Online inspiratiegids social accountability in de praktijk lit by Departement Omgeving

International Medical Education

An Interdisciplinary Community Diagnosis Experience in an Undergraduate Medical Curriculum: Development at Ghent University Bruno Art, MD, Leen De Roo, MA, Sara Willems, MA, PhD, and Jan De Maeseneer, MD, PhD

Abstract Since 2002, the medical curriculum at Ghent University has incorporated a community diagnosis exercise, teaming medical students with master of social work and social welfare studies students. The course focuses on the interaction between the individual and the community in matters of health and health care. During one week, small groups of students visit patients and their caregivers in six underserved urban neighborhoods, and they combine these experiences with public health data, to develop a community diagnosis. Local family physicians and social workers monitor sessions. The course requires

n 1992 Charles Boelen, chief medical officer for the World Health Organization’s Programme on Educational Development for Human Resources, defined the ideal profile of a doctor for today’s society. He or she should possess “a mix of aptitudes needed to carry out the range of services that health settings must deliver to meet the requirements of relevance, quality, cost-effectiveness, and equity in health.”1 Awareness of important public health issues, ability to use an interdisciplinary approach to solve problems, and adequate

Dr. Art is general practitioner and lecturer, Department of Family Medicine and Primary Healthcare, Ghent University, Ghent, Belgium. Ms. De Roo is lecturer, Department of Family Medicine and Primary Healthcare, Ghent University, Ghent, Belgium. Dr. Willems is senior researcher, Department of Family Medicine and Primary Healthcare, Ghent University, Ghent, Belgium. Dr. De Maeseneer is general practitioner, full professor, and head of department, Department of Family Medicine and Primary Healthcare, Ghent University, Ghent, Belgium. Correspondence should be addressed to Dr. Art, Department of Family Medicine and Primary Healthcare, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium; telephone: ⫹32 9 332 36 12; fax: ⫹32 9 332 49 67; e-mail: (bruno.art@ugent.be).

Academic Medicine, Vol. 83, No. 7 / July 2008

students to design an intervention tackling one community health issue. At the end of the course, the students present their diagnoses and interventions to community workers and policy makers who provide feedback on the results. In the authors’ experience, medical and social work students all value the joint learning experience. The occasional culture clash is an added value. The one-week course is very intensive for students, mentors, and cooperating organizations. Although students criticize time restraints, they feel that they reach the outlined objectives, and they rate the overall experience as very positive.

communication skills all contribute to becoming a “five-star doctor.”2 Moreover, factors such as living conditions, income, family status, occupation, and social environment have a serious impact on health, and doctors must take them into account when interacting with a patient. Medical faculties around the world have addressed shortcomings in their training by including community-oriented education to some extent.3 The six-year medical curriculum of Ghent University, Belgium, underwent a radical reform in 1999. An educational committee, chaired by the Department of Family Medicine and Primary Healthcare, consisted of members of all departments as well as students, who together prepared the curriculum reformation. The committee used the concept of the five-star doctor as the reference to evaluate the existing curriculum and to suggest changes. The committee also suggested the introduction of new didactic methods more adapted to the suggested new content of the curriculum. The faculty board ratified the suggestions of the committee, and the reformation transformed the traditional disciplinebased curriculum into an integrated

The authors find that this interdisciplinary, community-oriented exercise allows students to appreciate health problems as they occur in society, giving them insight into the interaction of the local community with health and health care agencies. Combining public health data with experiences originating from a patient encounter mimics real-life primary care situations. This campus– community collaboration contributes to the social accountability of the university. Acad Med. 2008; 83:675–683.

approach: patient-centered, studentcentered, community-oriented, problembased, and evidence-based. As a result, at several points throughout the whole six-year program, the curriculum emphasizes working in the community, working in primary care, and working with other disciplines, as well as learning and applying medical humanities and ethics, with a focus on early patient contact. In this article, we describe and discuss the structure and evaluation of the community-oriented primary care (COPC) exercise for third-year medical and master of social work and social welfare studies (hereafter, simply MSW) students at Ghent University. Background

COPC is a model that uses topics from the individual provider–patient encounter as a starting point. It combines individual patient and physician practice data with public health data at the community level, leading to a “community diagnosis.” The community diagnosis describes the “health status of the community as a whole or of defined segments of it.”4 A targeted intervention

675

International Medical Education

perspective. The COPC exercise also presents an opportunity to invite MSW students into a joint learning experience. Finally, with this exercise we aim to create a win–win situation for both community and students, thus incorporating some of the recommendations concerning communityoriented health education, such as allowing students to distinguish felt needs and actual needs, to let them learn socioeconomic determinants of health, and to let them be the community’s advocates.9

