Naomi Wortis, MD and Sharad Jain, MD
Fall 2003

Background Information

Physicians have a responsibility to care for the health needs of entire communities, not just individual patients. Most medical students arrive at UCSF with experience and/or interest in community health and social advocacy. Unfortunately, they have often had trouble finding mentors and opportunities for continued development in these areas during their medical studies. With the development of the new Area of Concentration (AoC) in Community Health and Advocacy, students will find a stronger infrastructure for developing skills in these areas in the future, both in the academic and community arenas.

The curriculum for this AoC in Community Health and Advocacy is being designed this year, with the plan to open it up for enrollment in Spring 2004. The first medical students completing this AoC will be doing their 4th year projects during the 2004-2005 academic year. Preliminary planning is underway for the development of a 2-week intensive core course that all 4th year students electing to do this AoC would be required to take in the fall of 2004. This core course will provide them with a framework and basic skills for doing community health and advocacy work. All students doing this AoC will need to have a faculty mentor and a community mentor to assist them while they plan and carry out their project. Recruitment and training for these mentors is also being planned. Finally, there will be monthly opportunities for students in this AoC to meet, share experiences, and reflect on their work.

With support from a prior grant from the Academy of Medical Educators, Sharad Jain has been reviewing current UCSF curricula in the areas of community health and social advocacy, reviewing curricula in these areas offered at other medical schools, and engaging faculty from multiple UCSF departments in a collaborative planning process for this new AoC. This voluntary collaborative planning group currently includes representatives from the departments of Internal Medicine, Family and Community Medicine, Pediatrics, and Psychiatry as well as two medical students. Another important addition to the team has been a community activist by the name of Robert Uhrle, who for the last few years has been contracting with the Department of Family and Community Medicine (FCM) to help teach their residents about community health from the community perspective. The plans described in this grant proposal are the result of these interdisciplinary discussions.

An important aspect of this AoC that needs to be further developed is the opportunity for representatives from local communities to be partners in the planning and teaching of the new curriculum and in mentoring the students on their projects. A core principle of community health work is that projects should be community-based, not just community-placed. This means that the community that is being targeted should be involved in all phases of the project. If medical students are to learn how to do this work well, they need the opportunity to learn about the community perspective as well as the academic perspective. The subject of this grant proposal is the development of "community partners" for this new AoC in Community Health and Advocacy.

Goals

The goals of this project are to develop community partners for the following aspects of the curriculum for the new AoC in Community Health and Advocacy:

· Design and teaching of the curriculum for the 2-week intensive core course to be required of all 4th year students enrolled in this AoC
· Development of opportunities for student projects in community health and/or advocacy within local communities
· Mentoring of students while they are doing their 12-24 week community health and/or advocacy projects
· Evaluation of student projects
· Evaluation of the new AoC curriculum

Procedures

Community partner input will be sought for the content and teaching of the 2-week intensive core course that all students choosing the AoC in Community Health and Advocacy will be required to take. Many of the proposed topics are currently being taught in other curricula at UCSF (including the 3rd year clerkship in Family and Community Medicine and the primary care internal medicine program at SFGH), and we plan to include faculty from those programs in this course. The following are topics that may be included:

· How to define a community
· How to characterize a community
· Cultural competence
· Community asset mapping
· Community needs assessment
· How to partner with community residents and/or organizations
· Project design
· Advocacy skills/strategies
· Community-based participatory research
· Program evaluation
· Leadership skills

We plan to have students use their pre-identified target communities as case-examples for learning about these various topics. Having input from both the community and academic perspectives on each of these topics would be invaluable. In addition to having community partners involved in didactic teaching and small group discussion, community partners could lead field trips to their own communities to help illustrate some of the concepts being introduced in the classroom. Students would come away with a more well-rounded sense of how to work successfully with communities if they were able to understand the community perspective better at the outset.

