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).
One of my fondest memories formed around my trip to Panama during college. A group of 25 pre-med students through Global Medical Brigades traveled to a very remote village near Campaña Panama, a pueblo with little access to fresh water and medical supplies. Throughout our week, we established clean drinking water to their homes and provided basic medical care to patients and their families. Able to speak the native language, I found that many locals entrusted me and my perspective seemed to turn from “other” to “one of us.” This was no easy feat! In the readings for this module, a common theme that seems to prevail is that of selfless giving and openness, to the people whom you serve. Instead of initiating some standard script or phrase, I simply tried to inquire how to best serve the person in front of me. There was an abuelita, Doña, who was quivering in fear as she approached our clinic, with a rosary dangling from her hands. She had traveled over 20 miles on foot to reach our clinic and she was pretty short of breath. Setting aside what I knew we had to get accomplished, we walked through that clinic door together, one step at a time, on her watch.
In reflecting on this experience, I found the most profound joy and happiness when I set aside my own personal agenda for the day and attempted to enter into another’s perspective. There was a sense of freedom in doing so. I often see many partnerships crippled by dependence and rigidity, whether it be through financial or research endpoints. I believe this is a large ethical challenge; if done the wrong way (often unilaterally), the unsustainable partnership shortly crumbles after the intervening group departs. We tried to prevent this. For instance, once we left the site, Global Engineers arrived to ensure that the water source and clinics were sound and reliable followed by Global Legal Brigades who established the basics of a local government. Furthermore, these student partnerships were formed on plans drafted by the local people. They had autonomy regarding how we intervened and how we could both measure successful outcomes. Walking hand-in-hand, joint leadership and partnerships flourished. Thus, it seems that a partnership is less so a science but a service, where the importance lies not in what you do, but how you do it.
I also travelled to Panama during undergrad with Global Medical Brigades over my winter break in the middle of sophomore year! It was also one of the highlights of my pre-med journey at UD. The trip was just months before COVID began and trips like that were suspended for over a year. I was one of the only sophomores accepted to go on the trip, and I am forever grateful that I had the opportunity to go before the pandemic prevented brigades like this from happening. It did make me wonder about the barriers and ethical challenges associated with these kinds of trips. I wondered about the small rural village that I visited — and the rest of the small rural villages that Global Medical Brigades served — during the worst of the COVID-19 pandemic. Did their access to medical care get completely cut off during that time? How does an organization like Global Medical Brigades balance the relative safety of their students and the healthcare access that the international communities need?
I recall preparing for this brigade with a biweekly one-hour seminar prior to the trip. The majority of the preparation centered around the ethics of “medical mission trips,” “international medical trips,” the white savior complex, and other ethical concerns when college students from the US travel to a lower income country for one week. I remember feeling frustrated that the preparation was so negative, and I found myself thinking, why are we doing this then? However, throughout the preparation, I began to feel better due to the close partnership with the community we were going to and the commitment Global Brigades had to providing consistent support through legal services, business services, engineering projects, and more, like you mentioned in your post.
Hi Quinn! That sounds like an incredible experience you had before medical school and one that clearly left an impact on you. I love how you talked about abandoning the “script” and focusing on the person in front of you and how you can best serve them. That’s an amazing attitude to take not only for your community partners but also your future patients! I also liked how you discussed followup with the interventions you did during the trip. Follow-up makes it much more likely that there will be long-standing change.
Like I mentioned in my response to Quinn’s post, the first ethical challenge that comes to mind is the history of people from high income countries descending upon small communities in lower income countries to “fix” or “save” them. There has been a longstanding movement in changing the way “medical mission trips” work, pointing out the many ethical issues associated with dropping in and out of communities, providing services that don’t make sense for the community, and discounting all traditional beliefs about health and healing. Instead of partnering with communities, many groups of people forced their ways upon others without much of a second thought. When I went to rural Panama with Global Medical Brigades, my professors had already vetted a number of organizations to ensure that the one we went with would be the most ethical as possible and that we wouldn’t be imposing ourselves on the community. We learned how brigades went to many of the communities quarterly so as to provide some semblance of continuity of care. In addition to the medical brigades, communities met with Global Brigade leaders with projects that they were interested in getting help with, such as building new community centers/schools, agricultural projects, and getting clean water/electricity to remote areas. There seemed to be equal buy in from both parties — the Global Brigades staff/volunteers and the community leaders/members.
