International Medical Education
An Interdisciplinary Community Diagnosis
Experience in an Undergraduate Medical
Curriculum: Development at Ghent University
Bruno Art, MD, Leen De Roo, MA, Sara Willems, MA, PhD,
and Jan De Maeseneer, MD, PhD
Abstract
Since 2002, the medical curriculum at
Ghent University has incorporated a
community diagnosis exercise, teaming
medical students with master of social
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work and social welfare studies students.
The course focuses on the interaction
between the individual and the community
in matters of health and health care.
During one week, small groups of
students visit patients and their
caregivers in six underserved urban
neighborhoods, and they combine these
experiences with public health data, to
develop a community diagnosis. Local
family physicians and social workers
monitor sessions. The course requires
I n 1992 Charles Boelen, chief medical
officer for the World Health Organization’s
Programme on Educational Development
for Human Resources, defined the ideal
profile of a doctor for today’s society. He
or she should possess “a mix of aptitudes
needed to carry out the range of services
that health settings must deliver to meet
the requirements of relevance, quality,
cost-effectiveness, and equity in health.”1
Awareness of important public health
issues, ability to use an interdisciplinary
approach to solve problems, and adequate
Dr. Art is general practitioner and lecturer,
Department of Family Medicine and Primary
Healthcare, Ghent University, Ghent, Belgium.
Ms. De Roo is lecturer, Department of Family
Medicine and Primary Healthcare, Ghent University,
Ghent, Belgium.
Dr. Willems is senior researcher, Department of
Family Medicine and Primary Healthcare, Ghent
University, Ghent, Belgium.
Dr. De Maeseneer is general practitioner, full
professor, and head of department, Department of
Family Medicine and Primary Healthcare, Ghent
University, Ghent, Belgium.
Correspondence should be addressed to Dr. Art,
Department of Family Medicine and Primary
Healthcare, Ghent University, De Pintelaan 185,
9000 Ghent, Belgium; telephone: ⫹32 9 332 36 12;
fax: ⫹32 9 332 49 67; e-mail: (bruno.art@ugent.be).
Academic Medicine, Vol. 83, No. 7 / July 2008
students to design an intervention
tackling one community health issue. At
the end of the course, the students
present their diagnoses and interventions
to community workers and policy makers
who provide feedback on the results.
In the authors’ experience, medical and
social work students all value the joint
learning experience. The occasional culture
clash is an added value. The one-week
course is very intensive for students,
mentors, and cooperating organizations.
Although students criticize time
restraints, they feel that they reach the
outlined objectives, and they rate the
overall experience as very positive.
communication skills all contribute to
becoming a “five-star doctor.”2 Moreover,
factors such as living conditions, income,
family status, occupation, and social
environment have a serious impact on
health, and doctors must take them into
account when interacting with a patient.
Medical faculties around the world have
addressed shortcomings in their training
by including community-oriented
education to some extent.3 The six-year
medical curriculum of Ghent University,
Belgium, underwent a radical reform in
1999. An educational committee, chaired
by the Department of Family Medicine and
Primary Healthcare, consisted of members
of all departments as well as students, who
together prepared the curriculum
reformation. The committee used the
concept of the five-star doctor as the
reference to evaluate the existing
curriculum and to suggest changes.
The committee also suggested the
introduction of new didactic methods
more adapted to the suggested new
content of the curriculum. The faculty
board ratified the suggestions of the
committee, and the reformation
transformed the traditional discipline-
based curriculum into an integrated
The authors find that this interdisciplinary,
community-oriented exercise allows
students to appreciate health problems
as they occur in society, giving them
insight into the interaction of the local
community with health and health care
agencies. Combining public health data
with experiences originating from a
patient encounter mimics real-life
primary care situations. This campus–
community collaboration contributes to
the social accountability of the university.
Acad Med. 2008; 83:675–683.
approach: patient-centered, student-
centered, community-oriented, problem-
based, and evidence-based. As a result,
at several points throughout the whole
six-year program, the curriculum
emphasizes working in the community,
working in primary care, and working with
other disciplines, as well as learning and
applying medical humanities and ethics,
with a focus on early patient contact.
In this article, we describe and discuss
the structure and evaluation of the
community-oriented primary care
(COPC) exercise for third-year medical
and master of social work and social
welfare studies (hereafter, simply MSW)
students at Ghent University.
Background
COPC is a model that uses topics
from the individual provider–patient
encounter as a starting point. It combines
individual patient and physician practice
data with public health data at the
community level, leading to a “community
diagnosis.” The community diagnosis
describes the “health status of the
community as a whole or of defined
segments of it.”4 A targeted intervention
675
International Medical Education

