Communities, Social Justice, and Academic Health Centers

Abstract

In November 2015, the Association of American Medical Colleges (AAMC) held its annual meeting in Baltimore, MD. In response both to health and health care inequities faced by residents of Baltimore and to the imminent trial of the police officers charged with Freddie Gray’s death, AAMC leaders thought it crucial to address issues of health inequity, social injustice, and the role an academic health center (AHC) can play in improving the health of the community it serves. In collaboration with community-engaged researchers from Johns Hopkins University and University of Maryland, Baltimore, AAMC staff interviewed Baltimore residents, soliciting their perspectives on how medical education, clinical care, and research can and should respond to social injustice and the social determinants of health. The authors used the resulting videoed interviews to frame a conversation during the annual meeting aimed at developing concrete actions that an individual, an institution, or the AAMC can take to address social injustice and health inequities in the Baltimore community and beyond. The robust conversation and the action steps identified by participants led to the development of a toolkit to build the capacity of AHCs and their communities to engage in similar, action-oriented programming. The success of the conversation inspired future meeting sessions that purposefully incorporate community voices and expertise. This Perspective presents results of this action planning and places the proposed set of activities within the current health care context to demonstrate how community expertise and wisdom can inform and advance efforts to improve the health of all.

In the United States, health and health care inequities—systematic, measureable, and avoidable differences in health-related outcomes between groups—persist despite decades of efforts to identify, understand, and ameliorate them.^1,2 In Baltimore, MD, for example, a 5-mile trip from the Roland Park neighborhood to the Madison East End community yields a 20-year drop in life expectancy.^3,4 Access to healthful food, reliable transportation, safe housing, and quality education are a few of the social and economic forces, the so-called “social determinants of health” (SDOH), that explain a significant proportion of these gaps in health and health care.⁵

Beauchamp and Childress’ Principles of Biomedical Ethics includes justice as one of the 4 basic pillars of medicine’s ethical framework and charges practitioners to ensure fair distribution of health resources and to be fair when making decisions about who gets what treatment.⁶ The Charter on Medical Professionalism similarly encourages physicians to “promote justice in the health care system,” and to “work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”⁷

These professional commitments, coupled with the effects the SDOH have on the health of patients and communities, imbue academic health centers (AHCs)—often among the most heavily resourced institutions in underserved and under-resourced communities—with an ethical responsibility to directly address issues of social and economic injustice. Such injustices remain a main driver of disparities, and they threaten the health of the populations that AHCs serve. Unfortunately, a clear and present disconnect exists between the lived experience of populations facing inequity in health care and health outcomes and the charters and missions of most health care systems.

The good news is the ethical imperative to eliminate disparities and to work for justice in health and health care is now joined by emerging economic imperatives. Value-based health care demands that hospitals and health systems turn upstream to address community-based barriers that increase the likelihood of readmissions and resultant penalties.⁸ The Center for Medicaid and Medicare Innovation Center’s “Accountable Health Communities” model aims to test whether comprehensive screening for and development of interventions targeting unmet social needs can lower total health care costs, reduce inpatient and outpatient health care utilization, and improve quality of care.⁹ Not-for-profit hospitals are also now required by law to assess, prioritize, and address local community health needs on a triennial basis or risk losing tax-exempt status.

Importantly, medical education across the continuum is also increasingly focused on incorporating themes of equity and SDOH into the learner experience. When medical school aspirants sit for the MCAT exam they are now tested on the psychological and social foundations of behavior and health. The Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review includes expectations that residents and fellows develop competencies related to quality improvement and health care inequities.¹⁰

Federally funded research initiatives have also increasingly addressed health inequities and social justice. For example, the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ) have both offered funding opportunities specifically for research examining health disparities. Likewise, the Patient-Centered Outcomes Research Institute, which lists “Addressing Disparities” as a main focus area, offers funding for research examining the SDOH and injustice.¹¹

As these new efforts develop, however, it is imperative that educators, scientists, physicians, and administrators partner with community residents to gather, incorporate, and deploy local expertise; without the wisdom of the community, without local residents’ input in designing and implementing programs, even the most well-intentioned health care system is unlikely to address the SDOH in effective and meaningful ways.