Community partners will also be useful in the development of 4th year project opportunities. Projects should allow for students both to learn about community health and advocacy and also to provide a concrete service to the community. Past student projects have included developing a smoking cessation class at Southeast Health Center and developing a curriculum on obesity for Lowell High School. Some students may find their own projects independently, but others will need guidance in choosing a community to work with and developing a project within that community. It will be challenging for students to accomplish something of practical use to the community within the 12-24 weeks that they will typically have available to work on the projects in the 4th year. Target communities will need to be involved in the project planning as early on as possible. Since students on such a limited timeline will probably not have time to develop grassroots community involvement in their projects, it is likely that their community partners will need to be pre-existing community-based organizations (CBO's) which are interested and willing to host students. It will take some care to choose appropriate CBO's and find people who work at those CBO's who actually have the time to take on a medical student project. This is essential if the project is to have any chance of sustainability after the student graduates. Ideally, a database could be developed and maintained of interested CBO's, their target populations, and their areas of programming. The Department of FCM has numerous community contacts already and is in the process of developing more (see list in Appendix).

A particularly important role will be played by the community partners who are actually serving as community mentors for the students while they are doing their projects. Unless these community mentors are people who have already been involved in the design or teaching of the core course, they will need some training introducing them to the overall medical student curriculum, covering the goals and structure of this AoC curriculum, and clarifying what their mentoring responsibilities are. Ideally, prior to starting their project, each student would have at least one opportunity to meet with both their faculty and their community mentors at the same time to make sure that they are all in agreement on the goals of the project and their respective roles.

As will be outlined in more detail below, there will be a process for evaluating the student projects and the AoC curriculum. Students' community and academic mentors will evaluate their work and their project outcomes. Feedback will also be solicited from community partners about whether the students are learning the basic skills they need from the core course.

It should be noted that efforts are currently underway to determine which of the electives available to 1st and 2nd year medical students may be relevant to their future involvement in the AoC in Community Health and Advocacy. It remains to be decided whether participation in one or more of those electives will be encouraged or required for completion of the AoC, as well as whether other service learning opportunities (e.g., volunteering at the student homeless clinic) will be required of the pre-clinical students. Also, all medical students are required to complete a 3rd year clerkship in Family and Community Medicine (FCM-110). That clerkship includes an introductory curriculum on community health. That opportunity to introduce all 3rd year medical students to the concept of community health will also be a valuable opportunity to remind students of the possibility of choosing to do an AoC in Community Health and Advocacy and to recruit them to this program. For students who already know that they are interested in doing this AoC, they will have the opportunity during FCM-110 to spend time doing a community health assessment and a preventive medicine mini-project related to their future AoC project if they wish. If students have already identified a community or community partner with whom they plan to do their AoC project, every effort will be made to have their FCM-110 project assignment made accordingly. Students would thereby fulfill their FCM-110 requirements and work on planning their 4th year AoC project simultaneously.

Plan For Measurement And Documentation Of Project Efficacy And Outcome

There will be multiple ways of measuring the efficacy of this new AoC curriculum. Each student will be expected to leave a "legacy" of some kind at his or her community site. These legacies will take different forms-e.g. health education curricula, data from community needs assessments, policy changes made as a result of advocacy work, etc. Students will be required to present the process and outcomes of their projects at a forum that will include other students and academic and community mentors.

Each student will be asked to complete an inventory of knowledge and attitudes about community health and advocacy at the time that s/he declares the area of concentration and upon completion of the project. Students will also be asked to complete evaluation forms covering their experience of the 2-week core course, their project placement, their community mentor, and their faculty mentor. Faculty and community mentors will be asked to complete evaluation forms covering the students' skills in conducting the project, their skills in working in partnership with the community, and the final outcome(s) of their project. We will also solicit feedback from our community partners regarding their experience of being involved in the development and teaching of this new curriculum. This could take the form of evaluation forms, individual interviews, or focus groups.

Plan For Continuation Of Project At The End Of Funding Cycle:

The AoC in Community Health and Advocacy will continue to exist and be refined after the end of this funding cycle. However, the time demands for academic and community partner faculty will be reduced compared to the initial effort of putting together the first 2-week core course, developing a database of appropriate project opportunities, orienting faculty and community mentors for the first time, and designing evaluation tools. It is likely that maintenance of these programs can be supported through funds directly from the School of Medicine for the AoC's and/or through support of faculty time from individual departments. It is possible that further funding might be requested from the Academy for new programming within this AoC.

For more information, please email:
Naomi Wortis, MD
Sharad Jain, MD