perspective. The COPC exercise also

presents an opportunity to invite MSW
students into a joint learning experience.
Finally, with this exercise we aim to create a
win–win situation for both community and
students, thus incorporating some of the
recommendations concerning community-
oriented health education, such as allowing
students to distinguish felt needs and actual
needs, to let them learn socioeconomic
determinants of health, and to let them be
the community’s advocates.9
At some point during each of the six
years of the medical program at Ghent
University, the curriculum emphasizes
one aspect of social responsiveness, thus
creating an educational continuum. The
COPC exercise precedes and follows
other primary care and multidisciplinary
activities, all aiming to reinforce
Figure 1 The community-oriented primary care (COPC) cycle.4 The COPC cycle starts with
attitudinal change (Table 1).
defining the community (e.g., the neighborhood, a patient list). Physicians work together with the
community to understand health problems and to establish priorities for finding solutions to these
Placement and objectives of the COPC
problems. To develop an intervention, physicians consult other data, but they also involve the exercise
community. This can be achieved either by directly consulting participants in the COPC comity or The four-day COPC exercise (Chart 1) is
indirectly by consulting local health workers. Involving the community in some way is vitally scheduled halfway through the second
important to ensure and enhance the accuracy and acceptability of the intervention. semester of the third year as the final part
Source: Used with permission from Garr, DR. Community-oriented primary care. Available at:
of a five-week Health and Society II unit,
(http://www.musc.edu/fm_ruralclerkship/copc.htm). Accessed March 28, 2008. Minor formatting
changes have been made.
which covers topics such as public health,
occupational health, global health, and
human rights. At this point in the
and evaluation complete the cycle.4,5 must make sure to reach those most in program, medical students have learned
Community involvement in all phases of need. The medical curriculum reflects this basic medical sciences, have developed
the process is mandatory5,6 (Figure 1). social accountability by training health care communication skills, and have already
This method provides tools to approach workers to be socially responsive and experienced some clinical exposure. The
problems that health care workers in the capable of working with different cultures third-year MSW students have had
community encounter. Researchers first as well as deprived communities. experience in community dynamics and
described the implementation of the have been involved in small, community-
COPC approach in 1952 and have again The Department of Family Medicine and based projects. We prepare students of
many times thereafter.7 However, the Primary Healthcare has a historical interest both disciplines with a lecture on
application of its methodology is not in the COPC model because, for decades, community and COPC, and we provide
widespread. Accounts of a complete several staff members have applied some some background on the other
COPC cycle are rare, and they are almost principles of COPC in their clinical discipline’s main characteristics.
nonexistent in Europe.8 practice. Because the COPC model Specific learning objectives of the COPC
perfectly fits the general aims of the exercise are
reformed curriculum—in particular, the
The COPC Exercise
multidisciplinary and the community- • to develop a practical understanding of
The medical curriculum oriented aspect—the Department of inequities in health,
In Belgium, medical school runs six Family Medicine and Primary Healthcare
• to gain insight into the meaning of
years: three years to earn the bachelor developed a COPC-inspired exercise,
health and illness and their practical
degree, three years to the master degree. which was accepted by the educational
consequences in the primary health
Masters have entrance to the medical committee as a regular component in the
care context,
profession after clinical training in a curriculum. The aim of the exercise is to
chosen specialty (e.g., family medicine, give students a greater understanding of • to appreciate the impact that the
specialist care, public health) that lasts an the situation of individual patients in the community has on individual health,
additional three to six years. community, an appreciation of the roles
• to gain understanding of the range of
of patients’ different caregivers, and an
professionals and services involved in
The reformed medical curriculum at the opportunity to learn to combine data
health care, and
University of Ghent pays attention to obtained from different sources into a
“social accountability”: both health care community diagnosis, making the link • to learn how to make a community
agencies and educational institutions between the individual and the community diagnosis by collecting and integrating

676 Academic Medicine, Vol. 83, No. 7 / July 2008

 International Medical Education

Table 1
Social Responsiveness Emphases in the Medical Curriculum at Ghent University,
Belgium, 2006

