Christine O’Dea, MD MPH FAAFP
Robert and Myfanwy Smith Chair of Family Medicine
Associate Chair, Department of Family and Community Medicine
Co-Course Director, Medical Spanish/Latino Health Elective
Division of Urban, Underserved and Global Health
Department of Family and Community Medicine
University of Cincinnati College of Medicine
Learning objectives
- Describe three guiding principles of a successful community partnership
2. Identify tools you can utilize to support the success of the partnership
3. Identify ethical issues that may present potential community clinical-community and academic-community partnerships
Please read / view the above readings and then respond to one or both prompts below. As a group, use the page to respond to each other’s posts (at least one response to another student).
1.
Two ethical issues I’ve seen in the early stages of Bearcat Eye Service (BES) are:
Connecting Patients to Higher Levels of Care:
Providing the Resources the Community Wants:
2.
Improving Patient Care Transitions:
Engaging in Open Dialogue with the Community:
You have some great points Alec! I think some of the problems you have found are similar ones facing my community partner- having a greater need than resources available, and the problem of trying to find a way to make sure the allotment of resources is as equitable as possible. I liked your idea of engaging in an open dialogue with the greater community.
Alec, your point about the mismatch in community expectations vs. what BES can offer definitely raises some ethical concerns. I wonder this a lot with regard to UCCOM service orgs because their mission is two-fold: provide care to the community and provide clinical experience/training to the med students. You could argue that providing training will ultimately serve more people in the long run, but it does leave the patients going to our free clinics with some gaps in the care they might expect. There may be a way to provide more of the services people are looking for without further taxing the students/faculty running BES. For instance, I wonder if BES could partner with another local or even national organization that provides glasses. Or, there is always the approach of shifting your marketing. “Free Vision Exam” is very different from “Prevent Blindness with a Free Eye Disease Screening.” Managing expectations can go a long way!
Meeting the needs of the community can be challenging, often since we come in with an expectation of what the needs will be. Yes, the listening and revising and listening again will be an important part. Great suggestions about wording, partnerships. Having patients on boards is also a way to ensure the patient voice is also getting heard.
One of the ethical challenges I have witnessed while working with my community partner, and through my medical education, is the idea of equity, and the idea of triaging who most needs and deserves the available resources. My partner acts as both an inpatient and outpatient service to patients of all ages with complex medical needs including trachs, vents, and G-tubes. Therefore, the population they serve tends to require a great deal of resources, from physical resources to time and manpower. Therefore it can be difficult, when there are more people with more needs than there are resources, as we have to decide what is the best way of deciding who gets what. I have seen this on both my community partner’s side, as they try to decide who they have room for, and from the hospital side, as we try to find places for our patients to go on my complex care rotation. We have had some patients who simply have to live in the hospital for extended periods of time, because there is nowhere for them to go that can adequately take care of them.
Truthfully, there is no perfect answer to this question. There are limited resources available to us, and the best thing we can do is to try and split up the resources as equitably as possible, and to get the greatest amount of resources through methods like recruiting volunteers.
Limited resources is a fact. I guess how we plan and react to those as a society or organization or community is important part. Your partner is feeling the struggle on both sides, which creates not such ethical challenges but also moral injury to staff when resources are withheld to clients.
I think this is a great insight into such an important problem. I agree that there is only so much you can do when resources themselves are the limiting factor. Hopefully with more awareness of and advocacy for these issues, there can be systemic change to increase access to resources and provide better long-term care options for these patients.
This is really interesting Grace. It reminds me of one of the 4 pillars of medicine, justice, that we learn about in medical school but I have yet to see it in real life. While there is no perfect answer, I wonder if there are written plans or rules in place to help medical teams allocate resources in the situation that you mention.
