Promoting Life-Long Community Involvement: An Integrated Service-Learning Course

Introducing osteopathic medical students to community service as an educational requirement.

By A. Kay Kalousek, DO, MS

Overview
During the 2005-2006 academic year, Western University of Health Sciences College of Osteopathic Medicine (WUHS-COM) initiated a Service-Learning course as part of the new curriculum. Elements of this course included instruction in public health, epidemiology, biostatistics, and a mentored community service project.

To complete the community service project, students determined a target population, performed a needs assessment, obtained Institutional Review Board (IRB) approval and consent, and performed the community service intervention. At the completion of the intervention, students individually wrote a paper that reflected on the experience, and as a group, produced a presentation outlining their project and its outcomes.

Students were surveyed regarding the experience and they overall felt that doing a community service project as part of the curriculum was a valuable experience.

The main suggestion for improvement was that students be given more direction in what type(s) of project to pursue. Further study will include periodic surveys of the student participants to determine their level of involvement with community service projects as they progress through medical school training, residency and practice as compared to students who did not receive this course as part of their curriculum.

Introduction
After almost two years of preparation and planning, WUHS-COM initiated a new four-year curriculum. Significant source material for the design and initiation of this new curriculum included:

A. Literature outlining changes in the learning styles of the student population during the past 10 years.
B. Changes in the content focus and question style of the Comprehensive Osteopathic Medical Licensing Examination (COMLEX).(1)
C. The Seven Core Competencies of the Osteopathic Profession,(2) which include:

1. Osteopathic philosophy and Osteopathic Manipulative Medicine
2. Medical Knowledge
3. Patient Care
4. Interpersonal and Communication Skills
5. Practice-Based Learning and Improvement
6. System-Based Practice

D. The Institute of Medicine Report: Crossing the Quality Chasm(3)
E. The Pew Health Professions Commission Report: "Recreating Health Professional Practice for a New Century"(4) which contains the following major recommendations:

1. Change professional training to meet the demands of the new health care system.
2. Ensure that the health profession workforce reflects the diversity of the nation's population
3. Require interdisciplinary competence in all health professionals
4. Continue to move education into ambulatory practice
5. Encourage public service of all health professional students and graduates

Based on this information and multiple other sources, the major elements of the new curriculum included the following:

• Integration of an osteopathic approach to all disciplines
• Emphasis on application of scientific information to the care of the patient through the use of
  case studies
• Early clinical exposure and clinical problem solving
• Doctor-patient communication training
• Cultural competency and diversity training
• Training in information management and medical informatics
• Evidence-based decision making
• Mentored community and public outreach and service

Background
Although volunteerism has been common among young people for many years, service-learning courses have arisen as a result of the recognition that students should receive formal exposure and training in the area of community service. During the past 10 years, numerous service-learning courses have been initiated for students from primary to professional school levels. Studies have shown formal training experiences that include community service can "influence how actively physicians will later interact with their communities."(5)

Service-learning differs from volunteerism in that it is a "teaching method which combines community service with academic instruction as it focuses on critical, reflective thinking and civic responsibilities."(6) Unlike typical volunteer activities, students in a service-learning course follow a formalized process to determine the scope of their project, have mentored guidance throughout the activity, demonstrate accountability through outcomes measurements, and reflect about their experiences through discussion and writing.(7)

Methods
During the first 12 weeks of the fall semester, first-year Osteopathic Medical Students (OMS I) were prepared for the Service-Learning course by participation in a pre-requisite Physician And Society course (PAS). The PAS course presented information through lectures, group projects and group discussions on topics including:

• History of medicine
• Medical professionalism
• Influences of literature and the media on the practice of medicine
• Medical ethics including beginning- and end-of-life issues, society and ethics, case studies and physician-patient relationships

After completion of PAS, the students moved directly into the Service-Learning course. The first seven weeks of the course consisted of didactic sessions designed to prepare students for their community service project. The topics of the sessions included:

• Service-Learning: What, Why, How?
• Introduction to Public Health
• Basic Concepts in Epidemiology
• How to do a Needs Assessment and Project Proposal
• IRB Approval Process
• Obtaining Informed Consent
• Project Fundraising Ideas

During this time, students determined their area of interest, divided into groups according to their area of interest, choose a faculty mentor, performed a needs analysis, met with their faculty mentor for small group planning sessions and produced the first draft of their project proposal (Appendix #1).