Curriculum objective (year in curriculum) Correlating courses and activities

To obtain general insight into societal needs and the role of Health and Society I: Sociology, Anthropology
medicine (1 and 2) Multidisciplinary clerkship
...................................................................................................................................................................................................................................................................................................................
To understand community-oriented primary care (COPC) (3) COPC week
...................................................................................................................................................................................................................................................................................................................
To understand “general practice” (3) Family physician clerkship
COPC week
...................................................................................................................................................................................................................................................................................................................
To know paramedical disciplines and practice interdisciplinary Interdisciplinary training exercises with participants from six other disciplines
approaches (4)
...................................................................................................................................................................................................................................................................................................................
To understand the strengths and objectives of primary care (5) Two-month primary care medicine clerkship
...................................................................................................................................................................................................................................................................................................................
To practice primary care (6) One-month clerkship

individual stories as well as • to present the results to a public audience These neighborhoods have a high
epidemiological data. of health care workers and policy makers. concentration of social housing, unhealthy
dwellings, and ethnic diversity, as well as a
We hope the students acquire the population generally more deprived than
following skills: In 2002, the course ran with 36 volunteer
medical students in two neighborhoods. the average population of Ghent.10
• to conduct semistructured patient and As a consequence of the growing student
caretaker interviews, starting with a set of population in Ghent (Table 2), each year A local community health worker gives
themes the students want to cover, but we invite new communities to participate. an introduction to the community
without a rigid interview style, thus studied, and we further split up the
allowing for elaboration on certain topics, groups of 20 into groups of 4, which will
Description of the COPC exercise each prepare to visit both a member of
• to work together with students from
The introduction to the exercise. The the community (further referred to as
other disciplines,
first day of the COPC exercise starts with patient) or family at home, and the
• to work autonomously and within a detailed information about the exercise patient’s or family’s professional
tight time schedule, itself and an introduction of all the caregivers. All patients, each with a
participants (Chart 1). We then divide specific sociomedical history (e.g.,
• to write a letter about a patient to an
students into groups of 20 and allocate chronic diseases, unemployment,
involved health care professional,
each group to one of the participating financial problems, difficult family
• to formulate possibilities for improvement neighborhoods, which are all situated in situations), participate voluntarily and
at the community level, and the 19th-century “belt” around Ghent. have given informed consent for the use

Chart 1
Course Schedule With Time Allotted in Minutes and Number of Participants for
Ghent (Belgium) University School of Medicine Community-Oriented Primary
Care Exercise, 2002–2007

Monday Tuesday Wednesday Friday

General Introduction Interview with caregivers Community diagnosis Preparation for presentation
(90 minutes) (30 minutes + preparation and (120 minutes) (120 minutes)
(all students, 1 lecturer) evaluation) (groups of 20 students, 1 mentor (groups of 20 students, 2
Visit to neighborhood (groups of 4 students) per group) supervising lecturers for all
(60 minutes) Visit with community workers student groups)
(groups of 20 students, 1 mentor (60 minutes)
per group) (small groups of 4 students)
Preparation for patient
interview
(60 minutes)
(groups of 4 students)
Interview with patient Community diagnosis Exploration of interventions Presentation
(60 minutes) (180 minutes) (180 minutes) (180 minutes)
(groups of 4 students) (groups of 20 students,1 mentor (groups of 20 students, 1 mentor (all students and mentors + jury
Interview with caretakers per group) per group) and invited caretakers)
(30 minutes + preparation and
evaluation)
(groups of 4 students)

Academic Medicine, Vol. 83, No. 7 / July 2008 677

 International Medical Education

Table 2
Numbers of Participants in the Ghent (Belgium) University School of Medicine
Community-Oriented Primary Care Exercise by Year

Social work and

Medical social welfare Patient
Year students studies students Mentors* Neighborhoods Patients caretakers
2002 36 0 2 2 12 30
...................................................................................................................................................................................................................................................................................................................
2003 102 25 5 3 33 85
...................................................................................................................................................................................................................................................................................................................
2004 118 32 6 4 39 98
...................................................................................................................................................................................................................................................................................................................
2005 120 37 7 4 42 105
...................................................................................................................................................................................................................................................................................................................
2006 147 33 8 5 46 115
...................................................................................................................................................................................................................................................................................................................
2007 172 46 9 6 55 138
*
The number of mentors followed the number of students but not the number of neighborhoods; some
neighborhoods welcome two groups of students working separately from each other.