Figure 1 The community-oriented primary care (COPC) cycle.4 The COPC cycle starts with defining the community (e.g., the neighborhood, a patient list). Physicians work together with the community to understand health problems and to establish priorities for finding solutions to these problems. To develop an intervention, physicians consult other data, but they also involve the community. This can be achieved either by directly consulting participants in the COPC comity or indirectly by consulting local health workers. Involving the community in some way is vitally important to ensure and enhance the accuracy and acceptability of the intervention. Source: Used with permission from Garr, DR. Community-oriented primary care. Available at: (http://www.musc.edu/fm_ruralclerkship/copc.htm). Accessed March 28, 2008. Minor formatting changes have been made.

and evaluation complete the cycle.4,5 Community involvement in all phases of the process is mandatory5,6 (Figure 1). This method provides tools to approach problems that health care workers in the community encounter. Researchers first described the implementation of the COPC approach in 1952 and have again many times thereafter.7 However, the application of its methodology is not widespread. Accounts of a complete COPC cycle are rare, and they are almost nonexistent in Europe.8 The COPC Exercise

The medical curriculum In Belgium, medical school runs six years: three years to earn the bachelor degree, three years to the master degree. Masters have entrance to the medical profession after clinical training in a chosen specialty (e.g., family medicine, specialist care, public health) that lasts an additional three to six years. The reformed medical curriculum at the University of Ghent pays attention to “social accountability”: both health care agencies and educational institutions

676

must make sure to reach those most in need. The medical curriculum reflects this social accountability by training health care workers to be socially responsive and capable of working with different cultures as well as deprived communities. The Department of Family Medicine and Primary Healthcare has a historical interest in the COPC model because, for decades, several staff members have applied some principles of COPC in their clinical practice. Because the COPC model perfectly fits the general aims of the reformed curriculum—in particular, the multidisciplinary and the communityoriented aspect—the Department of Family Medicine and Primary Healthcare developed a COPC-inspired exercise, which was accepted by the educational committee as a regular component in the curriculum. The aim of the exercise is to give students a greater understanding of the situation of individual patients in the community, an appreciation of the roles of patients’ different caregivers, and an opportunity to learn to combine data obtained from different sources into a community diagnosis, making the link between the individual and the community

At some point during each of the six years of the medical program at Ghent University, the curriculum emphasizes one aspect of social responsiveness, thus creating an educational continuum. The COPC exercise precedes and follows other primary care and multidisciplinary activities, all aiming to reinforce attitudinal change (Table 1). Placement and objectives of the COPC exercise The four-day COPC exercise (Chart 1) is scheduled halfway through the second semester of the third year as the final part of a five-week Health and Society II unit, which covers topics such as public health, occupational health, global health, and human rights. At this point in the program, medical students have learned basic medical sciences, have developed communication skills, and have already experienced some clinical exposure. The third-year MSW students have had experience in community dynamics and have been involved in small, communitybased projects. We prepare students of both disciplines with a lecture on community and COPC, and we provide some background on the other discipline’s main characteristics. Specific learning objectives of the COPC exercise are • to develop a practical understanding of inequities in health, • to gain insight into the meaning of health and illness and their practical consequences in the primary health care context, • to appreciate the impact that the community has on individual health, • to gain understanding of the range of professionals and services involved in health care, and • to learn how to make a community diagnosis by collecting and integrating

Academic Medicine, Vol. 83, No. 7 / July 2008

International Medical Education

Table 1 Social Responsiveness Emphases in the Medical Curriculum at Ghent University, Belgium, 2006 Curriculum objective (year in curriculum)

Correlating courses and activities

To obtain general insight into societal needs and the role of medicine (1 and 2)

Health and Society I: Sociology, Anthropology Multidisciplinary clerkship

To understand community-oriented primary care (COPC) (3)

COPC week

To understand “general practice” (3)

Family physician clerkship COPC week

To know paramedical disciplines and practice interdisciplinary approaches (4)

Interdisciplinary training exercises with participants from six other disciplines

To understand the strengths and objectives of primary care (5)

Two-month primary care medicine clerkship

To practice primary care (6)

One-month clerkship

individual stories as well as epidemiological data.

• to present the results to a public audience of health care workers and policy makers.

We hope the students acquire the following skills: • to conduct semistructured patient and caretaker interviews, starting with a set of themes the students want to cover, but without a rigid interview style, thus allowing for elaboration on certain topics, • to work together with students from other disciplines, • to work autonomously and within a tight time schedule, • to write a letter about a patient to an involved health care professional, • to formulate possibilities for improvement at the community level, and

In 2002, the course ran with 36 volunteer medical students in two neighborhoods. As a consequence of the growing student population in Ghent (Table 2), each year we invite new communities to participate. Description of the COPC exercise The introduction to the exercise. The first day of the COPC exercise starts with detailed information about the exercise itself and an introduction of all the participants (Chart 1). We then divide students into groups of 20 and allocate each group to one of the participating neighborhoods, which are all situated in the 19th-century “belt” around Ghent.