During the early part of the spring semester, the project proposals were reviewed by the faculty mentor and the Service-Learning Course Director. After revisions and approval, the students formulated a checklist of tasks necessary to complete the project and submitted their project proposals to the Western University of Health Sciences IRB. Although most of the projects received IRB approval, a few had to be revised and re-submitted. After IRB approval was obtained, students proceeded to perform their community service activities.

The didactic portions of the spring semester Service-Learning curriculum included additional cases in public health and epidemiology, as well as instruction in biostatistics.

After completion of the project, each student wrote a brief (one- to three-page) reflective paper recounting their experiences and discussing how the project affected them personally. All student groups produced a brief presentation which outlined their project and its outcomes in a Microsoft PowerPoint or digital-video format, which was posted to Blackboard (WUHS-COM's online learning system) so that all students could view the projects. Several representative presentations were posted to the Service-Learning page on the college Web page, which was created as a result of the course.

Results
There were 52 individual projects (Appendix #2), and a total of 214 students participated. Individual student activities ranges from 10 to 50-plus hours of community contact with an average of approximately 20 hours per student, resulting in the generation of more than 4,200 hours of community service.

Additionally, a recent survey of the students (August 2006) demonstrated that greater than 37 percent of the students who were involved in the service-learning projects have continued to work with the agencies and communities that they served. This has resulted in the following benefits:

• Continued exposure of WUHS-COM and osteopathic medicine in general to the surrounding community
• Continued contact with schools and community organizations
• Funding support for the projects from community-based organizations
• Interest and anticipation for the course by the new OMS I students
• Start-up of a new free clinic which serves the homeless population in the surrounding areas

At the end of the Service-Learning course, the class was surveyed using the CoursEval academic course evaluation software. The majority of the respondents thought that the project enhanced their learning, and that it would enhance their future interaction with patients. The main suggestion for improvement of the course was that approximately one-third of the respondents said they would like more direction in what type of project to perform. Several students also wrote they felt too "stressed out" by performing their other coursework to focus on the project in the way that they would have liked.

Discussion
The Service-Learning course at WUHS-COM provided an opportunity for students to perform community service in a structured learning environment which includes instruction in public health, epidemiology and biostatistics.

1. Challenges to this program included:
2. Competing courses in the academic curriculum.
3. Lack of familiarity of many students with the resources of the surrounding areas.
4. Tendency of some students to try to take on too large of a project for the limited time period available.
5. Lack of continuity in the following year's curriculum.

Future directions for the course will include:

• Specific tracks with projects that have already been approved by the community agencies to help streamline the process for the students
• Faculty project mentors that are chosen prior to the start of the course according to interest, content expertise, and availability
• One or more formal session(s) for student presentation in which university and community leaders will be invited
• Extension of the project deadline so that students will have more time for completion
• Consideration for future modification of the course to include time during the OMS II year for follow-up on the project
• Increased number of case-based presentations for the biostatistics section
• Online delivery of some of the didactic material via the Blackboard learning system
• Attention to each aspect of the four-domains of community involvement for physicians(8)

1. Attention to socio-cultural aspects of patient care
2. Familiarity with the community's health resources
3. Participation in health activities in the community
4. Participation in and assimilation in the community

Future research will include:

• Periodic surveys of the student participants to determine their level of involvement with community service projects as they progress through medical school training and into residency and practice as compared to students who did not receive this course as part of their curriculum
• Determination if there are differences in student satisfaction based on the type of
  project chosen
• Surveys of the service recipients for outcomes measures of the interventions
• Global community needs assessment to determine future directions for the projects done in this course
• Determination if there were positive changes in the COMLEX scores that are concerned with the public health, epidemiology, and biostatistics domains as a result of the changes in the presentation of the material (didactic + case-based + experiential through the project presentation with outcome measures) versus the didactic-only presentation of this material performed in previous years.