of their summarized medical file for such as the health and well-being of the physiotherapists), teachers, pharmacists,
students to prepare the interview (Table patient and the patient’s priorities and community workers. The students
3). A family physician familiar with the regarding his or her housing, social focus on the role of the agency in the life
patients and with the neighborhood is situation, and view of the local of the patient they visited by both
available for questions. The group of four community. The four students discuss addressing this patient’s priorities and by
students prepares the interview without the interview, which leads to a list of comparing these priorities with the
formal vetting of the actual questions health care priorities for the patient. agency’s priorities. They also discuss the
they plan to pose, but with general This list serves to prepare the agency mission and tasks of the agency with
guidelines concerning semistructured interviews. Next, the four students regard to the community. The objective is
interviews, professional behavior, and the interview three care providers per to gain insight into the possible functions
objectives of the process. patient, choosing among available social this agency can have at the individual and
Visiting the community. The group of service providers, health care workers community levels. We encourage the
four students interviews the patient at (e.g., general practitioners, nurses students to stroll around the neighborhood
home, without other parties present, for [practice nurses, psychiatric nurses, in their spare time.
about one hour. The group covers topics mother- and child-welfare nurses],
Community diagnosis. On Tuesday
afternoon, students studying the same
community meet on campus in groups of
Table 3 20 to share experiences and to propose a
Patients Visited by Medical, Master of Social Work, and Master of Social Welfare list of characteristics regarding their
Students in One Neighborhood (Estate Nieuw Gent) During the Ghent (Belgium) neighborhood based on the data from the
University College of Medicine Community-Oriented Primary Care Exercise, 2004
interviews. They consider medical needs as
Patient participants (age in well as social, environmental, and other
ayears)* Major problems problems. This list is the basis for the
Parents (34, 36), three children (2–8) Children: Enuresis nocturna, behavioral problems consultation of secondary resources
All: Obesity, recurrent head lice infestation, and financial that contain information about this
problems community. The students retrieve data
.........................................................................................................................................................................................................
Mother (30), child (3) Language, ear–nose–throat infections and epidemiological material from local
.........................................................................................................................................................................................................
Single man (56) Alcoholism, diabetes mellitus, smoking, renal failure agencies, health-needs-assessment
.........................................................................................................................................................................................................
Single man (60) AMI, diabetes mellitus, smoking, hypertension, loneliness surveys, crime statistics, and social
.........................................................................................................................................................................................................
Parents (45, 46), three children Parents: Chronic migraines, chronic back pain, financial databases maintained by the city and the
(8–21) problems, conflicts with children national government. At the end of the
Children: Epilepsy, problematic contraception afternoon, the groups of 20 students
.........................................................................................................................................................................................................
Mother (40), child (8) Mother: Financial problems, educational problems combine these data with those from the
Son: Encopresis, enuresis, attention-deficit/hyperactivity interviews to form a priority list, leading
disorder to a community diagnosis. Local family
.........................................................................................................................................................................................................
Single woman (80) Arthrosis, hypertension, loneliness physicians and social workers mentor the
.........................................................................................................................................................................................................
Couple (60, 36) Man: Schizophrenia students during these sessions and
.........................................................................................................................................................................................................
Parents (33, 36), four children (4–14) Youngest child: Hypothyreoidy support the discussion, without too
Parents: Psychological problems with asylum and social much interference on the content.
isolation, language
.........................................................................................................................................................................................................
Single woman (52) Schizophrenia, financial problems, chronic obstructive On day three, in the larger groups of 20,
pulmonary disease, obesity
students brainstorm about possible ways
*
Patients represent a wide variety of nationalities and speak a wide variety of languages. to address some of the problems that they

