Implementing Community-based Education: Essential Elements and Recommendations

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Implementing

Community-based

Education:

Essential

Elements

and

Recommendations

Lucy M. Osborn, MD, MSPH

ABSTRACT. Two elements are essential for imple-menting community-based educational programs: a vi-sion of how community experiences fit into the training of the health professionals of the future and a local

environment that will support innovation, change, and

growth. Change cannot occur unless very basic assump-tions regarding medical education are challenged. What is “quality education”? Can programs oriented toward

tertiary and specialty care adequately provide the train-ing that should be the core of a 3-year general training program? Do schools and programs select and train phy-sicians to function within the microcosm of the academic center, or do they prepare physicians to manage the

coun-try’ 5health care needs? National consensus has had little influence over local environments. Each medical school, training program, and teaching facility must reexamine its values and its culture. Each must have a vision of the

physicians of the future and a commitment to train them appropriately.

The role of vision and culture in creating successful programs has been clearly described. Several key ele-ments have been found to be consistent with success, the

first being vision. Four basic principles will bring the vision to fruition: (1) preserving core values while still stimulating progress; (2) emphasizing the process by which programs are created, implemented, and changed rather than the product; (3) avoiding the “tyranny of the or,” learning to be inclusive with a broad vision rather than limited to an “either-or” approach; and (4) aligning the process, management, and values in working toward envisioned progress for the future. Effective leadership is essential for a group or organization to accomplish its mission, as is an organizational structure that aligns

re-sponsibility, authority, resources, and accountability. Pediatrics 1996;98:1264-1267; community-based educa-tion, health care, medical eduction.

ABBREVIATIONS. COCME, Council on Craduate Medical

Edu-cation; DME, direct medical education; IME, indirect medical

ed-ucation.

Community-based education is not new, nor is it

unique to medical education.1 At this conference,

program elements have been described and

dis-cussed in enough detail that residency and student

clerkship programs could take the blueprints

pro-vided and create high-quality community

experi-ences. Moving from concept to actual

implementa-tion is, however, an arduous and difficult task.

Although model programs of community-based

ex-From the University of Utah Health Sciences Center, Salt Lake City, Utah.

Acad-emy of Pediatrics.

periences have been in existence for many years, this

educational paradigm has not been widely

accept-ed.2’ Two essential elements must be present before

implementation can proceed: a vision of how

corn-munity experiences fit into the training of the health professionals of the future and a local environment

that will support innovation, change, and growth.

From each of these elements, specific

recommenda-tions for implementation can be derived.

A VISION FOR THE FUTURE

Not since the Flexner era has there been such a

demand for change in the training of health

profes-sionals. Then, as now, the general consensus was that

there were too many physicians. Education was

re-formed with adaptation to a model, such as the one

in France and Germany, in which schools of

medi-dine were affiliated with universities. Training was

shifted from an apprenticeship model to an academic

one. As accreditation of medical schools developed,

more than half of the medical schools in the United

States closed. The American medical education

sys-tem has gradually evolved so that the overwhelming majority of training occurs within academic health den-ters with emphasis on specialty care and technology.

Whether the perceptions that there are too many

physicians and too many specialists are accurate,

they are widely accepted. Consensus that the

number and mix of physicians and their training

need to change is growing. According to the Sixth

Report of the Council on Graduate Medical

Educa-tion (COGME): “The growth of managed care will

magnify the deficiencies of the current educational

system, yet will also provide new and essential

ed-ucational opportunities to improve the preparation

of physicians for their future roles.”4 The council’s

recommendations included changing the numbers

and types of physician trainees so that the work force

more appropriately meets the nation’s needs and

changing the clinical curriculum to provide an

ade-quate education in ambulatory and managed care

settings.

