The CCPH Featured member is Lewis Lefkowitz, Professor, Emeritus at Vanderbilt University School of Medicine in Nashville, Tennessee. Often ahead of his time, in this interview Lewis humbly shares his extensive experience successfully influencing course offerings at a traditional medical school in order to give students an opportunity to learn and to research in the community. In recognition of his efforts in March 2001, Nashville's Campus of Human Development respite program dedicated the Vine Hill Community Clinic in his honor. In October 2002, the Vanderbilt Center for Health Services announced the creation of The Lewis B. Lefkowitz Internship to recognize and continue his commitment of extending medical education beyond the classroom and hospital, into the community.
is the mission of your organization?
A: I am an emeritus faculty member of Vanderbilt School of Medicine, and have conducted an elective community-based introductory course for health professional students since 1965. The organization's mission, of course, is that of a relatively typical private medical school, and this course is among a few opportunities for student interaction with community services and on the turf of their future patients. I have also served intermittently on the Board of the Center for Health Services of the Medical School, which is an umbrella organization founded in 1972 to support student initiatives in community settings.
I am one of 12 group leaders in Vanderbilt's recently
developed required course entitled, "The Ecology of Medical Care",
which is given weekly in the first semester of the first year. It deals
with issues of ethics, culture, medicalization and labeling, religion
and spirituality, interpersonal and interdisciplinary issues in health
care, confidentiality, end-of-life care, health services organization
and financing, clinical justice [equity], and medical education's role
in preparation in these areas. Dr. Larry Churchill is the course director.
A: The students with whom I have been principally involved in elective courses and the Center for Health Services projects are often eager to find opportunities in the surrounding communities to engage in direct services and population-based research. I want to be sure that they have the best chance of identifying appropriate and compatible venues for that activity. The career trajectories of many of them have been in public service. While I have no true control group for comparison and many may have been destined for such activity before the contact, their impulses have clearly been affirmed and stimulated by these experiences.
As to the new required course, it is too soon
to be sure. Again, affirmation can only be a facilitator for those who
are interested in the extramedical dimensions of their future careers.
A: My first "aha" experience was when I was a clinical clerk in the labor and delivery suite of Parkland Hospital in Dallas as a third-year medical student. Because of the fact that there were more births than the suite could manage effectively, the mothers were sent home after 24 hours. The 3-day postpartum examination of mother and child had to be conducted in the mother's home. Assigned medical and nursing students were sent to do this examination. We saw firsthand the conditions and circumstances that affected and would dominate the clinical and social events in the families we visited. I never looked at patients in the same way after that.
My second "aha" was in the early 1970s, when I was preceptor for a group of pre-professional students who conducted concurrent health fairs and community organization activities in isolated rural areas in Appalachia (later to be subsumed by the Vanderbilt Center for Health Services, which fortified and created partnerships with community organizations in those and other communities).
There have been many heartwarming reinforcements
of my convictions, along with some lessons learned about the obstacles
and pitfalls that punctuate the desired smooth course of partnerships.
A: Now that I have retired, my hope is that the medical curriculum will continue to expand its extramural opportunities for learning, and will create and nurture partnerships initiated by faculty, administration, and, particularly, by the students themselves. I have continued to act as preceptor for some of the activities currently taking place and will offer myself to those who need similar services in the future.
A: I can best respond by appending the answer I gave to a question posed by the American Association of Medical Colleges (AAMC) in the following request for opinions. Should community service or learning in the community be required of all graduating medical students?
Fundamentally, all medical students are different when they arrive; and, although they pass through "the eye of the needle" which is the Medical Curriculum, they all leave as different from one another as they began, in spite of it, jargon and white coat notwithstanding.
There could be no better or more fascinating and productive laboratory for all kinds of scientific and humanitarian endeavors during students' terms in medical school and residency than the community. This world, outside the walls of the medical school, is full of unexamined problems seeking solutions, infinitely varied and interesting. That is where most of the graduates will spend their post-academic lives and all their patients will experience virtually the entire course of their diseases. This is the reason it has increasingly attracted curriculum committees as they design and rationalize the changes they are proposing for medical education.
One approach that may have promise is the Partnership Paradigm. In this model, a community agency, private or public, has a clientele, a mission, and usually a number of obstacles to overcome. Their funding is mercurial, and their manpower is stretched. Their needs are multiple, ranging from administration, documentation and epidemiologic study all the way to direct services.
Embedded in these wish lists are duties that span the interest areas of most of our students, so that those who are not headed for patient care careers may find work of interest that does not involve direct personal services. In the process they will be introduced to the community in roles most like the ones they aspire to.
An important corollary must not be forgotten: Our first task as university partners is not to solve problems, but to learn. Our students are in our schools for that purpose. A university's agenda must be learning and discovery. Universities can only strengthen their commitment to service if they first study their own potential and the best ways to use their knowledge, energy and manpower to help others solve their problems. This mandate must be explicit in any negotiation with a potential community partner.
Finally, I should add the three big essentials: Communication, communication, and communication at every step one takes.
A: Recommend: Provide incentives and models for professional schools to collaborate among their components and with service agencies and community organizations
Say: Get smart and do what I have recommended,
unless you don't care about quality and just want to save money and lower
A: I was a charter member, one of the few among them who did not even submit a proposal in 1995 for the original Pew Foundation grant. I drafted a proposal for Vanderbilt, but the administration felt it was too soon to comply with the requirements of the Request for Proposals, though there was a task force in operation in the process of developing its own plan.
I would describe CCPH as a group of educators committed
to and involved in partnerships with community organizations and agencies
for the purpose of educating students of health-professional schools and
programs. Along with learning, service is a desired, but not essential,
component of the process.
A: Contractual [implicit or explicit] relationships between elements of the learning professions and groups or organizations representing or advocating for the public interest.
A: CCPH has been my continuing "support group" in my attempt to increase my influence on students and my colleagues. It is my hope that this effort to reach out to students will inspire a commitment to public service and make all students aware of the significance of the environmental factors in health status and their influence on what constitutes effective medical decision-making.
Long experience in a traditional medical school with students who want to learn in the community, and manage to do so in spite of the curriculum.
Observation of the growing realization of the
value of such experiences by peers and administration, and the obstacles
that remain in the way of implementation.
For more information please contact:
Lewis B. Lefkowitz