:3, 296-303, DOI: 10.1080/10401334.2014.911698 To link to this article: http://dx.doi.org/10.1080/10401334.2014.911698
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Teaching and Learning in Medicine, 26(3), 296–303 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.911698
Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective Kohar Jones Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
Laura M. Blinkhorn Family Medicine, Swedish Medical Center, Seattle, Washington, USA
Sarah-Anne Schumann Downloaded by [Mount St Vincent University] at 16:47 04 October 2014
Department of Medicine, OU School of Community Medicine, Tulsa, Oklahoma, USA
Shalini T. Reddy Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
Background: To address the country’s most pressing healthcare needs, medical students must choose careers in primary care and commit to working with underserved populations. Involvement in student service organizations has been shown to strengthen leadership, empathy, and commitment to underserved health and may lead students to pursue careers in primary care. Description: In 2010, the University of Chicago Pritzker School of Medicine developed a novel 1-year longitudinal service-learning elective called SERVE (Service, Education, Reflection, Volunteerism Elective). Students earned elective credit for completing three course requirements: 10 service sessions, monthly reflections, and a servicelearning project. Evaluation: One third of the class enrolled in the course (33/99), 25 students completed the course, and 20 completed the final evaluation. Both quantitative and qualitative analyses of the final evaluations demonstrated high satisfaction with the course, and appreciation of the opportunity to volunteer, teach, and develop service projects. SERVE students reported a strong commitment to continuing community service after graduation, with 100% planning to continue volunteering and 70% strongly
The opinions expressed in this article are those of the authors alone and do not reflect the views of the University of Chicago Pritzker School of Medicine or the Department of Family Medicine. The abstract of Teens Teaching Up (Teen Ambassadors) was presented at the 2011 University of Chicago Pritzker School of Medicine Medical Education Day. We thank the Pritzker School of Medicine and the 4th-year students who were the inspiration of the course, with special thanks to Kavitha Selvaraj, M.D.’12, Sophie Shay, M.D.’12, and Sarah Horvath, M.D.’12, for sharing their “Teen Ambassadors” project for this article. We also thank Irma Hasham and Karen Sanders for their help with research, references, and formatting. Correspondence may be sent to Kohar Jones, 5841 South Maryland Avenue MC 7110, Suite M – 156, Chicago, IL 60637, USA. E-mail: [email protected]
agreeing with the statement that they would practice in an underserved community in the future. This commitment was higher than that expressed by the graduating class of 2012 (34%) and higher compared to a national average (30.9%). Conclusions: SERVE is a unique 1-year course that reengages 4th-year medical students in service to their communities in a structured educational environment. SERVE students report that the course has increased their involvement in the community, supported their growth into a teaching role, and enhanced continuity within student-run free clinics. Future directions include assessing the impact of SERVE students on the experience of preclinical medical students in student-run free clinics; community response to SERVE projects; and the impact of SERVE on volunteerism, primary care specialty choice, and future practice in underserved communities for class participants during their medical careers. Keywords
service-learning, medical education, underserved communities, public health
curriculum,
BACKGROUND The number of Americans in need of a doctor is growing as baby boomers age and the Affordable Care Act brings healthcare access to the previously uninsured.1 The Association of American Medical Colleges (AAMC) and others predict physician shortages, especially for primary care, with underserved populations suffering the most from this shortage.2,3 Fitzhugh Mullan and others have called on medical schools to live up to their social mission by training students to tackle the country’s most urgent needs.2,4–6 To address shortages and disparities in healthcare, increasing numbers of medical students will need to practice primary care and commit to serving vulnerable populations. Medical schools must find ways to introduce students to the challenges, rewards, and excitement of this work.
