A behind-the-scenes look at how we developed and implemented “Introduction to Social Determinants of Health in the Hispanic Community” – an innovative curricular approach to addressing social determinants of health at the Cleveland Clinic Lerner College of Medicine.

A leading American Association of Medical Colleges (AAMC) strategic priority is to “inspire learners to serve the public, promote health, and improve care.”1 Medical schools are finding creative and engaging educational strategies to address the needs of an increasingly diverse population in ever evolving healthcare systems. Service learning is one strategy, as defined by the Liaison Committee on Medical Education, that promotes community service and self-reflection through structured learning experiences.2 How then should medical schools proceed to create the opportunities that “encourage and support medical student participation in service-learning and community service activities?”2

Medical schools are rising to the challenge to train future physicians to address health inequities and incorporate service learning as a means to reach under-served communities, promote learner reflective practice, and instill an ethos of life-long learning and service to communities. Educational strategies range from classroom didactic activities to simulated scenarios with standardized patients or role play, community-based guided visits or tours and community-based immersive clinical experiences.  A systematic review to understand the goals of service learning and community-based education revealed significant heterogeneity across programs and showed that most programs did not routinely involve community members or include reciprocated knowledge transfer.3 A service-learning framework can certainly be utilized to support curriculum development at different stages of training in medical education,4 but how prescriptive should we be?

In the fall of 2017, a group of second year medical students at the Cleveland Clinic Lerner College of Medicine took the lead in a community-based participatory research project with the local Hispanic community. In the implementation of the project, the students recruited and mentored a group of incoming first year medical students who then built upon their findings to design the following year’s project in their area of interest. The peer-to-peer mentoring and unique community engagement thereafter continues from year to year.  An organically grown pre-clinical and clinical elective titled “Introduction to Social Determinants of Health in the Hispanic Population” developed as a space for students to engage with the community, reflect on their findings and relate their experiences to the elective course objectives. The local Hispanic community is afflicted with staggering barriers to health including limited income and education, displacement and trauma augmented after Hurricane Maria in 2017, lack of or under-insurance, social isolation and language barrier. Learning from practicing physicians in the community, students appreciated the struggles with diabetes management and literacy and created a community-based project to explore health literacy and diabetes numeracy. The following year students led community-based focus groups, at the appropriate health literacy level, to explore culturally appropriate and desired diabetes education.

Continuing the peer-to-peer mentoring and expanding community engagement, the current group of students is designing culturally competent interventions to address food deserts and encourage healthier Hispanic cuisine. The students participate in shadowing or precepting experiences with a physician and mentor in the office and reflect on their community findings with clinical practice observations and vice-versa, thereby tying the learning objectives to their created service learning opportunities.  The trainee group continues to grow with increasing number of students and residents who are searching for service learning opportunities with this unique under-served community. Students may join existing community projects or may design new ones and explore their own interests through service learning.

A truly innovative approach to curriculum development engages two important stakeholders: the community and our students.  By engaging communities through community-based participatory research, educators can guide and empower our students through student-based, service and participatory learning on health equity, and social determinants of health.

-Monica Yepes-Rios, MD Community of Practice Member

Dr. Monica Yepes-Rios is an Associate Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.  She is the Director, Cleveland Clinic Longitudinal Clerkship Didactics and Learning Groups Program, addressing Health Systems Science, Social Determinants of Health, and The Physician and Society, and serves the Hispanic community through clinical, education, and community-based student engagement.

1.Association of American Medical Colleges.  The Strategic Imperative: Leading Change to Improve Health.  https://www.aamc.org/about/strategicpriorities/  Accessed July 12, 2019
2.Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. http://www.lcme.org/ March 2016.  Accessed June 18, 2019.
3. Hunt JB. Understanding the Goals of Service Learning and Community-Based Medical Education: A Systematic Review.  Acad Med. 2011;86:246–251.
4. Stewart T, Wubbena Z.  An Overview of Infusing Service-Learning in Medical Education.  International Journal of Medical Education. 2014;5:147-156

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