Building relationships: reimagining the community placement for medical students

Most medical students are familiar with asking the routine questions, “Can you tell me more about your living arrangement? Do you live alone? Where do you live?” that accompany the social history component of a patient interview. We often ask these questions in a scripted manner without recognizing the implications of our patients’ answers. Do we truly appreciate what it means to live in a supportive housing unit or to be in a financially difficult situation? As medical students, we must be able to say more than just “Thank you for sharing” before proceeding with our own agenda, and instead recognize the social determinants of health that shape our patents’ health and consider how we can address them. It is near impossible to gain an appreciation for these factors by sitting in a classroom. This is the gap that Community-Based Service Learning (CBSL) aims to fill, by bringing medical students into community organizations to learn from those with lived experience.

Central to CBSL is the relationship between the learners and the community. As both parties begin to navigate this relationship, complexities abound, such as role uncertainty and power imbalances. Crucial to overcoming these challenges is structured and facilitated dialogue that is supportive, without being prescriptive. Our experience in the University of Toronto’s Health in Community (HC) curriculum is illustrative of these considerations in CBSL.

In the existing Health in Community curriculum, students were matched with community partners and given approximately three hours each week to engage with community partners in four ways: 1) to observe, spending time behind the scenes; 2) to participate, getting involved with the work of the organization; 3) to contribute, creating a resource that responds to a community-identified need; and 4) to advocate, designing a potential advocacy activity and pitching it to the organization.¹ At each of the community placements, students and community partners were responsible for identifying activities to achieve co-created learning objectives. We, the students, noted a great degree of heterogeneity between their experiences and those of their peers.

Our experiences highlight the challenge in creating and nurturing relationships between students and community partners. We students identified concerns with overstepping the expertise of the agency or imposing a burden on an already resource-stretched community agency. Meanwhile, we felt that community partners were unaccustomed to participating in medical education and, despite being experts in their own work, community partners perceived their knowledge as being less valuable or useful to a medical student. It was our experience that both parties were unable to freely articulate their needs and come to a mutually beneficial understanding. It is reminiscent of a situation frequently encountered by medical learners, when asked by preceptors for learning objectives; due to power imbalances or lack of knowledge, the learner may not identify appropriate goals. The clinician is similarly unaware of the learner’s knowledge gaps and unable to individualize opportunities without input from the student.

To help address the challenges we experienced, we developed a “menu” of options to facilitate structure and provide a jumping-off point that can stimulate ideas and creativity. The menu is a list of different projects that were completed by previous cohorts during CBSL. Included in the menu are discussion questions for both medical students and community partners that can guide reflective conversations between the two parties with respect to learning goals and expectations.

Our experiences with CBSL highlight the need for further reflection on the different roles of knowledge and expertise and the nuances of working in community. An important question is posed: how can we set and achieve pre-defined learning objectives without disregarding community leadership, while still achieving the needs of a community organization? We may not have the answers, but as CBSL courses evolve across the country, we believe it is essential to consider these tough questions and work with the community.

As future physicians, we are obligated to be lifelong learners to provide compassionate, medically appropriate patient care, a duty that extends beyond staying up to date with new guidelines. By honouring this relationship and our duty to our patients, we can gain valuable insight into the lives of our patients and the myriad social factors which influence their health. As we gain this knowledge, we can become more compassionate physicians, prepared to advocate for our patients.

Authorship

Emily Bellicoso, Sung Min Cho, and Tiffany Got contributed equally to this work.