These neighborhoods have a high concentration of social housing, unhealthy dwellings, and ethnic diversity, as well as a population generally more deprived than the average population of Ghent.10 A local community health worker gives an introduction to the community studied, and we further split up the groups of 20 into groups of 4, which will each prepare to visit both a member of the community (further referred to as patient) or family at home, and the patient’s or family’s professional caregivers. All patients, each with a specific sociomedical history (e.g., chronic diseases, unemployment, financial problems, difficult family situations), participate voluntarily and have given informed consent for the use

Chart 1 Course Schedule With Time Allotted in Minutes and Number of Participants for Ghent (Belgium) University School of Medicine Community-Oriented Primary Care Exercise, 2002–2007

Monday

Tuesday

Wednesday

Friday

General Introduction (90 minutes) (all students, 1 lecturer) Visit to neighborhood (60 minutes) (groups of 20 students, 1 mentor per group) Preparation for patient interview (60 minutes) (groups of 4 students) Interview with patient (60 minutes) (groups of 4 students) Interview with caretakers (30 minutes + preparation and evaluation) (groups of 4 students)

Interview with caregivers (30 minutes + preparation and evaluation) (groups of 4 students)

Community diagnosis (120 minutes) (groups of 20 students, 1 mentor per group) Visit with community workers (60 minutes) (small groups of 4 students)

Preparation for presentation (120 minutes) (groups of 20 students, 2 supervising lecturers for all student groups)

Community diagnosis (180 minutes) (groups of 20 students,1 mentor per group)

Exploration of interventions (180 minutes) (groups of 20 students, 1 mentor per group)

Presentation (180 minutes) (all students and mentors + jury and invited caretakers)

Academic Medicine, Vol. 83, No. 7 / July 2008

677

International Medical Education

Table 2 Numbers of Participants in the Ghent (Belgium) University School of Medicine Community-Oriented Primary Care Exercise by Year

Year

Medical students

Social work and social welfare studies students

Mentors*

Neighborhoods

Patients

Patient caretakers

2002

2003

102

2004

118

2005

120

105

2006

147

115

2007

172

138

................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................

The number of mentors followed the number of students but not the number of neighborhoods; some neighborhoods welcome two groups of students working separately from each other.

of their summarized medical file for students to prepare the interview (Table 3). A family physician familiar with the patients and with the neighborhood is available for questions. The group of four students prepares the interview without formal vetting of the actual questions they plan to pose, but with general guidelines concerning semistructured interviews, professional behavior, and the objectives of the process. Visiting the community. The group of four students interviews the patient at home, without other parties present, for about one hour. The group covers topics

such as the health and well-being of the patient and the patient’s priorities regarding his or her housing, social situation, and view of the local community. The four students discuss the interview, which leads to a list of health care priorities for the patient. This list serves to prepare the agency interviews. Next, the four students interview three care providers per patient, choosing among available social service providers, health care workers (e.g., general practitioners, nurses [practice nurses, psychiatric nurses, mother- and child-welfare nurses],

Table 3 Patients Visited by Medical, Master of Social Work, and Master of Social Welfare Students in One Neighborhood (Estate Nieuw Gent) During the Ghent (Belgium) University College of Medicine Community-Oriented Primary Care Exercise, 2004 Patient participants (age in ayears)* Parents (34, 36), three children (2–8)

Major problems Children: Enuresis nocturna, behavioral problems All: Obesity, recurrent head lice infestation, and financial problems

Mother (30), child (3)

Language, ear–nose–throat infections

Single man (56)

Alcoholism, diabetes mellitus, smoking, renal failure

Single man (60)

AMI, diabetes mellitus, smoking, hypertension, loneliness

Parents (45, 46), three children (8–21)

Parents: Chronic migraines, chronic back pain, financial problems, conflicts with children Children: Epilepsy, problematic contraception

Mother (40), child (8)

Mother: Financial problems, educational problems Son: Encopresis, enuresis, attention-deficit/hyperactivity disorder

Single woman (80)

Arthrosis, hypertension, loneliness

Couple (60, 36)

Man: Schizophrenia

Parents (33, 36), four children (4–14)