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Service-learning curricula may help to achieve this social mission of medical education. Service-learning courses provide richness and depth to the medical education experience. Students who participate in service organizations have strengthened commitment to underserved health,7 leadership skills,8,9 and increased empathy.10 Studies on involvement in service and future specialty choice have been less clear.7,11 The goal of service-learning is to create a mutually beneficial balance of community service and student learning.12 In response to community-defined health needs, students create projects and partnerships in underserved communities and reflect critically on the experience. Inspired by John Dewey and David A. Kolb’s writings on experiential education, servicelearning courses help students practice medicine more thoughtfully through service and reflection.13,14 Ideally, students engage in community service throughout their time in medical school and apply the lessons they learn in formal curricular activities to the care of underserved communities. In designing service-learning curricula, each medical school must examine the needs of its students and surrounding community. The University of Chicago Pritzker School of Medicine is a private medical school located in a culturally rich but socioeconomically disadvantaged urban community. Many students choose to come to Pritzker because of the opportunity to engage with the neighboring community on Chicago’s South Side. In the 2011 AAMC graduation questionnaire, 85.6% of graduating Pritzker students reported that they had some involvement in student-run free clinics (SRFCs) during their time in medical school, with 32.4% reporting participation in a structured service-learning experience (2011 data as reported in the AAMC 2012 Medical School graduation questionnaire, Question 12 [SRFC] and Question 11 [service-learning]).3 Although this level of involvement is laudable, engagement in community service had previously occurred almost exclusively during the first 2 years of medical school and generally without formal academic guidance. Rather, underclass students participate in student-run outreach organizations and clinics. Participation in service activities decreases dramatically during subsequent years of medical school due to the increasing complexity and quantity of coursework, board preparation, clinical rotations, and ultimately the residency application process. This drop-off in student participation has led to discontinuity in clinic leadership; loss of mentorship opportunities for underclassmen and missed opportunities for 4th-year students to reengage in service activities after they have had meaningful clinical experiences through their clerkships. Many Pritkzer 4th-year students want to resume community service activities but identified several barriers. These barriers include the need to fulfill graduation requirements and time constraints imposed by the residency application process. Students noted that providing course credit for service-learning would facilitate participation in volunteer activities. At the same time that students were identifying a desire to reengage in community service, there has been a growing
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national recognition of the importance of service-learning in medical education. In 2008, the Liaison Committee for Medical Education (LCME) issued the following standard regarding service learning: IS-14-A. Medical schools should make available sufficient opportunities for medical students to participate in service-learning activities, and should encourage and support student participation.15
Many innovative service-learning curricula have been developed in response to this standard.16–19 Many service electives target preclinical medical students, though a few address the particular needs of 4th-year students.20 We present a description and evaluation of a unique 1-year service-learning elective for 4th-year students, established in response to 4th-year student requests to obtain needed credits for graduation while returning to work in student service organizations, in compliance with new LCME service-learning objectives. SERVE provides students the opportunity to increase their knowledge of underserved medicine, teach underclassmen, and develop and implement service projects in the Pritzker community. The course also guarantees stability in student-run clinics and enhances interstudent communication between the preclinical and clinical years. Long term, the goal of the course is to nurture an ongoing commitment to underserved medicine, regardless of students’ specialty choice, while building the skills to confidently practice as primary care physicians in the future. DESCRIPTION One of the authors (SAS) piloted a yearlong 4th-year ServiceLearning Elective in 2010–2011. The objective of the course was to provide structured educational opportunities that would allow 4th-year students to learn by serving community-defined health needs. The course, renamed the Service, Education, Reflection, and Volunteerism Elective (SERVE), has continued to operate under the direction of two of the authors (KJ and STR) as an expanded elective. The course was specifically designed to accommodate 4th-year schedules, including flexibility around the residency application process. We hypothesize that the elective would benefit 4th-year students by allowing them to explore their interest in community service, work with and teach underclassmen in a community setting, and solidify their commitment to vulnerable populations before the beginning of residency. We also hypothesize that this elective would strengthen existing student-led service groups by creating more stability in leadership and allowing for the implementation of projects. COURSE DESIGN SERVE is a 1-year longitudinal elective course that is available to interested 4th-year students who have completed their core clinical rotations. The 2011–2012 course consisted of three main components: (a) monthly reflection assignments, (b) participation in 10 direct service sessions, and (c) the completion
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TABLE 1 Reflection topics for SERVE course Didactic Session Title
Date
Course Overview & Expectations “What is Service-Learning?”