678 Academic Medicine, Vol. 83, No. 7 / July 2008


diagnosed. They design, by consensus, a
proposal for an intervention, including
both population involvement and
evaluation, in one of the problem areas.
In the smaller groups of four, they discuss
this intervention along with the community
diagnosis with neighborhood workers (at a
previously organized appointment). The
neighborhood workers provide feedback,
allowing for improvements that make the
intervention more realistic and feasible.
Presentation. On the morning of the
fourth day, all 20-member groups
prepare a presentation of their
community diagnosis. In the afternoon,
they present their diagnosis and
intervention to fellow students, teachers,
members of agencies involved in the
communities, and local policy makers.
The students design a poster addressing
the community diagnosis or the
intervention that will be used in the local
health centers.
Assessment
We assess the students in three ways.
First, we ask them to individually write a
letter to an agency or caretaker in which
they address a specific problem in the
social or health situation of the patient
they visited, a problem to which a part of
the solution may lie in the hands of the
addressee. One staff member grades the
students on their ability to write a clear
and correct letter, their understanding
of the task of the agency, and their
demonstration of realistic problem-
solving capabilities. The students actually
send the letters to the addressed agencies,
and sometimes these letters contribute to
new initiatives by the caregivers.
A jury of health care workers from the
visited communities and some faculty
members grade the presentations at the
end of the course according to content
(i.e., appropriateness of the community
diagnosis, relevance of the proposed
solutions, feasibility) and formal aspects
of the presentation. Thirdly, the mentor
gives grades to each individual student,
reflecting the student’s participation
during the group discussions.
Organizing the exercise
Given the multitude of individuals who
have to be contacted for an appointment
with the students on the first two days of
the exercise, the university provides two
persons (total 0.4 FTE) for the exercise.
These employees plan the exercise and
Academic Medicine, Vol. 83, No. 7 / July 2008
support the local partners by providing a
scenario about how to recruit a
representative selection of patients. They also
make most of the appointments that the
students have to attend on the first two days
of the exercise, and they schedule suitable
rooms for the community diagnosis
sessions. They prepare the evaluation,
initiate suggestions for ameliorations, and
support the mentors during the actual
exercise.
In June of each year, we estimate the
number of students participating during
the next semester, and, if necessary,
we contact new neighborhoods. In
December, representatives of each
neighborhood meet to address practical
issues such as recruiting patients and
caregivers, finding a location for the
community introduction, etc. In March,
the mentors meet to prepare the sessions.
The actual exercise takes place later in
March, leading to a lot of organizational
stress: last-minute changes; students,
patients, or caretakers not showing up;
etc. In June, we evaluate the whole
process, making yearly improvements to
both content and organization.
Evaluation
Each year, we survey students about the
exercise, and we evaluate and then
adapt it where necessary. Students
anonymously complete a Likert-scale
questionnaire with 22 questions on three
domains: (1) the practical organization of
the exercise (5 questions), (2) whether
they reached the learning objectives (10
questions)—for example, if students
understood the connection between their
patients and the epidemiological data
they gathered (Figure 2A); and (3) their
community-oriented and primary care
attitudes (6 questions). One question
addresses the interdisciplinary aspect of
the exercise (Figure 2B). Figure 2A and
2B shows the aggregate mean values
scored for the period of 2003 to 2007.
In their reactions, students commented
most on the course’s organization and the
time restraints they experienced. Secondly,
comments referred to the students from
the other disciplines. To a lesser extent,
students shared some of their experiences
and anecdotes from their interactions with
patients and caretakers.
According to their comments, the
medical students most valued being in
International Medical Education
the community and experiencing real-life
situations, which, for some, were real
eye-openers.
I will never forget the family I interviewed
and how they felt lost in our city where
they do not know anybody besides their
son’s school.
Our patient was always telling us to become
as her “house doctor,” who obviously
played an important role in her life.
I didn’t know this kind of neighborhood
existed so close to the university.
The students appreciated working together
towards a clear goal. Many mentioned their
positive surprise to notice that the social
work mentors and students demonstrated
expertise in analyzing data and working
with a community instead of individual
patients.
The tutor, while not being medically
trained, really helped us during this
stressful week.
It was nice to be able to work together to
a clear goal, and the other students knew
very much where I knew nothing.
They [the social work students] made me
look quite differently at why the elderly
woman I visited feels unsafe.
Most of the medical students felt they
had reached the course objectives.
However, we have not yet performed a
formal measurement of the extent to
which the one-week experience has a
lasting imprint on the medical students.
Frequently, the medical students wrote
negative remarks with regard to the time
restraints and the idea that students
might have anything to tell the caretakers
(via the letter or the presentation).
Having to do all this work in one week
put us under a lot of stress. And in the
evening I was so exhausted I was unable
to do any of the other work I need to do.
Having to write a letter to the doctor I
visited seems useless to me, how can I tell
him anything after one week?
The MSW students, already having some
experience in fieldwork, were more
critical in their comments.
Medical students are strange.
I enjoyed very much meeting [patient’s
first name] and her daughter. However, I
feel unsatisfied not being able to really
help her some more.
One week is largely insufficient to get to
the core of this neighborhood’s problems.
679
International Medical Education

100 %

90 %

80 %

70 %

60 %
Percent of 50 %
respondents
40 %

30 %

20 %

10 %

%
1 2 3 4 5
A
Disagree Agree
100 %
90 %
80 %
70 %
Percent of 60 %
respondents 50 %
40 %
30 %
20 %
10 %
%
1 2 3 4 5
B Disagree Agree

100 %
90 %
80 %
70 %
Percent of 60 %
respondents 50 %
40 %
30 %
20 %
10 %
%
1 2 3 4 5

C Disagree Agree

Medical students MSW and Master of Social Welfare Studies students

Figure 2 The mean percentage of third-year medical students and master of social work (MSW) and master of social welfare studies students
(2003–2007) agreeing or disagreeing with statements on a questionnaire evaluating the effects of the community-oriented primary care (COPC)
exercise at Ghent University, Belgium. Figure 2A shows which percentage of students agreed or disagreed with the statement, “I succeeded in making
the link between the patient and the epidemiological data”; Figure 2B shows which percentage of students agreed or disagreed with the statement,
“Working with students of another discipline was an enriching experience”; and Figure 2C shows which percentage of students agreed or disagreed
with the statement, “The COPC exercise shows a big overlap with previous courses.”

