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Putting 'community' in community medicine

The Summer Institute at OU-Tulsa gives health care students a glimpse into the daily lives of the patients they will treat.

Patients are not a list of symptoms and a diagnosis.

They are whole people who have lived whole lives and whose experiences and environments have contributed to their health.

That concept is woven throughout the curriculum at the University of Oklahoma-University of Tulsa School of Community Medicine and is introduced before students begin working in the classroom.

Each August, all first-year medical and physician assistant students, along with those in social work and nursing, are invited to attend the Summer Institute.

Now in its 10th year, the summer program immerses participants in a weeklong education experience that engages an interdisciplinary group of students and faculty in interactive, experiential service learning. More than 100 students took part in this year’s institute, which was hosted by OU-Tulsa.

OU-Tulsa students Mason Kennon (left), Jordan Beasley and Abby Boehning (front) weigh produce during a shopping excursion with Dr. Martina Jelley. The students were given $11 to feed a family,                                                                             Tulsa World

 “We are really trying to train a different kind of health care provider,” says Meredith Davison, associate dean for academic services. “Our whole goal is to have providers who are not only very skilled at treating individual diseases, but also understand that the patient lives in a community where there are other factors that will impact their health.”

Jeanne Hayes, M.D., assistant dean for academic services and vice chair of pediatrics, says that the Summer Institute is the first time many students get to see the impact that community can have on health.

“A lot of times you don’t think of those things when you’re starting out. You tend to think of the purely medical aspects of people’s health, but there are a lot of other factors,” says Hayes.

Social determinants include the environment, nutrition, upbringing, education, social support network, employment and access to health care.

Students spent the first day exploring Tulsa and learning about the demographics, tendencies and trends of the city’s different neighborhoods and how those aspects are a part of community medicine.

If you don’t take into account what happens outside the clinic then you aren’t caring for the whole person.
Robin Rainey Kiehl, first-year             medical student

The students took a bus tour from one end of the city to the other, traveling primarily down Peoria Avenue — a road that takes you from some of the most poverty-stricken areas to some of the wealthiest in a 10- to 15-mile stretch.

“You can see the best and worst that Tulsa has to offer in terms of living,” Davison says.

Robin Rainey Kiehl, a first-year medical student at the OU-TU School of Community Medicine, calls the experience “eye opening.”

“If you don’t take into account what happens outside the clinic then you aren’t caring for the whole person,” Kiehl says. “This is why we’re needed. This is our calling and it’s crucial to improving health care in Oklahoma.”

Kiehl, who earned an undergraduate degree from OU, says that her experience working as an emergency medical technician led her to seek a career as a physician.

“The health care needs and disparities are pretty shocking when you see them in an emergency situation,” she says. “That brought to life a lot of situations in our state that I wasn’t aware of.”

The second day of the institute put students face-to-face with the kinds of patients they will be treating and introduced them to some of the difficulties those patients deal with on a regular basis. The students — in small teams that included medical, nursing and social work disciplines — conducted patient interviews inside the patients’ homes.

The patients, who had all sought treatment with OU Physicians-Tulsa, shared their experiences, positive and negative, with the health care system. They discussed their diagnosis and the impact it had on their daily lives. Many shared their struggles of poverty.

Kiehl’s group interviewed a patient who had a rare form of cancer. “Hearing her struggles throughout the health care system and trying to find work while in and out of treatment really made her issues very real and go from something that you just see on paper to something that is very present and very important,” she says.

The institute also featured several lectures, meetings and group work in addition to the hands-on community experiences.

“It was a pretty torrid pace, but quite enjoyable,” says Chris Thibeault, a first-year physician assistant student. “They tried to give us a real-life appreciation of the difficulties many people in this city are going through to find affordable health care and make it with their economic struggles.”

Thibeault says that during his patient interview he realized the impact a health care provider’s empathy, or lack thereof, can have. His team was interviewing a woman who had been diagnosed with three types of cancer, and she shared the experience of how she was told.

“She made it seem like the person giving the news was giving a run-of-the-mill diagnosis. ‘Oops, you have cancer,’ ” he says. “Our words can have an impact, and how and what you say to a patient can have a big effect. You need to have empathy and grace in those situations.”

During the Summer Institute, students make lists of the challenges facing Tulsa's underserved and how those factors play into the overall health of an individual.

During one of the exercises, students were given dietary restrictions of real patients and an amount of money based on assistance they receive and the size of their family. Then they were sent to the grocery store to purchase ingredients for a healthy meal. Thibeault’s group, for instance, had $11 to feed a family of six.

“That was a struggle,” Thibeault says. “Fast food is so much easier and faster and unhealthy. I can see why it’s the go-to option.”

The shopping experience helped the medical students appreciate that they need to be practical and understanding when doling out “doctor’s orders.” Often what they and their patients want is not easily accomplished. For students like Abby Boehning, who is working toward her master’s degree in social work, the shopping experience was an opportunity to put herself in the shoes of the people she’ll be serving.

“If I can understand the challenges my clients are experiencing, it will make me a better social worker and a better person,” she says.

The institute also featured a poverty simulation where students role played members of various families and were tasked with paying bills, going to or looking for work, getting the kids to and from school or daycare, and paying for transportation. Stations representing situations from banks and the workplace to pawn shops, homeless shelters and a jail lined the walls. Students had limited amounts of time to complete requirements at each stop or face consequences.

“Many of our students have not had the opportunity to realize the things that can go on in life,” Davison says.

Some students ended up in jail or homeless, and there were long lines at the social services and payday loan stations.

The institute also featured a poverty simulation where students role-played members of various families and were tasked with paying bills, going to or looking for work, getting kids to and from school, and paying for transportation.

“We have to look at how everything around a person affects them and start to look at how we can impact their health more than just individually,” Hayes says. “We’re going to have to look at the population level to really improve the health and well-being of a patient, and by doing that you improve the health of the whole community — because social problems don’t affect just one.”

Many concepts introduced during the institute are threaded throughout the curriculum in an effort to help students make the connection between health and the impacts of social determinants.

“I can’t think of a better way to start your medical school career,” Kiehl says. “I think every medical student should start with a community component so they can understand the city they’ll serve, not just in the hospitals, but outside, in the homes of the patients they’ll treat.”

Michael Averill is a reporter for the Tulsa World.

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