I love your comment about continuity of care and think that is so cool Global Brigade leaders try to get into their communities quarterly. It probably felt so good going on this trip and knowing there was an established relationship in place. I personally have struggled to find avenues for serving and partnering outside of the academic calendar since our schedules are so rigid in school. I hope that participating in more longitudinal service that is dictated by a community partner’s schedule be can be something I prioritize in residency and beyond.
I also spoke about medical brigades programs, and I love what you shared about the effort to make the program as sustainable as possible. Especially seeking out organizations that would make this possible, and going quarterly rather than once a year. I also believe that buy-in from both parties is essential to addressing some of the ethical challenges that come up in global medical service. I think that a factor I hadn’t considered is how uniquely different each medical brigades program can be, depending on what the program lead is prioritizing. In this case, it sounds like sustainability was a huge priority, and that is something that can really vary from one program to the next.
I was really struck by the phrases “drive-by” or “helicopter” research comments in Celina Su’s paper. I have tried to make service a big part of my medical school time and have worries sometimes that I create more work than benefit for the community partners that I work with in the relatively short time that I am with them. Obviously, this is not my intention when I set out on a project because I do want to serve, and I choose projects or partners to work with that do align with my passions and skills. Thinking of my M1 summer internship with Urban Health Project, my community partner spent a lot of time and energy helping me get started – showing me around, telling me about their needs, introducing me to others, showing me the technology, talking to me about previous students, etc. This makes me reflect on the “emotional load” for the people who worked at my partner site and the fact that I was only there during an academically focused length of time. Creating a project was a requirement of my summer and, of course, was flexible, but the time constraints forced my project to occur during those weeks rather than working with the community partner to determine when would be best. This is a well-established, well-intentioned community partnership, and I still think there are areas when it is not necessarily benefitting the community partner most.
Further complicating things, I’ve been thinking about students doing service more when starting to dive into residency programs and seeing data that shows me the counts of publications or service experiences that students who’ve matched had on their application. I fear this concept of “counting up” experiences to put on a CV or in an ERAS application will make a lot of students guilty of not spending time working towards the guiding principles of partnership, which is time intensive and requires intentionality. This is a very large ethical challenge because it blurs the incentive for the service in the first place! Again, I hope students are doing service because they are passionate and have the skills to meet a community need, but there is a lot of external incentive out there that may work against some of the best practices in our readings.
What do we do about this? I am not sure how to address the overall academic push to publish or the ERAS stats, but I think proper identification of community partners and projects is hopefully a good start for reducing some of the emotional load for partners when students are working with them. I think it’s great when a partner reaches out looking for help or even has an idea of a specific thing that they need help with. This way, we aren’t creating a bunch of new work for a partner, especially if there are time constraints around when we are able to work with them (whether that be the duration of a summer or an academic year). To address students asking the same questions to a partner repeatedly or repeating work that wasn’t successful the first time, maybe a centralized database created by the academic institution of previous projects organized by community partner could be helpful so that students can be knowledgeable of the entirety of the partnership, rather than just their individual relationship. I hope this could also alleviate some of the load that partners carry when students come into their space.
Caroline, your reflection is incredibly thoughtful and touches on some of the most pressing ethical tensions in student-community partnerships. I appreciate your vulnerability in acknowledging how even well-intentioned service can unintentionally place emotional and logistical burdens on community partners. Your idea of a centralized database of past projects is a concrete and actionable solution that could help reduce redundancy, honor community memory, and better prepare students to enter partnerships with humility and awareness. It also reflects Su’s (2022) call for clarity and continuity in collaborations, addressing the “drive-by” research concern by recognizing the community’s ongoing labor and wisdom. I also share your unease about how the pressure to “count” service for applications can blur motivations, and I think creating institutional cultures that prioritize depth, reciprocity, and long-term relationships over resume-building is essential to realigning incentives with equity.
I love your idea of a centralized database for past community projects at our institution. This would be so helpful to not only avoid past projects and their mistakes, but to learn from people across the University of Cincinnati. I have noticed people at CAIN who come from UC, but from the master’s in Spanish or are undergraduates, and they are all doing different projects than mine. They also bring a different perspective to projects, a reframe that could be helpful when trying to think of new ideas for projects. Further, there are a lot of community partners who are working in shared spaces with other community partners, and if there were a database like this which was easily accessible, community partners could also learn from each other. I think the largest barrier to establishing something like this would be continuity. The university wide center for community engagement would be a great repository for something like this, and maybe they already have something like this going.