June
Introduction
July
1) What is service-learning? Seifer SD. “Service-learning: 2) What are its promises? Community-campus 3) What are the perils? partnerships for health 4) What aspect of service-learning will professions education.” Acad you be engaging in? Med. 1998 5 5) What are your goals for your servicelearning experience? Begin thinking about what project you will want to do. What community will you serve? What health needs do you want to address? 1) Describe the 5 microskills for Neher JO, et al. A five-step teaching “Microskills” model of clinical 2) How will you apply these techniques teaching.” J Am Board Fam in your precepting of first and second Pract.6 year students? Meet with community/organizational leaders—what are their concerns? Do they have a project they want you to work on? Do you have a project you will bring to them? 1) Describe an ethical dilemma you Buchanan D, Witlen R. “Balancing faced while engaged in serviceservice and education: Ethical learning. management of student-run clinics.” J Healthcare Poor Underserved. 2006 7 Decide on your project; identify community and faculty mentors. 1) What challenges does your Caines LC, et al. “The revolving student-run organization face with door of resident continuity transitions of leadership and student practice: Identifying gaps in involvement each year? transitions of care.” J Gen Intern 2) What could be done to make this Med. 20118, 9 easier and improve patient care? 3) What can you do to improve leadership transitions? 1) Project description 2) Reflect challenges/supports Project, context, specifics, outcome, broader impact, future What went well? Challenges? Quality Improvement for course
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Project Milestone
Your Impact on Students “Five Microskills for Clinical Teaching”
August
Project Milestone
“The Ethics of Service-Learning”
September
Project Milestone “Leadership Transitions in Student-Run Free Clinics”
Project Reflections Project Presentations End-of-Year Reflection
October
November December January–April
Trigger Questions for Reflection
of a project that applies the principles of service-learning.21 Students have flexibility in how and when to complete the course requirements to allow them to travel for away rotations and residency interviews. Reflection sessions can be completed either
Reading —
in person via a small-group didactic session or through online journaling. Both didactic and journaling exercises are anchored by a reading in a relevant topic. Four special topics are covered and are shown in Table 1. Faculty who have expertise in the
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TABLE 2 Specialty choice
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Choice of Specialty Anesthesiology Dermatology Emergency Medicine Family Medicine General Surgery Internal Medicine Internal Medicine/Pediatrics Neurology Obstetrics and Gynecology Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Plastic Surgery Psychiatry Radiology Radiation Oncology Urology Primary Care Specialties (Family Medicine, Internal Medicine, Pediatrics) No. of Responses
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TABLE 3 Final course evaluation results
SERVE Class of Participants (%) 2012 (%) 0 0 8 20 4 36 4 0 4 4 0 4 0 4 0 4 4 0 4 60
25
7 1 5 4 6 28 3 4 4 2 7 3 3 4 2 5 5 2 3 36
99
topics are guest lecturers for the class meetings. The remaining monthly assignments ask that students reflect on their experiences with volunteerism and provide updates on their projects. In the first 2 years the course was offered, students were required to volunteer in 10 outreach sessions for a student-run free clinic or neighborhood school outreach program. Students are also made aware of opportunities to volunteer in one-time events such as student organized health fairs or days of service. The service sessions involve providing not only direct service to the community but also mentorship and teaching to underclassmen at the clinics and organizations. The requirement was reduced to eight outreach sessions in the 2012–2013 year in response to course evaluations. Before beginning their project, students are introduced to the service-learning model.12 They are encouraged to identify a need in an existing student service organization and develop a project to improve care, efficacy, or quality. For example, one student found that there was inadequate and ineffective screening for depression at a student-run clinic. This student developed a worksheet explaining how to administer a validated depression screening questionnaire and a list of resources for patients who had a positive screen. Students are given the option
Questiona
M (SD)
How much prior exposure did you have to the content covered in this course?b The course is meeting the objectives stated in the syllabus. The course is well organized. The course provides me with useful knowledge, skills, or insights. The course material is presented at an appropriate level. The content material is well paced, so the workload is spread evenly. The content material is constructively challenging. The effort required to learn the material is reasonable. The assigned readings are valuable adjuncts to the course. The clinical relevance of the course material is made apparent. I am planning to practice in an underserved community in the future. I am planning to volunteer in the future. Overall, this is an outstanding course to date.