After briefly discussing community engagement as a core component of an institution’s efforts to promote justice, this Perspective details the effort of the Association of American Medical Colleges (AAMC) to develop, along with community partners, a community-focused session during its annual Learn Serve Lead meeting. The goal for the session was to give the local community a voice and to share the community’s perspective on how an AHC could fulfill its ethical obligation across its medical education, clinical care, and research missions. The richness of the ensuing dialogue and the interest of session participants to initiate similar conversations at their home institutions led to the development of a widely disseminated toolkit that medical schools, teaching hospitals, and their community partners have used to engage in action planning to address salient local SDOH.

Community Engagement is a Crucial Method to Make Progress

Working collaboratively with community members in a partnership can be a powerful way to influence health system changes, educate tomorrow’s health professionals, and ensure that the benefits of research extend to all.^12,13 Several tried and true principles guide effective community engagement. First, recognizing that the shared identity of the community can extend beyond socio-demographic factors is important. Characteristics such as same geographic origin, physical attributes, living conditions, religion, or skin color do not in themselves create a sense of social cohesion. Using a community-derived and -responsive definition of “community” is a crucial first step in appropriately designing and implementing research protocols, service learning opportunities, and/or health promotion activities.

Following other guiding principles of community engagement can help increase the likelihood that an AHC’s collaborative efforts to promote justice and equity are effective. Involving community members as full collaborators in all phases of the research process, demonstrating respect and trustworthiness, facilitating mutually beneficial partnerships, approaching research and program development as iterative processes, and expeditiously disseminating research and evaluation findings to all partners can help ensure community health improvement activities take root and are sustainable.¹⁴

As a result of NIH support for community-engaged science through its Clinical and Translational Science Award program and other funded centers, literature about the most valid ways to conduct and evaluate community-partnered scholarship is available.¹⁵ The benefits of community engagement accrue to all partners and products: not only does adding community voices to research and program planning help identify acceptable ways to phrase questions, gather data, and enhance representativeness of study participants, but doing so also foments trust between the academy and local residents. Further, participating in research helps increase the capacity of local communities to advocate successfully for their own health and sustain their own efforts to promote equity and justice.¹⁶

AAMC Annual Meeting: Developing Actions Steps in Response to Community Perspectives

Community engagement also improves the ability of national associations to develop tools and resources their members can use to close health and health care gaps. In November 2015, the AAMC convened its annual Learn Serve Lead meeting in Baltimore, Maryland. The city and site had been selected years in advance, long before the death of Freddie Gray and the ensuing unrest. In response both to the imminent trial of the Baltimore police officers charged with Mr. Gray’s death and to the persistent health and health care inequities faced by residents of Baltimore City, AAMC leaders thought it crucial to address head on the issues of health inequity, social injustice, and the role an AHC can play in improving the health of the community it serves. To do this authentically and respectfully, conference organizers sought to bring community voices and expertise into the annual meeting in order to spark community-responsive action planning.

In collaboration with researchers at Johns Hopkins University, the University of Maryland School of Medicine and School of Social Work, and local Baltimore City residents, AAMC researchers developed an interview protocol to gather local residents’ perspectives on what an AHC, across its medical education, clinical care, and research missions, can and should do about community health and the social factors that impact the lives and well-being of Baltimore residents.