In regards to the rest of your post, I have personally struggled with the feeling of being a burden to my community partner when I hop into their space for an academically-defined period of time, then change my relationship with them as soon as that academically defined period has ended. I’ve had robust discussions with my community partner about this. One positive spin for them is that when medical students repeatedly get involved with community organizations, they begin to understand what it is like to work with medical students, making it easier for the next student to come along. And part of the longitudinal relationship with a community organization can be the repeated presence of a medical student, even if it is not you personally. Outside of this positive spin, it can be difficult and discouraging to feel like you are inserting yourself in a way that aligns with your needs but forces your community partner to adapt theirs to suit you. I think open and honest conversations from the start of a partnership can help to alleviate this, but it is something that we have to keep re-visiting throughout the relationship.
I relate to the concept of “emotional load” completed by organizations trying to get students up to speed on their long history and priorities. They are already overburdened and underpaid, and I frequently feel that by trying to complete an academic requirement I am inherently adding to that. I often feel that academia is self-serving. As you say, the idea of quantifying experiences as though a higher number of them produces greater value is flawed. It stretches both students and organizations thin, sacrificing quality, trust, and meaningful outcomes to a community. I hope that by aligning ourselves with our own values through intentional engagement, we attract programs on ERAS that do the same, and more importantly, grow our own humanity and impact.
One ethical challenge I’ve witnessed in building community partnerships is the tendency for academic or clinical institutions to approach communities with predetermined agendas, leading to extractive or “helicopter” models of engagement. As Su (2022) notes, this results in community members being asked to share their time and stories without benefiting from the outcomes, a dynamic that undermines trust and reciprocity. True partnership requires co-ownership of data, shared decision-making, and recognition of emotional labor. Too often, these elements are completely overlooked by academics and perpetuate fragility in the relationship that is attempting to be built.
Another challenge is tokenistic inclusion, where community voices are present but not meaningfully integrated into planning or evaluation. Beck et al. (2021) emphasize the importance of “intentional and meaningful inclusion of diverse voices” in clinical-community partnerships. Without structures like MOUs or shared governance, partnerships risk reinforcing the very inequities they aim to address.
To address these barriers, we must prioritize transparency, shared power, and mutual benefit from the start. Developing tools like memoranda of understanding can help clarify expectations, roles, and ownership of data in ways that respect community priorities (Su, 2022). These agreements foster accountability and give space to address tensions like emotional labor and conflicting timelines.
Equitable partnerships also require continuous co-design and inclusion of community voices, not just in implementation but in defining goals and measures of success. As Beck et al. (2021) argue, partnerships are strongest when built on “collaborative methods” and a shared theory of action rooted in community needs. Ongoing reflection, flexibility, and a commitment to capacity-building are essential to move from transactional to transformational relationships.
I really like the article and reading tie-ins here. Just like in my post, I find many similarities with your extrapolation of the viewpoints from Su and Beck et al. Shared decision-making and collective visioning enable the helper to provide service but, and if not almost to the same degree or greater, shift autonomy and ownership to the person/people receiving help. I also resonate with the idea that many helpers pick and choose aspects of the community which will advance personal agendas, rather than writing up a more holistic viewpoint or perspective. How can these partnerships succeed if there really is no accountability, shared governance or collective planning but rather an idealized, isolationist approach? Albeit sometimes arduous, more time taken to completely and thoroughly address everyone’s ideas serves both parties well in the long-term.
Research fatigue at my community partner is very real. I know it can feel like an annoyance when there is someone asking questions at CAIN every other week, and this is something that I have tried to think about when designing the surveys that I will be giving out at CAIN. It certainly helps that we can offer small gift cards to shoppers when they fill out a survey, but with cost of living going up and grocery prices being particularly hard hit, a $10 Kroger gift card doesn’t go as far as it used to. The surveying I will do for my project has both a focus group and a survey that shoppers can fill out while they are in the waiting area. But when people are filling out surveys that might not seem so different from the surface, how can we account for research fatigue impacting the way they answer these questions?