3.40 (1.05) 4.65 (0.49) 4.10 (0.91) 4.55 (0.60) 4.55 (0.69) 4.55 (0.60) 4.60 (0.60) 4.80 (0.41) 4.47 (0.77) 4.70 (0.47) 4.50 (0.83) 4.85 (0.37) 4.60 (0.60)
a Unless otherwise specified, questions utilized Likert scale of 1 (strongly disagree) to 5 (strongly agree). b 1 = no exposure at all; 5 = a great deal of exposure.
of working independently or in small groups of two to five under the guidance of a faculty mentor. Almost all student projects involve close interactions with the underclass students who run the service organizations and clinics. The projects are presented to the class in the latter half of the year. Several projects have been continued over the 3 years that the course has been offered. EVALUATION During the 2011–2012 school year, 33 students enrolled in the course from a class of 99 (33.3%). A total of 25 students completed the course, 16 women and nine men. The SERVE students matched in a broad range of future specialties (see Table 2), but the potential primary care specialties (as defined by the AAMC—internal medicine, pediatrics, family medicine) had a larger proportion than in the graduating class (60% vs. 36%). For comparison, the AAMC 2012 medical school graduate questionnaire Question 21a showed 22.9% in IM, 6.0% peds, and 2.4% in FM for a total of 31.3% of medical school graduates entering potential primary care specialities.22
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TABLE 4 Qualitative analysis Themes
No. of Comments
Representative Quote
1) How, if at all, did SERVE shape your future plans? “SERVE inspired me to dedicate my future practice to underserved communities.” 4 “It gave me a chance to try teaching, which was fun.” 5 “I did gain helpful insight into organizational management and institutional transitions that will be helpful to me in the future.” d) self-efficacy 5 “I learned a lot about the pros and cons of service learning and how to create a service learning project in my community.” 2) What can we do differently next year to make the class go even better?
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a) commitment to underserved patients b) joy of teaching c) practical experience
4
a) logistics b) flexibility
8 5
c) fewer required service sessions d) increased involvement of 1st-year students
4
“regular class meeting times” “I think it was really helpful that you expanded the volunteer requirement to include service outside of the student-run clinics, as it was challenging at times to arrange to work in the clinics.” “fewer number of volunteering sessions”
2
“more communication for the first-year students”
3) What went well with the SERVE elective? a) teaching 4
“The interactions with underclassmen were great . . . . it kept me clinically engaged and also put me in a position to teach on the go.” b) service 7 “The service experiences themselves were very valuable.” c) projects 7 “The project mostly ran smoothly.” d) flexibility 4 “flexibility of attending a class or writing a reflection.” e) theory 3 “Great balance of volunteer requirements mixed with helpful lectures.” 4) What were the challenges with the SERVE elective? a) scheduling b) clinic cancellation
12 2
c) group work
2
“Some scheduling difficulties.” “The volunteer days I signed up for were frequently cancelled due to the lack of a physician.” “Group organization. Needed more intervention from instructors.”
Quantitative Data The SERVE 2011–2012 course was well received by 4th-year students. At the end of the year, students rated the course using a standard evaluation form that consisted of a 5-point Likert scale. Eighty percent (20/25) of the SERVE students enrolled in the class at the end of the year responded to the final evaluation. Quantitative results are shown in Table 3. On average, students reported moderate prior exposure to the course content (3.40, SD = 1.05; 1 = no exposure, 5 = a great deal of exposure). Students strongly endorsed the statement that SERVE was an outstanding course (4.60, SD = 0.60; 1 = strongly disagree, 5 = strongly agree). They found the material to be clinically relevant (4.70, SD = 0.47) and rated the readings as valuable (4.47, SD = 0.77).
SERVE students reported a strong commitment to continuing community service after graduation. All students plan to continue volunteering, with 85% of students (17/20) in strong agreement and 15% (3/20) in agreement with the statement that they would volunteer in the future. Seventy percent (14/20) strongly agreed with the statement that they would practice in an underserved community in the future. This commitment to working with underserved patients was higher than that expressed by their peers in the graduating class of 2012 (41.5%; 35% excluding SERVE participants) and much higher compared to a national average (30.9%; AAMC 2012 Question 25). On the 2012 AAMC Questionnaire, 35.1% of graduating Pritzker students reported plans to care for a primarily underserved population compared to a national average of 27.8% (AAMC 2012 Question 26).