Youngest child: Hypothyreoidy Parents: Psychological problems with asylum and social isolation, language

physiotherapists), teachers, pharmacists, and community workers. The students focus on the role of the agency in the life of the patient they visited by both addressing this patient’s priorities and by comparing these priorities with the agency’s priorities. They also discuss the mission and tasks of the agency with regard to the community. The objective is to gain insight into the possible functions this agency can have at the individual and community levels. We encourage the students to stroll around the neighborhood in their spare time. Community diagnosis. On Tuesday afternoon, students studying the same community meet on campus in groups of 20 to share experiences and to propose a list of characteristics regarding their neighborhood based on the data from the interviews. They consider medical needs as well as social, environmental, and other problems. This list is the basis for the consultation of secondary resources that contain information about this community. The students retrieve data and epidemiological material from local agencies, health-needs-assessment surveys, crime statistics, and social databases maintained by the city and the national government. At the end of the afternoon, the groups of 20 students combine these data with those from the interviews to form a priority list, leading to a community diagnosis. Local family physicians and social workers mentor the students during these sessions and support the discussion, without too much interference on the content.

Single woman (52) *

Schizophrenia, financial problems, chronic obstructive pulmonary disease, obesity

Patients represent a wide variety of nationalities and speak a wide variety of languages.

On day three, in the larger groups of 20, students brainstorm about possible ways to address some of the problems that they

678

Academic Medicine, Vol. 83, No. 7 / July 2008

International Medical Education

diagnosed. They design, by consensus, a proposal for an intervention, including both population involvement and evaluation, in one of the problem areas. In the smaller groups of four, they discuss this intervention along with the community diagnosis with neighborhood workers (at a previously organized appointment). The neighborhood workers provide feedback, allowing for improvements that make the intervention more realistic and feasible.

support the local partners by providing a scenario about how to recruit a representative selection of patients. They also make most of the appointments that the students have to attend on the first two days of the exercise, and they schedule suitable rooms for the community diagnosis sessions. They prepare the evaluation, initiate suggestions for ameliorations, and support the mentors during the actual exercise.

Presentation. On the morning of the fourth day, all 20-member groups prepare a presentation of their community diagnosis. In the afternoon, they present their diagnosis and intervention to fellow students, teachers, members of agencies involved in the communities, and local policy makers. The students design a poster addressing the community diagnosis or the intervention that will be used in the local health centers.

In June of each year, we estimate the number of students participating during the next semester, and, if necessary, we contact new neighborhoods. In December, representatives of each neighborhood meet to address practical issues such as recruiting patients and caregivers, finding a location for the community introduction, etc. In March, the mentors meet to prepare the sessions. The actual exercise takes place later in March, leading to a lot of organizational stress: last-minute changes; students, patients, or caretakers not showing up; etc. In June, we evaluate the whole process, making yearly improvements to both content and organization.

Assessment We assess the students in three ways. First, we ask them to individually write a letter to an agency or caretaker in which they address a specific problem in the social or health situation of the patient they visited, a problem to which a part of the solution may lie in the hands of the addressee. One staff member grades the students on their ability to write a clear and correct letter, their understanding of the task of the agency, and their demonstration of realistic problemsolving capabilities. The students actually send the letters to the addressed agencies, and sometimes these letters contribute to new initiatives by the caregivers. A jury of health care workers from the visited communities and some faculty members grade the presentations at the end of the course according to content (i.e., appropriateness of the community diagnosis, relevance of the proposed solutions, feasibility) and formal aspects of the presentation. Thirdly, the mentor gives grades to each individual student, reflecting the student’s participation during the group discussions. Organizing the exercise Given the multitude of individuals who have to be contacted for an appointment with the students on the first two days of the exercise, the university provides two persons (total 0.4 FTE) for the exercise. These employees plan the exercise and

Academic Medicine, Vol. 83, No. 7 / July 2008

Evaluation

Each year, we survey students about the exercise, and we evaluate and then adapt it where necessary. Students anonymously complete a Likert-scale questionnaire with 22 questions on three domains: (1) the practical organization of the exercise (5 questions), (2) whether they reached the learning objectives (10 questions)—for example, if students understood the connection between their patients and the epidemiological data they gathered (Figure 2A); and (3) their community-oriented and primary care attitudes (6 questions). One question addresses the interdisciplinary aspect of the exercise (Figure 2B). Figure 2A and 2B shows the aggregate mean values scored for the period of 2003 to 2007. In their reactions, students commented most on the course’s organization and the time restraints they experienced. Secondly, comments referred to the students from the other disciplines. To a lesser extent, students shared some of their experiences and anecdotes from their interactions with patients and caretakers. According to their comments, the medical students most valued being in

the community and experiencing real-life situations, which, for some, were real eye-openers. I will never forget the family I interviewed and how they felt lost in our city where they do not know anybody besides their son’s school. Our patient was always telling us to become as her “house doctor,” who obviously played an important role in her life. I didn’t know this kind of neighborhood existed so close to the university.