Su’s article brought up another dilemma that I have witnessed from both sides, the right to research of the participants. I have seen this in a more paternalistic way (which we should fix) from when I volunteered with Women Leading Healthy Change. While I am proud of the work that we did and the classes that we offered, WLHC did not involve the women themselves in the research. We passed out surveys at the start of every class and used this to evaluate how well we were getting our points across. And we used this research to guide the curriculum changes each year, but we did not involve the women we were teaching in this, other than to get their answers. Involving these women could be exceedingly hard, as the populations of the shelters is transient even over the course of the block of lessons we offered. And the turnaround from the medical student leadership is also quite rapid, making it difficult to add another item to the task list there. Time and experience have shown me otherwise.
On the other hand, CAIN does an amazing job empowering the right to research of the community through it’s Poverty Liberation Collective. This group meets and discusses what the shoppers of CAIN feel would be most helpful, and is filled with community members themselves, an approach that should be modeled elsewhere.
As I read Su’s paper, I couldn’t help but think back to physician and society and reading Medical Apartheid. In almost every situation discussed in that book, there is a disconnect between institutions conducting research and those it benefits, in the past to disastrous conclusions. While thankfully the Tuskegee Syphilis study could not happen in today’s research environment, the disconnect between labor and beneficiary still exists. I think that in order to help facilitate meaningful relationships with community partners, an attitude of humility must be at the forefront. In medical school we’re taught not only how to recognize the pathology, but how to talk about it with patients and build influence to where they’ll listen to the treatments were recommending. When interacting with a community partner, the attitude has to completely change. We should enter with the mindset that we don’t know what is best for the community partner in the long run and letting them lead the discussion on how we could help serve their mission. This doesn’t mean that we can’t have our own unique viewpoints on the project, but rather that the initial attitude should be one of curiosity and adaptability before interjecting our own viewpoints. I fell like this attitude helps avoid the “helicopter” research that Su describes in her paper.
At an institutional level, it is much more difficult to enact meaningful change, as the disconnect referenced above is as old as medicine in the United States. From a values standpoint, I think medicine could very much benefit from getting away from the “publish or perish” attitude. It causes rushed and imperfect research and also presents another barrier to actual change being done in the community. Once the project is done, there should be some form of quality improvement to make sure that research doesn’t just fall to the wayside.
I agree with the publish or perish attitude that is rampant in academic medicine. I think this is especially true for medical students as we are encouraged to publish as many papers as we can and are recruited as free labor pretty easily. As a result, I feel many of my peers including myself don’t necessarily have passion in the research they do, and when we graduate, we often abandon the research project to our younger colleagues who do the same. While this sort of recruitment makes research go faster and publish quicker, it also makes for more lackluster outcomes and algorithmic approaches to fit the average researcher without care for specialized skills or depth of research for more experienced researchers.
What ethical challenges have you witnessed in building relationships / partnerships with communities?
One of the more difficult challenges I have faced is when my values do not necessarily align with that of a community I wish to support. Or, when I need to maintain good rapport with a community partner that has alternative priorities. For example, when I worked as a program director, there would be domestic disputes between partners. In my own mind, I wanted to interject immediately (and did), but interjecting as much as I wanted to (ie, asking someone to permanently leave the property) sometimes put both partners back into homelessness and an even more dangerous position. Sometimes I had to accept ethical scenarios which strained me emotionally as a better of two frankly poor scenarios. In other cases, our guests would have emotional support animals in rooms on property that were not potty trained and damaged property. This harmed our partnership with hotels in the area, and possibly the reputation of the nonprofit I worked for. At the time (a covid pandemic with limited shelter options) it seemed a no-brainer to keep these animals and people on property, but others could make an arguable case that damaging partnerships and a reputation can do more harm down the road to an unknown number of people through less grants, less partnership, and less trust. That nonprofit could not continue to keep its doors open on weekends after covid funding ran out, and I worry that the strain of my program contributed to this, although I have never been told as much.
In my current project, I am struggling to establish rapport with new faces quickly and lay the groundwork for a meaningful project while also balancing my own pressures of acting internships and general fatigue from M3 and Step 2. I really loved the article about community-based research. It is indeed work to lay the groundwork, build trust, listen, and “put your hands in your pockets,” as Dr. ODea states. Maybe in being present, I will be able to move forward with something that engages more of the community.
I think the best way to address ethical challenges is to try to constantly improve with the knowledge that hindsight offers.