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TABLE 5 Service-learning projects 2011—2012
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Pritzker Day of Service
5 course participants organized quarterly days of service in the fall, winter, and spring semesters. Students partnered with 3 neighborhood sites to do various projects, including gardening, tutoring, and organization. In the fall 62 students participated, 55 participated in the winter, and 45 in the spring. Teen Ambassadors 3 course participants worked with neighborhood teenagers to create a curriculum to teach physicians how to communicate effectively with teenagers. Depression 2 course participants translated the PHQ-9 Screening into dozens of East Asian languages and taught clinic volunteers how to utilize the instrument. Clinic Teaching 5 course participants developed a Curriculum curriculum for 1st- and 2nd-year medical students who volunteered in a student-run free clinic (Community Health Clinic Curriculum). Education 2 course participants formalized a teaching Curriculum for curriculum for a substance abuse School-Based prevention educational program Education (Adolescent Substance Abuse Program). Clinic Leadership 2 course participants oversaw the creation Transitions of manuals to improve clinic handoffs at all clinic sites. Healthcare for 2 course participants organized sessions Vulnerable for a year-long lecture series attended by Populations medical students, residents, and attendings on primary care for vulnerable and underserved populations. Physician 1 course participant reached out to faculty Recruitment in primary care specialties to recruit potential physician volunteers. Preclinical 1 course participant designed the Correlation curriculum for several small group, Lectures 15-minute didactic sessions to be taught before clinics opened. Topics included common primary care complaints such as low back pain, hypertension, and mood disorders. Qualitative Data In their final evaluations, students also submitted comments to open-ended prompts addressing their future plans and their assessment of the SERVE elective. Qualitative results are shown in Table 4. Data were analyzed using the constant comparative method, consistent with a grounded theory approach, to analyze student course evaluations.23 Three authors (KJ, STR, LMB)
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independently identified themes in the responses to each question prompt. The themes were compared and chosen for each question prompt. Then two coders (KJ, LMB) independently assigned themes to each comment and met to compare and reconcile the analysis. Prompts used to gather comments were as follows: (a) How, if at all, did SERVE shape your future plans? (b) What can we do differently next year to make the class go even better? (c) What went well with the SERVE elective? (d) What were the challenges with the SERVE elective? A total of 54 comments were analyzed. Data are presented next by questions. 1. How, if at all, did SERVE shape your future plans? (11 responses). We identified four themes from 11 unique responses. Students found that the course strengthened commitment to underserved patients (“Re-affirmed my desire to work with underserved communities”), introduced them to the joy of teaching (“It gave me a chance to try teaching, which was fun”), offered insight into the practical aspects of community work (“I learned . . . how to create a service-learning project in my community”), and enhanced self-efficacy (“SERVE gave me the space to grow as a servant of the surrounding community”). 2. What can we do differently next year to make the class go even better? (14 responses). The four themes that emerged as suggestions to improve the course were better logistics, increased flexibility, fewer service requirements, and more integration of 1st-year students. Student suggestions included “Having a pre-planned schedule for SERVE meetings” and “Getting first years even more involved in the course.” 3. What went well with the SERVE elective? (15 responses). The five most frequent themes that arose in the qualitative comments about what went well in the course were: pleasure of teaching (“Terrific to work with first-years in the clinic”), appreciation of the opportunity to re-engage in community service (“Loved working in the clinic as an M4!!!”), enjoyment of the projects (“I really enjoyed learning about other people’s projects”), and appreciation both of the flexibility of the class (“Having the freedom to create and implement a communitybased project”) and the theory grounding the service (“Great balance of volunteer requirements and helpful lectures”). 4. What were the challenges with the SERVE elective? (14 response). Students identified a number of challenges that they encountered with the course, primarily related to the logistics of scheduling service sessions during the busy 4th year of medical school. Other students had difficulty fitting in to the clinic schedule, working in groups on projects and accommodating clinic cancellations. One student noted, “Scheduling—sometimes difficult to get into assigned clinic, either because of limited numbers of spaces or because of other scheduling conflicts.”