When I was on the board of the UC Food Insecurity Collaborative, we worked very closely with an organization that had deep ties in Walnut Hills called Black Power Initiative. The majority of our work was simply to support BPI’s existing efforts in food distribution. One of the principles that was impressed upon us as we took over leadership roles from the rising M3s was that the community expected to see the same few faces every week. The previous board had worked hard to build familiarity and trust and we wanted to continue that. However, since UCFIC was also considered a service organization at UCCOM, there was an expectation that we would provide volunteer opportunities for classmates. We couldn’t really expect consistency and commitment from students who were not on the board (we know how busy med school is), but it felt like we would let someone down either way. In the end, we prioritized consistency and had a board member present at every “Food Friday” while creating only 1-2 volunteer positions for those days. UCFIC has now folded and I wonder if we would have had more interest in the organization if we could have provided more ways for other students to get involved.
You know this is a great point, and something I struggle with as a medical student participating in service projects. Not having committed and consistent participation makes it hard to build that community trust. As part of UHP, I know it was something that I felt conflicted about when we were trying to maintain relationships with organizations and communities. Though UHP and UC were a constant presence, I couldn’t help but wonder how much of student involvement was just volun-tourism vs. actual service. How can we promote sustainable community engagement for medical students without infringing on their already busy schedules? I think the longitudinal electives are certainly one way to do that, but definitely something to reassess. Atleast for UHP more students are opting for part time or modified schedules which makes me wonder if students truly understand the importance of regular community engagement as part of service-learning.
Taylor and Pooja – you both bring up important point of service – a regular, dedicated, connection to the community. What is the exact frequency? Don’t quite know, but enough that the the volunteer and community member are both engaged and committed to the outcome for the community. How can medical school avoid volunturism? Should be a session itself.
The balance between regular volunteers and one-off volunteers is an aspect of volunteering that I find really challenging. Similar to UCFIC, with Saturday Hoops, it’s hard to expect a person to spend every Saturday morning volunteering, and yet it is the consistency that allows the kids to open up to volunteers and benefit the most from the program. Oftentimes the volunteer groups that join for a single session end up interacting more amongst themselves, probably because they (understandably) may not feel comfortable jumping into stations immediately and thus have limited interactions with the kids. At the same time, it’s really wonderful that anyone makes the time to volunteer at all, and I don’t want to every discourage or downplay the value of one-off volunteering. And sometimes awareness of the organization or a work group one-off volunteer day causes a domino affect of connecting in a new organization or igniting a service project that otherwise would never have happened. But it can be a substantial amount of work to find ways for more casual/non-routine volunteers to contribute, and within Saturday Hoops we have talked over whether we need a designated person from the regular volunteers to focus on the new/one-off volunteers every week, but that would then take away from a regular volunteer being to direct their energy into the kids.
An ethical challenge I have seen is navigating the distrust community members have with system or previous bad experiences with people who have tried to help them. This is especially true with the medical system as there is a history of abuse and bigotry. When I working at a community health fellowship before medical school, I would often find patients who despite their many medical issues felt very inclined to handle everything on their own. They were hesitant to accept help from a stranger who knew little about their community or their struggles. It is always important to recognize that as an ignorant outsider, I may not ever reach a point of mutual trust, but I found that continued genuine interest in patient/community member concerns was enough to overcome most barriers.
The recurring ethical dilemma I have witnessed (which has been presented in previous posts) is the mismatch between services offered and what a community desires. OTRCH and the Jimmy Heath House where I have been partnered has tried to address this with a housing first model. In most housing shelters there are conditions to stay including getting medical treatment and staying sober, among others. However, these conditions make it hard for clients to maintain their housing when their needs revolve around making money or having a consistent safe place to live. With a housing first model, OTRCH aims to place individuals in stable housing removing the dangers of being on the streets – and offering centralized resources for healthcare should members decide to pursue it. The many benefits also include being able react when clients have overdoses, and allowing tenants to have a safe place to conduct sex work. I think framing housing from the perspective of tenants can help advocate for more housing first models in Cincinnati.
Pooja this is some really interesting work OTRCH has going on, and I’m so glad you are working with them. I would love to hear more about their initiatives and if they have conducted any research comparing their model to the standard models of housing you mention. I could see their programs causing hesitance to some community members in the same way that people sometimes are hesitant towards needle-sharing programs. However, when an organization can measure their impact, I think it’s easier to convince others of its efficacy. Here is a link to a story of a program that had a “radical” idea that ended up being approved by Florida legislature and went on to have massive positive impacts for example in Miami, Florida (https://www.youtube.com/watch?v=ldTxMIblePk&t=339s). Here’s an article talking about the impact it has had since opening: https://miamifoundation.org/blog/how-a-needle-exchange-is-saving-lives-in-miami-dade/. A colleague heard the leader of this program speak at a conference and he mentioned it has saved the state of Florida a lot of money in expenditures that would have typically gone to medical costs!
