by Sylvia J. Moore, R.D., Ph.D. and Suzanne M. Allen, M.D., M.P.H.
Atul Gawande, in his recent New Yorker article titled “Slow Ideas,” describes how changes in health care can be difficult to implement quickly, even if the research is credible and the change could lead to profound improvements. Gawande reminds us that social process is critical to the acceptance of new ideas, and he encourages health and medical educators to help their students learn social and community awareness.
The University of Washington School of Medicine (UWSOM) serves as a medical school for five states – Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI). Begun in the early 1970s, the WWAMI medical education program strives to continually improve the environment for student learning even as it has expanded to serve more students in response to regional needs. One of WWAMI’s many innovations was to join with Area Health Education Centers across the five states to offer students transitioning from the first to the second year of medical school a four-week immersion experience with practicing physicians who were providing care for rural and/or underserved populations. The Rural/Underserved Opportunities Program (R/UOP) proved very popular, and each summer 30-50% of rising second year medical students chose to participate. Other students, however, chose to spend the summer between first and second year working on an eight-credit research requirement, the Independent Investigative Inquiry (III). To allow more students to participate in R/UOP, an approach was designed that integrated the research requirement into the R/UOP experience. The result is the R/UOP III.
R/UOP III is a six-week program where experience drives inquiry. Writing assignments (Anderson) are used to enhance and guide the learning experience. Performance expectations and a time line for students are communicated clearly on the R/UOP III website, and students participate in a group orientation (some via distance learning technology) before going to the field. Students are asked to spend one week prior to traveling to their assigned practice sites to gather demographic, cultural, and health indicator data about the site/community. However, students cannot identify a research project until they arrive on the site and have time to finish the community needs assessment and consult with community members to identify a public health problem. Students then are encouraged to engage community members in developing an intervention. The process is modeled after Community Oriented Primary Care (COPC).
With the student at the center of the learning process, a special web interface allows each student regular communication with a faculty mentor. Students are required to write about their learning experiences in journals that are submitted via web. Students at all the sites also are encouraged to post highlights of their experiences and share those highlights, or questions that might arise, with their peers. Before leaving the site/community, the student shares his intervention (usually a pamphlet, community education session, policy or practice change, or similar approach) with community members. In November, all summer participants in R/UOP III meet at the medical school to share their experiences with mentors, faculty, and leadership at the UWSOM at the Seattle campus. At an afternoon reception setting where all medical school faculty and students are invited, R/UOP III students, along with all other III students, present academic posters about their research work and findings, and the interactive presentations are judged by medical school faculty. Students are encouraged also to submit their posters for presentation at the Western Students’ Medical Research Forum (WSMRF) held in Carmel, California each January. Students whose posters win acceptance to the juried event get their travel expenses paid by the Dean of UWSOM and participate in a celebratory reception hosted by the Dean at WSMRF.
R/UOP III has evolved as a curriculum “that cultivates students’ abilities to learn to integrate deeply and meaningfully” (Randy Bass – EDUCAUSE review March/April 2012). Student learning sits at the center of the six week experience, and the immersion in community helps students integrate their learning in ways that make sense in a real world environment. Students find themselves adapting prior learning to fit multiple audiences – patients, community members, allied health professionals, physician mentors, and physician preceptors. The writing assignments strengthen this adaptability by requiring reflection (journals), formal/academic formats (abstracts and research posters), and teaching/persuasion (pamphlets/community education sessions).
The R/UOP III also helps campus-based medical students begin to shift their “sense of self” from a more narrow, learner perspective to a broader sense of what it means to be a medical provider in a community. Students often share reflections about the pleasure and reward they find in helping patients or working with communities, and they also point with pride to the times when they learn a new technique or master a procedure that allows them to contribute meaningfully to the physician preceptor’s work load. In addition, students note they feel their faculty mentors and preceptors value them as developing colleagues, and they begin to strengthen their identities as members of a community of medical professionals. (Etienne Wenger provides a comprehensive overview of communities of practice.)
Gawande notes that “to create new norms, you have to understand peoples’ existing norms and barriers to change.” A recent R/UOP III student on her third day in a rural community shared a reflection that bemoaned: “Children in this town don’t even wear bicycle helmets!” The student identified a public health problem and she set to work interacting with community members to try to find ways to encourage a change to the community norm for bicycle safety. As Gawande wrote, the student was discovering that “…human interaction is the key force in overcoming resistance and speeding change.”
Sylvia J. Moore, R.D., Ph.D., served as a regional assistant dean in the School of Medicine at the University of Washington and as Director for the Wyoming Program of the WWAMI Medical Education from 1996 to 2008. Following a statewide leadership role in a multi-institutional higher education system, she now works as an independent consultant, assisting organizations and individuals with strategic planning, grant acquisition and management, faculty development, and higher education policies and practices.
Dr. Suzanne M. Allen, M.D., M.P.H., was appointed to the position of Vice Dean for Regional Affairs for the University of Washington School of Medicine in December 2009. As the Vice Dean for Regional Affairs, Dr. Allen helps with the WWAMI program and Area Health Education Centers across the Washington, Wyoming, Alaska, Montana and Idaho region. Dr. Allen holds a Clinical Professor faculty position within the Department of Family Medicine at the University of Washington School of Medicine.