In September, 2015 seventeen Baltimore City community leaders and lay people offered their views and experiences in video-recorded, 30-minute interviews. Some community leaders and lay participants were personally invited by research partners at Johns Hopkins University or the University of Maryland, Baltimore. Additionally, AAMC staff—all PhD-level researchers from the AAMC’s Health Equity and Research and Policy team (including P.M.A. and K.M.S.)—approached potential interviewees on the street. These AAMC staff members invited all passers-by to participate until enough people consented for the researchers to reach their target sample size. The project received an exemption from the American Institutes for Research’s Institutional Review Board, and all participants underwent both an informed consent and video consent process. Interviewees received a $25 dollar gift card for their time, and all participants received invitations to attend the annual meeting session at no cost (five of the seventeen interviewees ultimately attended and actively participated in the conversation). The interviewers asked the 17 local Baltimore residents about the following:

• Their definitions of “community” and their perceptions of its health;

• How their individual social circumstances affect (or do not affect) their well-being;

• What a healthy community would look like;

• Their thoughts about how clinicians, medical students, and scientists can better work with communities to mitigate injustice, minimize inequity, and improve the health of all.

The interview footage was edited into four videos, each 6-minutes long, dedicated to, respectively, “Community,” “Clinical Care,” “Medical Education,” and “Biomedical Research.” List 1 presents community-endorsed actions that AHCs can take to meet communities where they are and begin to work toward health and health care equity. A common theme was the need for scientists, clinicians, and medical students to spend more time in the community speaking to local residents, learning about their lives, and incorporating that knowledge into their practice. Additionally, community members advocated the inclusion of content related to economic and social drivers of health in medical school curricula. They also wanted scientists to improve dissemination efforts related to research findings, the impact of these findings, and opportunities for community collaboration.

List 1. Community-Derived Actions for Academic Health Centers to Promote Health Equity and Justice.

… in the clinical care mission

• Become more aware and ask about the social circumstances of their patients.

• Devote less focus to biological determinants and more focus to social determinants.

• Incorporate more home visits.

• Be more involved with the community and invest in more “out of the office” time.

• Become more attentive and understanding about the needs of the community.

• Look at each patient as an individual.

… in the medical education mission

• Learn about the challenges and social circumstances community members face.

• Learn how to navigate culturally diverse situations.

• Understand that each patient is different.

• Devote less focus to biological determinants and more focus to social determinants.

• Integrate economics, social science, and cultural sensitivity classes into the curriculum.

• Learn to listen and consume information from the patient.

• Be more involved in the community, by participating in community meetings, asset mapping, or even walking through the community.

• Learn more about the traditions of certain communities.

… in the research mission

• Work together with the community to build trust.

• Shorten the participant time requirements for research studies.

• Involve community members throughout all phases of the research project.

• Find effective methods to disseminate information and knowledge.

• Find methods to share and educate community members about research projects.

• Make research participants feel like what they are doing is helpful to the study.

• Use the data gathered from studies to do something/help the community.

• Share the data/information learned from research studies back with community.

• Assess the true needs of the community prior to beginning a research project.

After presenting each video, session facilitators encouraged the 400+ attendees at the Learn Serve Lead session to react to and reflect on their own communities (and the communities served by their institutions) and to develop concrete actions (presented in Table 1) that an individual, an institution (e.g., AHC, hospital), or the AAMC could take to address social injustice and health inequities. Participants highlighted the need for clinicians and medical students to be cognizant of the power dynamic that exists between patients and providers. Additionally, audience members suggested that hospitals and health systems could better integrate community-engaged research into their overall medical education, clinical care, and research missions. Attendees urged the AAMC to continue to provide venues highlighting exemplary community-engaged scholarship so that effective programs can be scaled and disseminated.

Table 1.