Long story short, this sounds awesome, and I’d love to hear more about it and its potential impact compared to the current norm for housing shelters (if there is one)!
Yes, often there is that mismatch in medicine and service in what is being offered and what the patient/community desires. Housing First and harm reduction are great examples of meeting patients where they are and reduce risk.
These are excellent points, Pooja! Acknowledging and validating medical mistrust, rather than becoming defensive as the provider, is a huge step to establishing a trusted partnership with community members. Additionally, when developing structures and programming for vulnerable populations, we cannot become blind to the numerous barriers that communities face. Without any targeted efforts to mitigate specific social determinants- we can expect negative impacts to persist and should not set unrealistic expectations for partners.
Two of the challenges in partnerships that both Dr. O’Dea and the CCPH touch on that I have also experienced with my community partnership are the lack of established, shared goals at initiation of a project and incomplete plans when ending a partnership. As Dr. O’Dea shared, when shared goals are not established from the start, the goals of the partners – even when they have the best intentions – might not actually be addressing the needs of the community members. In the context of my project, it took multiple conversations and iterations of research project ideas to establish a long-term project that would meet the needs of the community our project is centered around. Similarly, challenges arise when there are no official end points or plans for ending a project. While my community partner and I have started to discuss what the end goals of our project will look like, there is still some ambiguity in our final project. I anticipate the interactive food map Jenna and I are working on for our community partner will be an evolving document even after we finish, but my concern is that without having clear outcomes and plans for keeping the project moving after we are done, that the work we put into the map will be for naught. It is my hope that there will be more students in the future who can dedicate time to finishing the map, but I think Jenna and I will need to set clear next steps for the project after we are finished to keep the momentum going.
I agree there has been a lot of ambiguity in our project, and not much face to face time with the community that I worry may negatively impact the outcome of our project. The project is evolving which I think is fine, but I worry that because Caroline and I struggle to see the end goal we may not be contributing in the most efficient way. Student interaction in these projects are great, but I think there needs to be extra effort and attention made to involve them in the very beginning to make sure we are doing right by the community and putting our best foot forward for them.
It’s difficult trying to create a lasting partnership when our time can be very limited in medical school. You don’t want to just jump into a community you know nothing about, complete a project, and then leave with no plan. The element of building trust and learning about a community at the beginning of a project is such a crucial step and can help avoid the “savior” complex that sometimes comes with these community service projects. It can actually be harmful to communities and build distrust if projects are not done thoughtfully and with community input.
Learning from a community about their perspective and what they want out of a project leads to a true partnership. In addition, involving people from the community can help make sure the project continues on a productive path. As one of the articles quoted, “Nothing about us without us is for us”. The Community-Campus Partnerships for Health recommends principles and processes be established with the input and agreement of all partners, as well as balancing power and sharing of resources. These recommendations also include that partners share the benefits of the partnership’s accomplishments. I thought these were very good points, the very definition of partnership involves a balance of power and sharing of information between groups who are working toward a common goal.
I agree that attempting to create a lasting partnership, while our time actually working in the partnership is very transient, is very difficult. If not done right, it certainly can prevent growing a foundation of trust with the community. This is a problem I have experienced with my own project. Something that I think will be vital to wrapping up the project will be establishing a more permanent person to continue the project once you step down.
I think you make a really great point, Jenna. It is important to work with a community partner to establish realistic goals based on funding, resources, time committed to a project. Problems can arise when there is overcommitment and goals are not reached. This can lead to disappointment in the community and a breakdown in the relationship that can impact progress in the future.
