Perceived Benefits of Training Clinicians in Community Engagement for a Leadership Development Program

The United States spends more per capita on health care than other developed nations, yet has worse health outcomes.1 As we work to improve the nation’s health, we need to train primary care clinicians to engage with communities to transform health care delivery and address social drivers of health (SDOH).2

According to the Centers for Disease Control and Prevention, community engagement (CE) is

the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.3

CE can improve the health of disadvantaged populations and enhance program feasibility, quality, and sustainability,2 and primary care clinicians are well positioned to partner with communities to transform clinical care and SDOH.⁴ Since the creation of Clinical and Translational Science Awards in 2006, there has been a growth in CE training for researchers and communities, but we found little evidence that these lessons have been adopted broadly in medical education curricula.10 Despite growing attention to related concepts of SDOH and service learning, only a small number of schools train learners to collaborate with communities to design and implement research or population health improvement initiatives. A small amount of literature describes CE training in undergraduate medical training.5-9 A systematic review of leadership development programs for practicing physicians revealed no evidence of CE in the curricula, despite the need to make it more central in academic medical centers.3,11,12

The Health Resources and Services Administration (HRSA) is sponsoring primary care transformation fellowships to train physicians and physician assistants to lead health care transformation and improve health in their communities. Duke Department of Family Medicine and Community Health’s 2-year Primary Care Transformation Fellowship (PCTF) curriculum begins with a course on CE strategies and practices titled “Community Engaged Approaches to Health Improvement.” The course introduces CE, including community-engaged research (CEnR), and explores CE programs and initiatives as tools for population health improvement. The course aims to provide learners with an appreciation for the value of CE and its challenges, develop their basic skills in CE, and let them practice those skills through a hands-on project. Finally, they are introduced to resources to assess and develop their engagement practice. Table 1 provides greater detail on the course. This paper describes what the fellows have gained from this training in CE.

Cohort 1 (2019) consisted of three MD’s and four physician assistants, and Cohort 2 (2020) consisted of two MD’s and three physician assistants. Each fellow was required to write a reflection paper (approximately 10 pages in length) on the ways in which learning about CE has impacted their work, career, and their understanding of health improvement. At end of the course, students presented their project work to date and turned in the reflection paper. We used a general inductive approach for analysis.13 The codebook was developed by two reviewers and modified by consensus; one reviewer did primary coding and analysis with verification by the second. We are attentive in analysis to being clear as to when we could and could not attribute fellow knowledge and attitudes to the course. The Duke University institutional review board exempted this research from formal review.

Six major themes were identified from the papers (Table 2). Each appeared in at least four papers, with some occurring in as many as nine. We observed no pattern of difference for physician assistants and MDs.

More than half of fellows had some prior understanding of SDOH, but gained greater depth in their understanding of SDOH from the course. The concept of SDOH was new to others. One mentioned having a “light bulb” moment, realizing the significance of how SDOH affect a person’s health and ability to stay healthy.

Fellows were struck by the pertinence of CE to their work and noted the importance of valuing and prioritizing what the community needs and wants. Three fellows referenced that successfully navigating partnership requires a great deal of work, dedication, and attention to detail.

Fellows realized that engaging a community requires first defining it. They developed a new appreciation for the different communities they are part of, the value of one’s communities, and how communities are interrelated.

For many fellows, the course brought to light the importance of identifying and celebrating small wins early and often to help create and maintain momentum.

Fellows realized the importance of thinking early about strategies for dissemination of their work, including defining and understanding target audiences.

Fellows noted internal growth/transformation while taking the course. Strikingly, this went beyond understanding CE. For example, one fellow cited increased confidence and a new appreciation for the value of being a clinical leader; another said that they were redefining the clinical role. Another mentioned the importance of listening, maintaining humility, and communicating vision.

Our analysis revealed multiple benefits from CE training. Fellows reported that the course helped them understand how CE can shape strategies for daily practice, practice transformation, and broader civic engagement to promote health. More surprisingly, the benefits went beyond just learning about CE. Fellows conveyed that they grew as leaders, gained confidence, and redefined their role as clinicians. However, our analysis was limited due to the small sample size of only two classes of fellows, 12 in total.

As these fellows implement transformational fellowship projects, they now have tools for CE and can teach colleagues to authentically partner with communities to address their needs. Educating primary care clinicians in CE has the potential to improve the health of communities, make clinicians more effective leaders, and provide them with a broader understanding of their societal role. Additional research on the impact of CE training would shed further light on the value of integrating this topic into more curricula.