Despite repeated recommendations by many

influ-ential groups and the pressures created by the

cur-rent upheaval in the health care system, there is little

movement toward educational reform, particularly

at the residency level. Preliminary findings of a

re-cent survey of internal medicine training programs

indicated that training positions continue to increase,

that more programs plan to add trainees than to

reduce them, and that specialty fellowships continue

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SUPPLEMENT 1265

change program focus included: (1) the existing

pro-grams were well balanced and of high quality; (2) the

programs had no problems in recruiting; and (3) the

program graduates entered practice as general

inter-nists. Survey results indicate that residency

pro-grams still maintain a parochial point of view,

re-sponding to their own needs and values rather than

to those of the populations they should be serving.

Change cannot occur unless very basic

assump-tions regarding medical education are challenged.

What is “quality education”? Can programs oriented

toward tertiary and specialty care adequately

pro-vide the training that should be the core of a 3-year

general training program? Do schools and programs

select and train physicians to function within the

microcosm of the academic center, or do they

pre-pare physicians to manage the country’s health care

needs? National consensus has had little influence

over local environments. Each medical school,

train-ing program, and teaching facility must reexamine

its values and its culture. As stated in the recent

COGME report, institutions must “. . . reassess their

roles and responsibilities regarding the physician

work force and medical education . . . and share in

the responsibility to train the number and types of

physicians appropriate to the nation’s needs.”4

The experience of implementing a

community-based program at the University of Utah provides an

example of the importance of creating a shared

vi-sion. The process that was used at this university

before the implementation of the community-based

primary care program serves as an example of the

necessity and value of starting with basic

assump-tions. Beginning in 1984, a committee of key pediatric

faculty and leaders met for more than a year to

examine fundamental issues, including the purpose

and curriculum of the required third-year medical

student clerkship, whether to train residents, the

purpose of a general pediatric residency training

program, the number and kind of trainees that

would best be trained at the institution, and the

desired capabilities of program graduates. A retreat

was then held so that concepts developed by the

committee could be presented to and debated by the

faculty as a whole. Given the opportunity to discuss

the overall future of pediatric education and how

their program fit into a broader context, the faculty

arrived at a consensus that led to support for

pro-grammatic changes. Although the methods for

at-taming the goals developed during the retreat have

been repeatedly and appropriately challenged, the

vision created provided a strong foundation for the

dramatic modifications that were needed to meet the

department’s defined educational mission. During

the ensuing years the faculty has continued to

sup-port continuous educational experimentation and

re-form, insisting on strong evaluation that can

deter-mine whether components of its programs better

achieve the department’s educational goals.

Conse-quently, the community component of the program

came to be seen as integral and essential to training

rather than as an isolated experience that is

sepa-rated from the academic center.

Those in leadership roles in the field of medicine

can learn a great deal about adapting to a changing

environment from colleagues in business and

man-agement. The role of vision and culture in creating

successful programs has been clearly described by

Collins and Porras.6 Their recommendations are

based on a study of what they term “visionary

corn-panies,” companies that are premier, highly

re-garded institutions in their respective industries and that have existed for more than 50 years, have

weath-ered the ups and downs of business cycles with

multiple generations of chief executives, and have

“made an indelible imprint on the world in which we

live.” They found several key elements that were

consistent, the first being vision. Vision defined the

core values and the purposes of the companies. One

of the distinguishing characteristics of success was

that the ideology of these businesses involved far

more than simply making profits. Companies that

flourished embraced four basic principles: (1)

“pre-serving the core” while still stimulating progress; (2)

“clock building” rather than “time telling,” which,

roughly interpreted, means building the process and

system that creates the product rather than the prod-uct itself; (3) avoiding the “tyranny of the or,” learn-ing to be inclusive with a broad vision; and (4)

align-ing process, management, and values in working

toward envisioned progress for the future.