The role of (para)medical caregivers
(and their attitudes towards
community and patients) was most
interesting to the MSW students, as was
learning more about the relationship
between an individual patient’s health
and the environment. Also, they
appreciated the opportunity to get to
know the medical students.11 Their
comments indicated both that they
understood the complementary roles
they and medical students play and that
they gained genuine respect for the
individual care the visited physicians
offered.
I know now that doctors have a unique
view on community problems, which is
complementary to my own.
I loved being able to walk around the
neighborhood, and talking to people who
dedicate their professional life to it. That’s
what I want to do.
The MSW students criticized the time
restraints as well as the aspect of being a
minority in the process.
I thought the whole week was too much
of a rush, without time to really get into
the subject.
My colleague and I were dominated by 17
medical students throughout the week,
who didn’t seem to care about our views.
It is striking how much students of the
same age but from different training
backgrounds think in different theoretical
paradigms. As a result of their training so
far, and apparently regardless of previous
efforts to broaden their perspectives,

680 Academic Medicine, Vol. 83, No. 7 / July 2008


medical students start from a problem
and try to “cure” it, whereas the MSW
students want to start from the available
opportunities in a community and
develop those. One illustrative anecdote
is how different the medicals students’
approach was from that of the MSW
students to the problem of Belgian elders
living in a more and more culturally
diverse neighborhood and their feelings
of insecurity, following and leading to
immobility and lack of social contacts.
Where MSW students wanted to search
for commonalities among the different
age and cultural groups and work with
those, the medical students proposed
placing more security cameras in the
block of flats and installing bus services
to accompany the elderly to targeted
activities.
In 2004, we also surveyed health care
professionals involved in the experience,
and 56 of 97 (58%) responded. The
respondents reacted positively to their
teaching roles, and they appreciated the
course objectives. Finding time in their
tight schedules was the most problematic
issue for the participants. All respondents
were willing to participate in the future.
It is unclear whether the nonresponders
were less satisfied with their role in the
exercise.
We have not yet surveyed cooperating
patients. However, informal contacts
suggest a very positive experience for
most of them, as do accounts of similar
courses.12
Apart from the Department of Family
Medicine and Primary Healthcare
evaluation, an external, international
committee evaluated the exercise during
the accreditation procedure of the medical
training in 2005. In their report, the
committee highly valued the community
orientation of the curriculum as well as the
emphasis on social accountability. The
committee evaluated the latter as a
particularly commendable characteristic of
the medical curriculum.13
Discussion
In this paper we report the development,
organization, and evaluation of a
community diagnosis exercise for
medical and MSW students. In this
one-week course, we offer students an
opportunity to enhance their knowledge
about local underserved communities
Academic Medicine, Vol. 83, No. 7 / July 2008
as well as the factors that influence
the health and health care of these
communities. We challenge the students
to be critical of their attitudes towards
these communities and of their opinions
about health care priorities and delivery.
The students sharpen their skills
in interviewing, working in an
interdisciplinary team to solve problems,
presenting their teamwork, and writing a
concise recommendation letter to a
future colleague. The combination of the
interviews with patients and caretakers
followed by a community diagnosis
exercise has many benefits:
• the exercise mimics real-life, primary
care situations where multidisciplinary
teams and community involvement
start at the patient level;
• the patient visit allows students to have
a realistic view of problems, and
using this visit as a permanent focus
throughout the week helps them in
making the process of working with
community data less vague;
• the exercise allows agencies to highlight
their different tasks, both on the
individual and community levels;
• the exercise forces students to be their
patients’ and their communities’
advocates, stimulating caregivers and
local authorities to reflect on their plans
of action regarding the patient or
community; and
• the immersion in the household
environment where a patient is cared
for, the contact with the close
caregivers, and the experience at the
community level help students see the
broader context of health and disease.
However, this approach has its
limitations. The combination of the
different learning goals raises conflicts:
selected patients must simultaneously
“illustrate” the community they live in
and require the assistance of the
caretakers who represent the various
services available in the area. This may
give students a biased view of the
community. We train the authority
responsible for patient selection from
each neighborhood to select a group
of patients who have the relevant
community characteristics. The
experience of visiting only one patient is
limited. Sharing stories, however,
broadens the students’ perspectives.