The students appreciated working together towards a clear goal. Many mentioned their positive surprise to notice that the social work mentors and students demonstrated expertise in analyzing data and working with a community instead of individual patients. The tutor, while not being medically trained, really helped us during this stressful week. It was nice to be able to work together to a clear goal, and the other students knew very much where I knew nothing. They [the social work students] made me look quite differently at why the elderly woman I visited feels unsafe.

Most of the medical students felt they had reached the course objectives. However, we have not yet performed a formal measurement of the extent to which the one-week experience has a lasting imprint on the medical students. Frequently, the medical students wrote negative remarks with regard to the time restraints and the idea that students might have anything to tell the caretakers (via the letter or the presentation). Having to do all this work in one week put us under a lot of stress. And in the evening I was so exhausted I was unable to do any of the other work I need to do. Having to write a letter to the doctor I visited seems useless to me, how can I tell him anything after one week?

The MSW students, already having some experience in fieldwork, were more critical in their comments. Medical students are strange. I enjoyed very much meeting [patient’s first name] and her daughter. However, I feel unsatisfied not being able to really help her some more. One week is largely insufficient to get to the core of this neighborhood’s problems.

679

International Medical Education 100 % 90 % 80 % 70 % 60 %

Percent of respondents

50 % 40 % 30 % 20 % 10 % %

Disagree

Agree

100 % 90 % 80 % 70 %

Percent of respondents

60 % 50 % 40 % 30 % 20 % 10 % % 1

Disagree

Agree

100 % 90 % 80 % 70 %

Percent of respondents

60 % 50 % 40 % 30 % 20 % 10 % % 1

Disagree Medical students

Agree

MSW and Master of Social Welfare Studies students

Figure 2 The mean percentage of third-year medical students and master of social work (MSW) and master of social welfare studies students (2003–2007) agreeing or disagreeing with statements on a questionnaire evaluating the effects of the community-oriented primary care (COPC) exercise at Ghent University, Belgium. Figure 2A shows which percentage of students agreed or disagreed with the statement, “I succeeded in making the link between the patient and the epidemiological data”; Figure 2B shows which percentage of students agreed or disagreed with the statement, “Working with students of another discipline was an enriching experience”; and Figure 2C shows which percentage of students agreed or disagreed with the statement, “The COPC exercise shows a big overlap with previous courses.”

The role of (para)medical caregivers (and their attitudes towards community and patients) was most interesting to the MSW students, as was learning more about the relationship between an individual patient’s health and the environment. Also, they appreciated the opportunity to get to know the medical students.11 Their comments indicated both that they understood the complementary roles they and medical students play and that they gained genuine respect for the

680

individual care the visited physicians offered. I know now that doctors have a unique view on community problems, which is complementary to my own. I loved being able to walk around the neighborhood, and talking to people who dedicate their professional life to it. That’s what I want to do.

The MSW students criticized the time restraints as well as the aspect of being a minority in the process.

I thought the whole week was too much of a rush, without time to really get into the subject. My colleague and I were dominated by 17 medical students throughout the week, who didn’t seem to care about our views.

It is striking how much students of the same age but from different training backgrounds think in different theoretical paradigms. As a result of their training so far, and apparently regardless of previous efforts to broaden their perspectives,

Academic Medicine, Vol. 83, No. 7 / July 2008

International Medical Education

medical students start from a problem and try to “cure” it, whereas the MSW students want to start from the available opportunities in a community and develop those. One illustrative anecdote is how different the medicals students’ approach was from that of the MSW students to the problem of Belgian elders living in a more and more culturally diverse neighborhood and their feelings of insecurity, following and leading to immobility and lack of social contacts. Where MSW students wanted to search for commonalities among the different age and cultural groups and work with those, the medical students proposed placing more security cameras in the block of flats and installing bus services to accompany the elderly to targeted activities.

as well as the factors that influence the health and health care of these communities. We challenge the students to be critical of their attitudes towards these communities and of their opinions about health care priorities and delivery. The students sharpen their skills in interviewing, working in an interdisciplinary team to solve problems, presenting their teamwork, and writing a concise recommendation letter to a future colleague. The combination of the interviews with patients and caretakers followed by a community diagnosis exercise has many benefits:

In 2004, we also surveyed health care professionals involved in the experience, and 56 of 97 (58%) responded. The respondents reacted positively to their teaching roles, and they appreciated the course objectives. Finding time in their tight schedules was the most problematic issue for the participants. All respondents were willing to participate in the future. It is unclear whether the nonresponders were less satisfied with their role in the exercise.