My community partner, PWC, and I are working to get families of children who have asthma with home triggers access to the vital home repairs they need to keep their child healthy. One ethical problem that this project has faced is that there is difficulty identifying and connecting individuals who may need services. Within the difficult to treat asthma clinic at Children’s Hospital, there are multiple different rotating attendings, fellows, and residents which has made it difficult to appropriately educate the clinicians about the services that PWC offers so that they can screen and discuss with their patients. Furthermore, there are screening surveys and social workers are aware of the program if the survey flags, but the survey is not a perfect predictor of who may need and be eligible for assistance.
At this point, the best person take ownership of the project and screen patients is me. This will help in the immediate interim of continuing to establish the program, and getting people set up with any assistance they may need. However, in the long term, we will need to work with the clinic to find a more permanent person who will take lead of the project and will be responsible for ensuring clinician and social work knowledge of the program.
You bring up a great point regarding different rotating attendings, fellows and residents that I think affects many community relationship/partnerships. When leadership within an organization isn’t consistent, it is tough to take an initiative that may have a meaningful impact on the community, and ensure its longevity. It’s a very similar situation the organization I am working with has faced in the past and continues to face. I think finding a permanent person to oversee the project will definitely help ensure its longevity. I think it’s great to be thinking of that at the beginning stages of a project, because that makes continuity a priority rather than something you scramble for at the end, which can make it more difficult.
What ethical challenges have you witnessed in building relationships / partnerships with communities?
How can we best address these barriers, so that we can create healthy and equitable partnerships with communities?
Within Saturday Hoops/CYC, an ongoing challenge centers around donor/service project interests vs community needs. Donors and service projects often have specific ideas of how they want to make an impact, however that approach may not address the actual needs of the community or be the immediate outcomes that the project seeks to address. The overarching goal of Saturday Hoops is to encourage “faith and education”, while guiding kids to avoid “guns and drugs”. While this big-picture goal defines the program, on an immediate week-to-week basis, the program is more focused on providing enough food for lunch and executing program activities (art, reading, basketball, yoga, soccer, etc). Practical matters, such as whether a child has a bathing suit for pool time or owns sneakers in sufficient condition to play, may not be as immediately obvious to newcomers looking to build a relationship/partnership. However, these are often essential components to maintaining a successful program. Disconnect between interests of potential donors/partners and the actual community needs often influences the success of service projects. Saturday Hoops has partnered with various community organizations and school-related service projects where well-intentioned efforts, such as clothing drives and toy donations, don’t manifest in meeting needs of the community or program and so have limited benefit for the kids. For example, a clothing drive last year left us with bins of adult-sized used clothing (a surprising amount with strong cigarette odor) to deal with, rather than the practical items (correct sized shoes) that many of the kids needed. Or when an external organization sought to do a service project to increase kid’s access to healthcare, it was quickly discovered that the lack of parental interest and accessibility was a formidable challenge to progressing the project. Altogether, identifying the true needs of a community partner before initiating a service project has been the biggest challenge I’ve observed while working with Saturday Hoops.
An ethical challenge witnessed in progressing partner relationships is communication gaps. When there is a difference in educational and/or cultural background, it is extremely important to meet your partner at their level of understanding. When this is not done, effectively establishing a shared vision and communicating expectations becomes difficult, and progress can be slowed as a result. To combat this, consistently follow up with your community partner and make important documentation available through multiple mediums in plain language. Additionally, ensure that the next steps with expected timelines are outlined at the end of each meeting!
While building a partnership with my community partner, Shelterhouse, I have contemplated how to best address the needs of the community I am serving while ensuring I am providing equitable solutions. My project is focused on addressing disparities in women’s health. This involves identifying gaps in care and connecting women with health services. Taking on this project requires a commitment to my community partner to ensure that each participant in the project is offered the appropriate care in a timely manner. For instance, if a participant has gone without a Pap smear for many years, my project entails connecting this participant to a clinic that can provide this service in order to help prevent or treat a cancerous lesion in a timely manner. Otherwise, I would be failing honor the partnership with my community partner and doing a disservice to the project participant. In order to overcome this issue, I am working with case managers who work closely with clients accessing services at the Shelterhouse to ensure there is an action plan created for each study participant and communication provided to each participant.