International Medical Education
Organizing a COPC exercise in Ghent is
challenging for a number of reasons. No
medical school in Belgium has ever fully
applied the proposed COPC model, so
mentors cannot draw from extensive
experience while teaching it. Although
teachers have experience with aspects
of rapid appraisal with regard to
health-needs assessment, community
involvement, and multidisciplinary
cooperation, genuine COPC cycles have
rarely been carried out. Also, small-
group education requires a complex
organization and adequate guidance.
Gradually building the course over the
years has provided us with a stable team
of experienced mentors.
Certainly, the learning goals are
ambitious, given the time restrictions and
the students’ relative lack of preparation
in earlier courses. The students are very
aware of these limitations. Nevertheless,
it is clear that they value the experience.
They highly appreciate a week
emphasizing small-group fieldwork and
self-directed discussions. Other studies—
one from New Zealand14 and one by
Lennox and Petersen,15 whose Leicester
experience inspired part of our
course15—report similar findings.
Community diagnosis introduces the
students to a world with which they are
unfamiliar, but by making the patient
contact the basis for the week, we have
tried to make this exercise as concrete as
possible. We have not yet found a way to
get back to the original patients at the
end of the exercise. Time and practical
constraints (e.g., gathering all these
people scattered over town, sending the
students back to the patients’ homes)
stand in the way of making a complete
COPC-cycle exercise in one week.
In 2006, reacting to comments criticizing
the overlap of the COPC exercise with
previous courses (Figure 2C), we placed
the course in year three of the MSW
curriculum rather than year four. A
similar course in Glasgow proved that
involving only medical students is
feasible,16 but we believe that the
interaction with MSW students creates an
added value (Figure 2B). This sometimes
takes the form of a genuine culture clash,
which puts a lot of adrenaline in the
group sessions. In our experience,
medical students go for quick,
operational solutions, whereas the MSW
students focus on the broader exploration
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International Medical Education
of the problem, stressing the importance
of citizen involvement. This could
indicate that despite the reform of the
curriculum, medical students are still
being trained to become “technical
professionals,” applying their tools to a
given problem, whereas MSW students
are more “normative professionals,”
questioning the nature of the problem. If
students learn to use both paradigms in a
complementary way, this adds to the
quality of the outcome.
Whether the students effectively reach
most of the learning goals needs further
investigation. With little formal
knowledge taught during this exercise
(only two lectures of 60 minutes each
before the start), the main objectives
lie in developing competencies
and attitudes. A small pre- and
postintervention questionnaire in 2002 of
36 students regarding their attitudes
doesn’t show much effect,17 although the
fact that the students were a small group
of volunteers may have biased the outcome
because we can guess that volunteers for
this kind of experience already have
generally positive attitudes toward the
issues examined. Longer community
immersions have been shown to have some
effect on career choices,18,19 but little is
known about attitudes.19 –21 By placing
this experience relatively early in the
curriculum, we hope to influence the
students at a moment when education and
experience can still modify attitudes.18,22
This kind of teaching obviously demands
the creation of a long-lasting relationship
between the university and community
stakeholders (i.e., the agencies participating
in the learning experience, such as public
centers for social welfare, private welfare
centers, police departments, community
development centers, schools, and
hospitals). In addition, individual
physicians, nurses, and other ambulatory
paramedics are involved. Working with
locally well-embedded community health
centers partially solves the problem of
establishing and maintaining relationships
between the university and community in
Ghent.
But what about the individual patients,
community workers, and the community
as a whole—what do they gain? This kind
of approach raises ethical questions.
We face the dilemma that we want to
expose the students to the social reality,
especially of the most disadvantaged, but
682
we do not want to exploit the poor and
underserved (no “social sightseeing”).
Therefore, we have tried to create a win–
win situation: through their report to the
politicians, students give a strong voice to
the needs of their patients; they become
their advocates. The immersion in the
community, as well as understanding the
possible roles of caregivers, contributes
successfully to forming students who are
more “community responsive.”23
Although not the primary objective of
this exercise, political authorities have
put suggestions to improve the situation
in the community into practice, creating
a new youth leisure facility in 2003 and
providing more green spaces in 2004.
Moreover, the students’ posters have
been used for various applications, such
as the cover of a publication listing
various social initiatives in one
neighborhood. Also, letters sent to
different caretakers about individual
patients have occasionally led to
ameliorations in caretaking relationships