• the patient visit allows students to have a realistic view of problems, and using this visit as a permanent focus throughout the week helps them in making the process of working with community data less vague;

We have not yet surveyed cooperating patients. However, informal contacts suggest a very positive experience for most of them, as do accounts of similar courses.12 Apart from the Department of Family Medicine and Primary Healthcare evaluation, an external, international committee evaluated the exercise during the accreditation procedure of the medical training in 2005. In their report, the committee highly valued the community orientation of the curriculum as well as the emphasis on social accountability. The committee evaluated the latter as a particularly commendable characteristic of the medical curriculum.13 Discussion

In this paper we report the development, organization, and evaluation of a community diagnosis exercise for medical and MSW students. In this one-week course, we offer students an opportunity to enhance their knowledge about local underserved communities

Academic Medicine, Vol. 83, No. 7 / July 2008

• the exercise mimics real-life, primary care situations where multidisciplinary teams and community involvement start at the patient level;

• the exercise allows agencies to highlight their different tasks, both on the individual and community levels; • the exercise forces students to be their patients’ and their communities’ advocates, stimulating caregivers and local authorities to reflect on their plans of action regarding the patient or community; and • the immersion in the household environment where a patient is cared for, the contact with the close caregivers, and the experience at the community level help students see the broader context of health and disease. However, this approach has its limitations. The combination of the different learning goals raises conflicts: selected patients must simultaneously “illustrate” the community they live in and require the assistance of the caretakers who represent the various services available in the area. This may give students a biased view of the community. We train the authority responsible for patient selection from each neighborhood to select a group of patients who have the relevant community characteristics. The experience of visiting only one patient is limited. Sharing stories, however, broadens the students’ perspectives.

Organizing a COPC exercise in Ghent is challenging for a number of reasons. No medical school in Belgium has ever fully applied the proposed COPC model, so mentors cannot draw from extensive experience while teaching it. Although teachers have experience with aspects of rapid appraisal with regard to health-needs assessment, community involvement, and multidisciplinary cooperation, genuine COPC cycles have rarely been carried out. Also, smallgroup education requires a complex organization and adequate guidance. Gradually building the course over the years has provided us with a stable team of experienced mentors. Certainly, the learning goals are ambitious, given the time restrictions and the students’ relative lack of preparation in earlier courses. The students are very aware of these limitations. Nevertheless, it is clear that they value the experience. They highly appreciate a week emphasizing small-group fieldwork and self-directed discussions. Other studies— one from New Zealand14 and one by Lennox and Petersen,15 whose Leicester experience inspired part of our course15—report similar findings. Community diagnosis introduces the students to a world with which they are unfamiliar, but by making the patient contact the basis for the week, we have tried to make this exercise as concrete as possible. We have not yet found a way to get back to the original patients at the end of the exercise. Time and practical constraints (e.g., gathering all these people scattered over town, sending the students back to the patients’ homes) stand in the way of making a complete COPC-cycle exercise in one week. In 2006, reacting to comments criticizing the overlap of the COPC exercise with previous courses (Figure 2C), we placed the course in year three of the MSW curriculum rather than year four. A similar course in Glasgow proved that involving only medical students is feasible,16 but we believe that the interaction with MSW students creates an added value (Figure 2B). This sometimes takes the form of a genuine culture clash, which puts a lot of adrenaline in the group sessions. In our experience, medical students go for quick, operational solutions, whereas the MSW students focus on the broader exploration

681

International Medical Education

of the problem, stressing the importance of citizen involvement. This could indicate that despite the reform of the curriculum, medical students are still being trained to become “technical professionals,” applying their tools to a given problem, whereas MSW students are more “normative professionals,” questioning the nature of the problem. If students learn to use both paradigms in a complementary way, this adds to the quality of the outcome. Whether the students effectively reach most of the learning goals needs further investigation. With little formal knowledge taught during this exercise (only two lectures of 60 minutes each before the start), the main objectives lie in developing competencies and attitudes. A small pre- and postintervention questionnaire in 2002 of 36 students regarding their attitudes doesn’t show much effect,17 although the fact that the students were a small group of volunteers may have biased the outcome because we can guess that volunteers for this kind of experience already have generally positive attitudes toward the issues examined. Longer community immersions have been shown to have some effect on career choices,18,19 but little is known about attitudes.19 –21 By placing this experience relatively early in the curriculum, we hope to influence the students at a moment when education and experience can still modify attitudes.18,22 This kind of teaching obviously demands the creation of a long-lasting relationship between the university and community stakeholders (i.e., the agencies participating in the learning experience, such as public centers for social welfare, private welfare centers, police departments, community development centers, schools, and hospitals). In addition, individual physicians, nurses, and other ambulatory paramedics are involved. Working with locally well-embedded community health centers partially solves the problem of establishing and maintaining relationships between the university and community in Ghent.