These four principles are particularly relevant in

the current health care market. With the upheaval, it

is particularly important to be ever mindful of

pre-serving the core while still stimulating progress. The

goals of medicine and the health care system have

not changed: to help individuals and populations

attain and maintain health. The purpose of medical

education is no different: to ensure that physicians

gain the necessary knowledge, skills, and attitudes to

provide the care that their patients need. Progress is

gained not through changing these ideals but, rather,

by improving the technology and the methods that

are used to attain these goals. Collins and Porras6

found three important characteristics that allowed

their visionary companies to continuously excel: (1)

willingness to have audacious goals; (2) willingness

to experiment, or in their words, “try a lot of stuff

and keep what works”; and (3) adherence to the

concept that “good enough never is.”6

Community-based educational experiences should

be placed in this larger conceptual framework as one

method of better achieving the goal of preparing

physicians for the practice of the future. Academic

centers have been subject to the tyranny of the or,

choosing to value hospital-based tertiary care so

highly that in many centers primary care and

corn-munity rotations have been excluded. Both are

es-sential.

Recommendation for Implementation I. To

success-fully implement community-based educational

pro-grams, the faculty of the school or training program

must question basic assumptions regarding the

edu-cational process and must reassess their roles and

responsibilities regarding the physician work force

and medical education.

at Viet Nam:AAP Sponsored on August 30, 2020

www.aappublications.org/news

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Recommendation for Implementation 2. Program

leaders and faculty must develop a vision for their

educational mission, one that preserves core values

and allows adaptation to the changing health care

environment.

Recommendation for Implementation 3. Programs and leaders must avoid the tyranny of the or through

incorporating the best elements of academic

center-based programs with community experiences.

ENVIRONMENTS THAT SUPPORT INNOVATION AND GROWTH

Creation of the vision and knowledge of how to

develop community educational experiences will

provide any program director with a basis for

pro-gram implementation, but this is simply a beginning.

Unless the overall environment of the school or the

program will support growth and innovation, the

implementation phase will be frustrating and

per-haps even impossible. Success will depend on two

factors: (1) leadership, and (2) an organizational

structure that aligns responsibility, authority,

re-sources, and accountability.

Effective leadership is essential for a group or

or-ganization to accomplish its mission. Although no

set of traits that are characteristic of effective leaders

has been defined, vision, knowledge, commitment,

and passion combined with a willingness to work

hard are critical. The successful leaders of the

vision-ary companies studied by Collins and Porras6 were,

in fact, not charismatic personalities but, rather,

peo-ple who dedicated themselves to building enduring

institutions rather than being great individuals. For

community experiences to be successfully integrated

into the educational process, leaders must be

corn-mitted to the concept and willing to work diligently

to remove obstacles and barriers for those who are

responsible for program development. They must

have reasonable communication skills, respect for

community personnel, and a willingness to delegate

tasks to capable individuals.

As responsibilities for program development and

implementation are assigned, careful consideration must be given to the functional organizational struc-ture. Particular attention must be given to role

defi-nition. Leaders should be responsible for policy

de-velopment. Program directors should be charged

with making operational decisions. Leaders define

the “what,” and directors define the “how.” If

re-sponsibility for fulfilling a task is not aligned with

the authority to make appropriate decisions or to

solve problems, programs will fail. Too often,

partic-ularly in trying to organize a program that depends

on personnel who are not full-time employees of an

academic center, the focus is on maintaining control,

rather than on examining tasks that must be

accom-plished and delegating the decision-making process

to those individuals who are charged with daily

operations.

One of the greatest obstacles to implementing

mean-ingful community experiences is lack of funding.

His-torically, reimbursement for medical education at the

resident level has been hospital based. Hospitals are

reimbursed by Medicare for direct medical education

(DME) and indirect medical education (IME).