or outcomes. For example, one visited
patient who did not have access to a
physiotherapy facility because of lack of
insurance was accepted after this facility
received letters from the students. In
addition, the city’s department of
infrastructure sped up work on projects
to improve mobility and safety in one
neighborhood, and several caretakers
contacted each other (sometimes for the
first time) to discuss a patient’s situation
after they received the letters. In this way,
the Ghent COPC exercise is an example
of a successful, mutually beneficial
community– campus partnership, in
which the local university gives
something back to the communities
from which its students learn.
Acknowledgments
The authors wish to thank Ms. Lut Dhont of the
University Health Centre Nieuw Gent for the
practical coordination of the COPC course since
2002 and for providing data for this article. They
also want to thank Leen Gyssels and Veerle
Piessens, who have been mentors since 2003.
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Teaching and Learning Moments
No Single Best Answer
As I looked out on the faces of the
second-year students awaiting the
Step Exam review, I couldn’t help
but think of the patient I had seen
recently—a 71-year-old woman with a
history of recent transient ischemic
attack and a right carotid bruit who
had refused to consider potential
angiogram and surgery. I knew what
the right answer would be on a
standardized exam. I did not know the
right answer for reality. How much of
a difference in statistical outcome is
needed— how low a number needed
to treat—would make it imperative for
me to push this reluctant patient to
consider having a simple Doppler
exam, an angiogram (at some risk),
and possible surgery? And what of the
cost-effectiveness of studies done and
time spent in persuasion? There is no
single best answer. What about the
patient’s fear of surgery and her
preference for “natural” approaches?
And “patient-centered communication
and problem-solving”? Is it coercive to
convince this patient, dead set against
surgery, to examine her preferences?
What difference in probable outcomes
would make this the moral approach?
And, of course, what is the benefit/risk
ratio of invasive intervention over
minimal intervention—and how does
that balance her actual concerns? And
what of the grandchildren she keeps
now so her daughter can work? Her
situation is rich with particular,
contextual details, but has no single
Academic Medicine, Vol. 83, No. 7 / July 2008
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Cornman-Levy D. The effect of an
interdisciplinary community health project on
best answer. Certainly, there are some
wrong answers, but there are many
equally good answers— depending on
so many specific aspects.
From Iowa tests through SATs, ACTs,
MCATs, and Step exams, we select our
students by single best answer. Yet
even compared to the long-stem,
“context”-related cases of the Step
exams, real patients are much more
broadly contextually situated—family
issues, cultural biases of the patients and
the doctors, funding resources and
changing rules, and on and on. We
select our students by their skills in
navigating a defined and calculable
world, and expect them to adapt to a
world of indefinites and ambiguity. Even
our beloved database of statistics and
prediction rules tells us what will happen
to 100 people, but not the one person in
front of us in the exam room.
My thoughts turned to the boards.
Here too, there is a canned world of
expected responses—a contrived,
monocultural world where all diabetic
patients are miraculously compliant
with all diets, monitoring, and
prescriptions, a world where there are
no misunderstandings of plainly spoken
English, where labs make no errors and
orders are carried out as written. Yet
students quickly discover in their third
year that many of the challenges of
medical practice are not addressed in the
database we teach and test.
Teaching and Learning Moments
students attitudes toward community health,
people who are indigent and homeless, and
team leadership skill development. J Allied
Health. 2003;32:122–125.
23 Oandasan IF, Barker KK. Educating for
advocacy: Exploring the source and
substance of community-responsive
physicians. Acad Med. 2003;78(10 suppl):
S16 –S19.
We select our students by single best
answer for a world of complexity and
ambiguity. We teach an intensive,
detailed database that is testable
by this format, and then struggle
to assess and value the skills of
communication and the attitude of
service. Strangely enough, the students
we have selected by single best answer
flock to specialties with limited
ambiguities, where they may feel smug
serenity in their single best answers.
We have developed and honed an
excellent testing and educational
process to select for individuals who
provide the single best answer. As
noted by Berwick,1 “every system is
perfectly designed to achieve the
results it achieves.” Perhaps if we want
different results, we need to rethink
and redirect our selection and training
processes. In the interim, I teach “out
of both sides of my mouth,” making
sure the students know the “single
best answer” as well of the variety of
right answers for real patients.
Martha L. Elks, MD, PhD
Reference
1 Berwick DM. A primer on leading the
improvement of systems. BMJ. 1996;312:
619 – 622.
Dr. Elks is associate dean, Department of Medical
Education, and chair and professor, Department of
Medical Education, Morehouse School of Medicine,
Atlanta, Georgia.
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