we do not want to exploit the poor and underserved (no “social sightseeing”). Therefore, we have tried to create a win– win situation: through their report to the politicians, students give a strong voice to the needs of their patients; they become their advocates. The immersion in the community, as well as understanding the possible roles of caregivers, contributes successfully to forming students who are more “community responsive.”23 Although not the primary objective of this exercise, political authorities have put suggestions to improve the situation in the community into practice, creating a new youth leisure facility in 2003 and providing more green spaces in 2004. Moreover, the students’ posters have been used for various applications, such as the cover of a publication listing various social initiatives in one neighborhood. Also, letters sent to different caretakers about individual patients have occasionally led to ameliorations in caretaking relationships or outcomes. For example, one visited patient who did not have access to a physiotherapy facility because of lack of insurance was accepted after this facility received letters from the students. In addition, the city’s department of infrastructure sped up work on projects to improve mobility and safety in one neighborhood, and several caretakers contacted each other (sometimes for the first time) to discuss a patient’s situation after they received the letters. In this way, the Ghent COPC exercise is an example of a successful, mutually beneficial community– campus partnership, in which the local university gives something back to the communities from which its students learn. Acknowledgments The authors wish to thank Ms. Lut Dhont of the University Health Centre Nieuw Gent for the practical coordination of the COPC course since 2002 and for providing data for this article. They also want to thank Leen Gyssels and Veerle Piessens, who have been mentors since 2003.

References

But what about the individual patients, community workers, and the community as a whole—what do they gain? This kind of approach raises ethical questions. We face the dilemma that we want to expose the students to the social reality, especially of the most disadvantaged, but

682

1 Boelen C. Medical education reform: The need for global action. Acad Med. 1992;67: 745–749. 2 Boelen C. The five-star doctor: An asset to health care reform? Hum Resour Dev J [serial online]. 1997;1. Available at: (http://www. who.int/hrh/en/HRDJ_1_1_02.pdf). Accessed March 28, 2008.

3 Richards RW. Best practices in communityoriented health professions education: International exemplars. Educ Health. 2001;3: 357–365. 4 Rhyne R, Bogue R, Kukulka G, Fulmer H, eds. Community-Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association; 1998:4. 5 Tollman S. Community oriented primary care: Origins, evolution, applications. Soc Sci Med. 1991;32:633– 642. 6 Henley E, Williams R. Is population-based medicine the same as community-oriented primary care? Fam Med. 1999;31:501–502. 7 Kark S, Cassel J. The Pholela Health Centre: A progress report. S Afr Med J. 1952;26:101– 104, 131–136. 8 Iliffe S, Lenihan P. Integrating primary care and public health: Learning from the community-oriented care model. Int J Health Serv. 2003;33:85–98. 9 Kristina TN, Majoor GD, van der Vleuten CPM. Defining generic objectives for community-based education in undergraduate medical programmes. Med Educ. 2004;38:510 – 521. 10 Vandermotten C, Marissal P, Van Hamme G, et al. Dynamic analysis of neighborhoods in difficulties in Belgian cities [in Dutch]. Available at: (http://www.politiquedesgrandesvilles.be/ content/what/expertise-development/knowledgeproduction/researches/atlasnl.pdf). Accessed March 28, 2008. 11 Art B, Piessens V, De Maeseneer J, Moeneclaey G. Teaching communityoriented primary care in an undergraduate curriculum: Experiences in Belgium. In: International Conference on Overcoming Health Disparities: Global Experiences of Partnerships Between Communities, Health Services, and Health Professional Schools. Atlanta Conference Proceedings 2004. Atlanta, Ga: Abstract 40: 2004. 12 Stacy R, Spencer J. Patients as teachers: A qualitative study of patients’ views on their role in a community-based undergraduate project. Med Educ. 1999;33:688 – 694. 13 Report on the Evaluation of the Medical Curriculum at Ghent University. Brussels, Belgium: Flemmish Interuniversity Council; 2005 [unpublished]. 14 Dowell A, Crampton P, Parkin C. The first sunrise: An experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Med Educ. 2001;35:242–249. 15 Lennox A, Petersen S. Development and evaluation of a community-based, multiagency course for medical students: Descriptive survey. BMJ. 1998;316:596 –599. 16 Davison H, Capewell S, Macnaughton J, Murray S, Hanlon P, McEwen J. Communityoriented medical education in Glasgow: Developing a community diagnosis exercise. Med Educ. 1999;33:55– 62. 17 Derese A, Maes L, De Maeseneer J. Community orientation and etnocentrism in the medical curriculum [in Dutch]. In: Proceedings of the NVMO-Congress, Nov 20 –21, 2003; Egmond aan zee, the Netherlands. Houten, Netherlands: Bohn Stafleu; 2003:93. 18 Howe A, Ives G. Does community-based experience alter career preference? New evidence from a prospective longitudinal