Academic Medical Center-Derived Actions to Promote Health Equity and Justice

Level at which to take action	Clinical care	Medical education	Research
Individual	Read your hospital’s community health needs assessment to increase awareness of community needs. Develop a list of local resources and have it on hand to make referrals for patients. Ask patients relevant questions about their health and social circumstances. Develop patient centeredness and communication skills. Be aware of the power dynamic that exists between patients and providers.	Understand that you will not be 100% culturally competent about every patient and that each patient presents a new opportunity to learn. Participate in community-engaged scholarship opportunities. Increase empathy/patient centeredness/communication skills. Be aware of the power dynamic that exists between patients and providers.	Incorporate short-term, visible outcomes, even in longitudinal studies and report back to community participants. Increase empathy/patient centeredness/communication skills. Be aware of the power dynamic that exists between research participants and researchers. Involve community members in all stages of the research process.
Hospital, teaching hospital, health system, and/or medical school	Integrate non-medical services into the core medical team (e.g., social work, the housing department, legal services). Create partnerships with local communities. Incentivize community engagement in the merit and promotion process. Provide interprofessional training on holistic patient care.	Address institutionalized racism and discrimination at your institution. Introduce cultural competency training earlier in education. Include principles of community-based participatory research as a mainstream portion of medical education. Incorporate community health needs assessment data and local community history into the curriculum. Provide interprofessional training on holistic patient care.	Integrate community-engaged research into medical education and clinical missions. Incorporate community development as part of the research plan and align research priorities with the community priorities. Create more opportunities for medical students and premed students to be involved in community-engaged research. Ensure each research team consults with a community advisory board.
Association of American Medical Colleges	Create a national taskforce that includes student affairs deans, researchers, information technology staff, business members, educators, etc. to come together and strategize about improving community health. Develop tools and resources to teach physicians about community engagement. Aid in advocacy efforts to demonstrate the value of community-engaged research.	Bridge the divide between community and academic medicine. Provide support for innovative educational programming like “hot spotting.” Work with member institutions to develop and evaluate curricula that address the social determinants of health.	Create a toolkit or technical assistance to help replicate community-based participatory research and social justice work in local communities. Provide a venue or resource which highlights the success stories of other institutions that are successfully addressing the social determinants of health. Provide resources for community-engaged research funding opportunities.

As a result of the rich dialogue and constituent interest in continuing these conversations at their home institutions, AAMC staff developed a toolkit, available on AAMC’s health equity research Webpage,¹⁷ so that faculty, students, staff, and community partners connected to AHCs across the country can recreate the annual meeting session and co-develop specific action steps to take together to promote justice and equity. In addition to the four videos, the toolkit contains PowerPoint slides, a facilitator guide, and reflection and action planning worksheets.

Plans are already in place to produce similar, community-partnered programming at future AAMC Learn Serve Lead meetings so attendees can learn directly from residents of the communities hosting the annual event. In November 2016 in Seattle, for example, members of the AAMC’s Health Equity Research and Policy team have presented interview footage of 16 Native Americans discussing their perceptions of precision medicine, research participation, and biobanking. Criminal justice health is likely to be the focus of our 2017 session in Boston.

Bringing communities and health professionals together to collect ideas and develop potential action items is an important first step in the promotion of health justice. The ideas presented in List 1 and Table 1 might have broader applicability than just to the City of Baltimore. Indeed, recent winners of the AAMC’s annual Spencer Foreman Award for Outstanding Community Service have effectively worked for social justice by providing community grants to local community-based organizations in response to Community Health Needs Assessment-identified priorities (Children’s Hospital of Philadelphia) and by engaging community residents directly in hiring research faculty to ensure scientists’ agendas match the needs of those they serve (Michigan State University).

However, as these two examples make clear, moving from developing a list of actions to actually taking action will require that AHCs heed the moral, economic, scientific, and educational imperatives to address the upstream factors that affect downstream health. This work will require AHCs to demonstrate leadership—that is, to cultivate and strengthen relationships with interested parties for collaborative goal-setting, commit financial and human resources, ensure that these actions benefit communities in meaningful ways, and build local capacity to sustain benefits over time. This leadership is necessary, yet will not be sufficient unless the work taps into the most important resource of all: the lived experience of the communities we aim to serve.