Approx-imately $6 billion per year is passed through to hospi-tals for physician training. Resident salaries for in-hos-pital experiences, as well as funds for indirect costs (the added expense of having trainees present in a clinical

facility), have been reimbursed by Medicare to

inpa-tient facilities. Unless a clinic is owned by a hospital, no funding is available to support outpatient or

commu-mty rotations. Title VII grants have provided some

funding to establish primary care residencies; however,

the amount of money available through this program is

woefully inadequate. Annually, total Title VII funds

available for primary care framing is less than 0.02% of

the Medicare DME and IME. Although most of the

creative programs that emphasize community

educa-tion have received their initial funding through Title

VII, relatively few programs have been able to access

the small amount of money available. Also, unlike

Medicare DME and IME, Title VII grants are

competi-tive and time limited. Thus, the funding base is

unsta-ble, a factor that has inhibited many programs from

applying. Medical schools have been generally more

successful than community-based residency

experi-ences in creating community preceptorships than

resi-dency programs, partially because they can divert state

support to establishing and maintaining such

pro-grams, and because, in recent years, several private

foundations have become interested in funding

pri-mary care medical education.

Costs associated with development of

community-based experiences include the time of the program

director and all program faculty who participate in

the coordination of the rotation; the academic

den-ter’s administrative staff time; direct costs of resident salaries and benefits; the time of community person-nel who teach, supervise, and interact with residents

and students; community administrative staff time;

and the indirect costs incurred by any facility that

accepts trainees. Historically, medical schools and

residency programs have depended on volunteer

faculty to donate their time and their facilities to

provide community based experiences. With the

in-creasing pressures of managed care to become more

competitive, fewer physicians and community

pro-grams will be willing to bear the costs of education. If schools and programs are to be able to implement

community-based educational experiences

success-fully, significant, stable funding must be established.

The imbalance in the work force and the necessary

adaptations of medical school and residency

curric-ula cannot be addressed unless current mechanisms

for funding graduate medical education are

drasti-cally altered.

Finally, for long-term success, programs must be

accountable for their outcomes. Program evaluation

has seldom been a strong, integral part of medical

education. Had schools and residencies actually

studied whether their educational endeavors had

ad-equately prepared their graduates, COGME would

not be citing the deficiencies of the current

educa-tional system.4 Pediatricians have repeatedly stated

in surveys that their training was inadequate.

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must have the authority to make operational

deci-SUPPLEMENT 1267

have not changed significantly during the past

de-cade.7’8 Once program goals and objectives have been

defined, reliable, valid indicators should be

deter-mined, and data should be collected in an ongoing

basis. If programs are not meeting their objectives,

then the educational methods should be questioned

and revised, and the program should be reevaluated

after a time that is sufficient for meaningful change to occur.

Both those who practice medicine and those

re-sponsible for preparing physicians should hope that

medicine wifi never become a static discipline.

Change will simply always be a part of the

profes-sional experience. With the advent of managed care,

development of universally required, excellent,

corn-munity-based educational experiences is essential.

Yet, these programs should not be unquestioningly

accepted, nor should they be enshrined as the

solu-tion for the current dilemmas facing professional

education. Without constant program evaluation and

willingness to examine the process of education

con-stantly, the 20th COGME report will state that the

educational system is clearly deficient. If the

chal-lenges of the future are to be met, all schools and

programs must take to heart one of the principles of

Collins and Porras: “Good enough never is.”6

Recommendation for Implementation 4. For

commu-nity-based educational experiences to be widely

in-corporated into medical education, leaders must be

committed to the concept and must be willing to

work diligently to remove barriers for those charged with program development.

Recommendation for Implementation 5. Those

respon-sible for program development and implementation

sions; they must have adequate financial resources

for program support; and they must be accountable

for program outcomes.

Recommendation for Implementation 6. For long-term

success, the innovators of today must accept the

concept that good enough never is. Continuous

pro-gram evaluation and modification are essential to

train the physicians of the future.

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primary care continuity clinics in pediatricians’ offices: nuts and bolts.

Pediatrics. 1993;91:1185-1189

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the Community Outpatient Practice Experience in a large pediatric

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4. Council on Graduate Medical Education. Sixth Report: Managed Health

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1996;98;1264

Pediatrics

Lucy M. Osborn

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