Academic Medicine, Vol. 83, No. 7 / July 2008

Teaching and Learning Moments cohort study of undergraduate medical students. Med Educ. 2001;35:391–397. 19 Steiner BD, Pathman DE, Jones B, Williams ES, Riggins T. Primary care physicians’ training and their community involvement. Fam Med. 1999;31:257–262. 20 Paterniti DA, Pan RJ, Smith LF, Horan NM, West DC. From physician-centered to community-oriented perspectives on health

care: Assessing the efficacy of communitybased training. Acad Med. 2006;81:347–353. 21 Wilkinson T, Gower S, Sainsbury R. The earlier the better: The effect of early community contact on the attitudes of medical students to older people. Med Educ. 2002;36:540 –542. 22 Rose MA, Lyons KL, Swenson Miller K, Cornman-Levy D. The effect of an interdisciplinary community health project on

students attitudes toward community health, people who are indigent and homeless, and team leadership skill development. J Allied Health. 2003;32:122–125. 23 Oandasan IF, Barker KK. Educating for advocacy: Exploring the source and substance of community-responsive physicians. Acad Med. 2003;78(10 suppl): S16 –S19.

best answer. Certainly, there are some wrong answers, but there are many equally good answers— depending on so many specific aspects.

We select our students by single best answer for a world of complexity and ambiguity. We teach an intensive, detailed database that is testable by this format, and then struggle to assess and value the skills of communication and the attitude of service. Strangely enough, the students we have selected by single best answer flock to specialties with limited ambiguities, where they may feel smug serenity in their single best answers.

Teaching and Learning Moments No Single Best Answer As I looked out on the faces of the second-year students awaiting the Step Exam review, I couldn’t help but think of the patient I had seen recently—a 71-year-old woman with a history of recent transient ischemic attack and a right carotid bruit who had refused to consider potential angiogram and surgery. I knew what the right answer would be on a standardized exam. I did not know the right answer for reality. How much of a difference in statistical outcome is needed— how low a number needed to treat—would make it imperative for me to push this reluctant patient to consider having a simple Doppler exam, an angiogram (at some risk), and possible surgery? And what of the cost-effectiveness of studies done and time spent in persuasion? There is no single best answer. What about the patient’s fear of surgery and her preference for “natural” approaches? And “patient-centered communication and problem-solving”? Is it coercive to convince this patient, dead set against surgery, to examine her preferences? What difference in probable outcomes would make this the moral approach? And, of course, what is the benefit/risk ratio of invasive intervention over minimal intervention—and how does that balance her actual concerns? And what of the grandchildren she keeps now so her daughter can work? Her situation is rich with particular, contextual details, but has no single

Academic Medicine, Vol. 83, No. 7 / July 2008

From Iowa tests through SATs, ACTs, MCATs, and Step exams, we select our students by single best answer. Yet even compared to the long-stem, “context”-related cases of the Step exams, real patients are much more broadly contextually situated—family issues, cultural biases of the patients and the doctors, funding resources and changing rules, and on and on. We select our students by their skills in navigating a defined and calculable world, and expect them to adapt to a world of indefinites and ambiguity. Even our beloved database of statistics and prediction rules tells us what will happen to 100 people, but not the one person in front of us in the exam room. My thoughts turned to the boards. Here too, there is a canned world of expected responses—a contrived, monocultural world where all diabetic patients are miraculously compliant with all diets, monitoring, and prescriptions, a world where there are no misunderstandings of plainly spoken English, where labs make no errors and orders are carried out as written. Yet students quickly discover in their third year that many of the challenges of medical practice are not addressed in the database we teach and test.

We have developed and honed an excellent testing and educational process to select for individuals who provide the single best answer. As noted by Berwick,1 “every system is perfectly designed to achieve the results it achieves.” Perhaps if we want different results, we need to rethink and redirect our selection and training processes. In the interim, I teach “out of both sides of my mouth,” making sure the students know the “single best answer” as well of the variety of right answers for real patients. Martha L. Elks, MD, PhD

Reference 1 Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312: 619 – 622. Dr. Elks is associate dean, Department of Medical Education, and chair and professor, Department of Medical Education, Morehouse School of Medicine, Atlanta, Georgia.

683