SERVE PROJECTS The SERVE student projects were designed by the students in response to community defined needs and were diverse in their scope and execution. There were nine separate
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individual or group projects including an effort to improve referral mechanisms in free clinics, the creation of educational tools for 1st-year medical student volunteers at free clinics, and the implementation of language specific screening tools for depression. Table 5 summarizes the student projects for the 2011–2012 academic year. An example of a project that was created using the service-learning model is “Teen Ambassadors,” which partnered medical students with high school students in a youth program to create a workshop to teach healthcare professionals how to communicate effectively with adolescents. This is detailed in the appendix.
CONCLUSION SERVE is a successful 1-year longitudinal 4th-year elective for medical students, which provides structure and credit for engagement in service-learning. The course is well received and has encouraged the development of novel community-based projects. At the conclusion of the course, students rated the elective highly, and demonstrated a strong commitment to future volunteerism and practice in underserved communities. We conclude that SERVE is a feasible model for incorporating structured service-learning into the medical school curriculum, reengaging 4th-years in service activities, and strengthening student organizations. All of these goals can be accomplished while improving teaching skills and student commitment to underserved communities. These skills will serve students well in their transition to residency. In response to student requests, we have decreased the number of service sessions to eight, and provided the full year’s class schedule at our first meeting. A by-product of SERVE has been a shift in the structure of student-run organizations, with increasing involvement in leadership over the 4 years of medical school. This, in turn, has strengthened organizational memory and provided opportunities for the 1st- and 2nd-year student leaders to learn from 4th-year SERVE students. Before the SERVE elective, few 4th-year students independently volunteered. Because the service-learning elective was formalized, Pritzker 4th-year students have returned to the organizations they volunteered and led in their preclinical years. They have valuable clinical experience to share with underclass students and can see the evolution of the student organizations and suggest new directions and improvements. Future directions for SERVE include formalizing the integration of 1st- and 2nd-year medical students into the SERVE elective, and identifying additional service-learning opportunities for 4th-year medical students. Limitations to our study include the level at which the success of the course was evaluated. Although the data thus far are almost exclusively from student reactions (Kirkpatrick’s first level), it is reassuring to learn from the qualitative comments that students’ desire to work with the underserved was strengthened by the course. The course remains popular with more than one
fourth of 4th-year students (23/82) enrolled for the 2012–2013 school year. Future studies will assess the underclassmen’s response to 4th-year involvement, evaluate community reactions to SERVE supported projects, and track prior SERVE students’ future dedication to underserved communities and primary care during residency and beyond. This latter goal is difficult to assess in the short term,24 so we will continue to follow the career trajectory of SERVE participants and observe the number who volunteer, go on to practice in underserved settings, choose to enter primary care from internal medicine and pediatric residencies, engage in teaching, and return to the communities they served as medical students to teach the next generation, supporting the social mission of medicine. FUNDING This course was established with a grant from the Academy of Distinguished Medical Educators: “Developing and Implementing a Scholarly Track in Community Health and ServiceLearning for Pritzker Students,” with ongoing support from the Department of Family Medicine at the University of Chicago. REFERENCES 1. Schwartz M. health care reform and the primary care workforce bottleneck. Journal of General Internal Medicine 2012;27:469–72. 2. West CP, Dupras DM. General medicine vs. subspecialty career plans among internal medicine residents. Journal of the American Medical Association 2012;308:2241–7. 3. AAMC 2012 Physican specialty data book: Center for Workforce Studies. Available at: https://members.aamc.org/eweb/upload/12039%20Specialty%20Databook final2.pdf. Accessed March 27, 2014. 4. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: Ranking the schools. Annals of Internal Medicine 2010;152:804–11. [Erratum appears in Ann Intern Med 2010;153:212]. 5. Markuns J, Culpepper L, Halpin WJ. Commentary: A need for leadership in primary care for the underserved: a call to action. Academic Medicine 2009;84:1325–7. 6. Foreman S. Social responsibility and the academic medical center: Building community-based systems for the nation’s health. Academic Medicine 1994;69:97–102. 7. Campos-Outcalt D, Chang S, Pust R, Johnson L. Commitment to the underserved: Evaluating the effect of an extracurricular medical student program on career choice. Teaching & Learning in Medicine 1997;9:276–81. 8. Veronesi MC, Gunderman RB. Perspective: The potential of student organizations for developing leadership: one school’s experience. Academic Medicine 2012;87:226–9. 9. Long JA, Lee RS, Federico S, Battaglia C, Wong S, Earnest M. Developing leadership and advocacy skills in medical students through service learning. Journal of Public Health Management & Practice 2011;17: 369–72. 10. Brazeau CM, Schroeder R, Rovi S, Boyd L. Relationship between medical student service and empathy. Academic Medicine 2011;86:S42–5. 11. Tong ST, Phillips RL, Berman R. Is exposure to a student-run clinic associated with future primary care practice? Family Medicine 2012;44:579–81. 12. Seifer SD. Service-learning: Community-campus partnerships for health professions education. Academic Medicine 1998;73:273–7. 13. Dewey J. Experience and education. New York, NY: Macmillan, 1963.