I feel like its easy to blame ourselves for the shortcomings of a larger project/group. I don’t think you strained the program that you were a part of to result in the changes in operational hours. However, I do think such experiences are a reflection of the organization as a whole. As you said, it is hard to build rapport in a short amount of time, especially with the ongoing pressures of our myriad of other obligations. This is where the organizations that work with communities need to step in. People come and go, however community organizations should have the rapport to smooth over the bumps associated with meeting and working with new people. I am not sure how best a organization would go about doing this, but I believe it has to start with the organization being built from the community itself. It is a lot easier to trust a new face if they have the endorsement of people you already know and trust. There is an aspect of modern society being very transient and hyper-independent that makes this hard. Its hard to take the word of a group that works in your neighborhood when you see yourself as a transient part of it rather than a neighbor who is there for a little while.
The main ethical challenges in building partnerships with communities is the gap in research knowledge between the researcher and the community involved. And often times, this is what causes an uneven power dynamic as well as the controller of the research study also controls what information is disseminated to the community involved, whether purposeful or not. One example is a study that my college did with parents from a local elementary school coming from rural backgrounds. While they all opted in for the study for the small financial benefits that the study gave them, a lot of them did not feel like active participants. When asked how they felt about the project at the end, they said “I actually don’t know what is going on”. Despite relegating the purpose of the project and all the details in the beginning of the project, and having at least one parent on the study committe, the school had failed to ensure that the participants understood what was said. I think one way we can create healthy and equitable partnerships is to always use teach back method and to involve more parents in study committees so that the community involved has more opportunity to discuss and participate in constructive feedback as was stated in both articles of critical friends and collective action.
I know I’m super late to the party, but I really enjoyed the readings for this discussion board and liked everyone’s responses. One ethical challenge I have witnessed in building relationships, is whether outcomes are meaningful for the communities that are involved. Often times academic institutions and medical professionals will engage in research that is important in understanding a given situation or medical disparity, but will not provide solutions at that time. It is important that this preliminary research be done, without understanding a topic it is not possible to address it. However, it can seem like communities are being used in a sense, being studied and not actually being helped. Su (2022) described this as “drive-by” or “helicopter” research. This type of research often leaves participants feeling like their needs continue to go unheard and causes local organizations to be more hesitant when it comes to future partnerships. Looking back at our M1 LC projects, much of the work we did felt similar to this “helicopter” research, where we in our LC’s worked on a predetermined goal with a set end point and then did not follow extend our results to the community at large. It was not intentional that our projects gathered data in such a way, one year is often too short a time to research a question and implement interventions based on the findings.
I think a way to address this type of extractive research is “co-design,” as described in Beck et al. When research is primarily focused on the generation of novel data, the generation of knowledge should be done collectively. In practice this could look like researchers working with communities to identify areas they themselves feel need to be researched, and work together to build the procedures and systems to do so. Another, perhaps easier way if co-design is not feasible for whatever reason, would be to simply maintain as much transparency as possible while doing research. Give the community access to the results and data so they can see the result of their cooperation.
An ethical challenge I have witnessed in building relationships and partnerships with communities is that, oftentimes, the outside group or institution’s priorities are what drive the activities rather than the needs of the community, as identified by the community. Many times, the outside group or institution will approach the community with already preconceived ideas of what is wrong, missing, or needs further study, usually including the community member perspective secondarily or excluding it altogether.
Other times, even if the community has the opportunity to communicate its needs, the ultimate methods and resources used are those most convenient or important to the outside group or institution. This shows up in programs like Medical Brigades, where the service provided is based on the capacity of those attending the trip. Particularly, in programs where tourism is an added component of the trip, the time spent with the community being served is shortened for the sake of leisurely activity. I remember being in college and hearing about the opportunity to do medical service overseas. As a global health studies minor, this appealed to me; however, as I learned more about the program’s structure as a one-time 7-day trip with 2 days for tourism at the end, I began to reevaluate the purpose and true impact of such a trip. I could see the desire and possibility of doing good, but I could not ignore the even greater inevitable harm I felt I might contribute to.
I also recognize that those seeking to do research with or serve communities in need have constraints and regulations that dictate what they’re able to do. I believe the solution involves a collaborative effort between the community in question, outside groups and institutions, and the entities creating the rules and guidance for the outsiders to follow. In conclusion, the elimination of ethical challenges requires many forces, people, and priorities to all converge into a common few. And while this may not be entirely feasible, I believe that increased opportunities for collaboration between all involved parties can help provide a solution.