Conclusion
The challenges of health care in the 21st century are far-reaching and call for changes in the educational paradigm for osteopathic medical students. Service-Learning presents an opportunity for students to meet some of these challenges; and should be considered for inclusion in the osteopathic medical curriculum.

A. Kay Kalousek, DO, MS is a member of the faculty of Western University of Health Sciences, Pomona, California.

1. Web site for the National Board of Osteopathic Medical Examiners. http://www.nbome.org
2. The Seven Core Competencies of the Osteopathic Profession. American College of Osteopathic Internists. http://www.acoi.org/CoreComp.pdf
3. The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. July 2001
4. Pew Health Professions Commission. “Recreating Health Professional Practice for a New Century: Executive Summary.” The Fourth Report of the Pew Health Professions Commission, December 1988.
5. Steiner, B.D., Pathman, D.E., Jones, B., Williams, E.S., and Riggins, T. “Primary Care Physicians’ Training and Their Community Involvement.” Family Medicine 31 (4): 257-262, 1999.
6. Campus Compact: Educating Citizens, Building Communities. Definitions for Service Learning. http://www.compact.org/resources/detail.php?id=19
7. Seifer, S.D. “Service-Learning: Community-Campus Partnerships for Health Professions Education.” Academic Medicine, 73 (3): 273-277, March 1998.
8. Pathman D.E., Steiner, B.D., Williams, E.S., and Riggins, T. “The Four Community Dimensions of Primary Care Practice.” Journal of Family Practice, 46 (4): 293-303, 1998.

Additional Resources

• Brill, J.R., Ohly, S., and Stearns, M. “Training Community-Responsive Physicians” Academic Medicine, 77 (7), April 1, 1999.
• Chung, K., Tupponce, D., Birnbaum, B. “Fulfilling a Social Contact: Alliance of Health Professional Students.” American Family Physician, 59 (7), April 1, 1999.
• Coulehan, J. “Viewpoint: Todays Professionalism: Engaging the Mind but Not the Heart.” Academic Medicine, 80 (10): 892-898, October 2005.
• Davidson, R.A., and Waddell, R. “A Historical Overview of Interdisciplinary Family Health: A Community-Based Interprofessional Health Professions Course.” Academic Medicine, 80 (4): 334-338, April 2005.
• Eckenfels, E.J. “Contemporary Medical Students’ Quest for Self-Fulfillment through Community Service.” Academic Medicine, 72 (12): 1043-1050, December 1997.
• Eyler, J., Giles, D.E., and Braxton, J. “The Impact of Service-Learning on College Students.” Michigan Journal of Community Service Learning, Vol. 4: 5-15, 1997.
• Fried, C., Madar, S., and Donley, C. “The Biomedical Humanities Program: Merging Humanities and Science in a Premedical Curriculum at Hiram College.” Academic Medicine, 78 (10): 993-996, October 2003.
• Furco, A. “Service-Learning: A Balanced Approach to Experiential Education.” http://www.floridacompact.org/pdf/resources/SL-ABalancedApproach.pdf
• Seifer, S., Hermanns, K., Lewis, J., and Zlotkowski, E. “Creating Community Responsive Physicians: Concepts and Models for Service Learning in Medical Education,” 2000.
• Steiner, B., and Sands, R. “Responding to a Natural Disaster with Service Learning.” Family Medicine, 32 (9): 645-649, 2000.
• Switzer, C.L. “Service Learning in a Medical School: Psychosocial and Attitudinal Outcomes.” PhD Dissertation, University of Pittsburg, DAI-B 60/09, p. 4935, March 2000.