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COMMUNITY SERVICE IN MEDICAL SCHOOL YEAR 4 14. Kolb D. Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall, 1984. 15. Liaison Committee on Medical Education Standards and Publications. Available at: http://www.lcme.org/standard.htm. Accessed February 17, 2012. 16. Averill NJ, Sallee JM, Robinson JT, McFarlin JM, Montgomery AA, Burkhardt GA, et al. A first-year community-based service learning elective: Design, implementation, and reflection. Teaching & Learning in Medicine 2007;19:47–54. 17. McNeal MS, Buckner AV. Using mini-grants and service-learning projects to prepare students to serve underserved populations. Journal of Healthcare for the Poor & Underserved 2012;23:20–6. 18. Packer CD, Carnell RC, Tomcho PM, Scott JG. Development of a fourday service-learning rotation for third-year medical students. Teaching & Learning in Medicine 2010;22:224–8. 19. Elam CL, Sauer MJ, Stratton TD, Skelton J, Crocker D, Musick DW. Service learning in the medical curriculum: Developing and evaluating an elective experience. Teaching & Learning in Medicine 2003;15:194–203. 20. Wolff M, Young S, Maurana C. A senior elective: Promoting health in underserved communities. Family Medicine 2001;33:732–3. 21. Seifer SD, Connors K, O’Neil EH. Combining service and learning in partnership with communities. Academic Medicine 1996;71:527. 22. AAMC Physician Workforce Policy Recommendations September 2012. Available at: https://www.aamc.org/download/304026/data/2012aamcwork forcepolicyrecommendations.pdf. Accessed March 27, 2014. 23. Harris I. What does “The discovery of grounded theory” have to say to medical education? Advances in Health Sciences Education 2003;8:49–61. 24. Eckenfels EJ. The purpose of service learning. Family Medicine 2009;41:659–62.
APPENDIX Service-Learning Course Example Project: Teen Ambassadors
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To promote urban adolescent health, three SERVE students partnered with eight teenagers from “Children Teaching Children” in the after-school Chicago Youth Program, housed in the same building as a preexisting student run free pediatric clinic. Under medical student guidance, the teenagers created then led a 45-minute workshop to teach doctors and medical students how to communicate with adolescents about sensitive health issues. By clarifying physician misconceptions of the needs of urban youth, and speaking across large differences in age, race, subcultural idiom, and socioeconomic background, the Teen Ambassadors seek to improve communication to improve the doctor–patient relationship and increase adolescent utilization of healthcare. From July through September 2011 the SERVE medical students worked with the community to brainstorm and plan the curriculum. Teen Ambassadors were recruited in October. From October through January the medical students guided the high school students to develop the presentations. This included assistance with preparing workshop material, coaching the teens on presentation skills, and empowering them to speak for their own needs. In February 2012 the Teen Ambassadors first led the workshop for health professionals in a special SERVE class session opened to all medical students and select faculty. The Teen Ambassadors will lead their workshop at annual board meetings of the Washington Park Clinic. Each year an evolving group of newly recruited Teen Ambassadors will renew the curriculum on adolescent health for medical students and physicians.
