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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
A Systematic Review of Service-Learning in Medical Education: 1998–2012 a
a
Trae Stewart & Zane C. Wubbena a
Department of Counseling, Leadership, Adult Education and School Psychology, Texas State University, San Marcos, Texas, USA Published online: 20 Apr 2015.
Click for updates To cite this article: Trae Stewart & Zane C. Wubbena (2015) A Systematic Review of Service-Learning in Medical Education: 1998–2012, Teaching and Learning in Medicine: An International Journal, 27:2, 115-122, DOI: 10.1080/10401334.2015.1011647 To link to this article: http://dx.doi.org/10.1080/10401334.2015.1011647
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Teaching and Learning in Medicine, 27(2), 115–122 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011647
GROUNDWORK A Systematic Review of Service-Learning in Medical Education: 1998–2012 Trae Stewart and Zane C. Wubbena
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Department of Counseling, Leadership, Adult Education and School Psychology, Texas State University, San Marcos, Texas, USA
Phenomenon: In the United States, the Affordable Care Act has increased the need for community-centered pedagogy for medical education such as service-learning, wherein students connect academic curriculum and reflections to address a community need. Yet heterogeneity among service-learning programs suggests the need for a framework to understand variations among service-learning programs in medical education. Approach: A qualitative systematic review of literature on service-learning and medical education was conducted for the period between 1998 and 2012. A two-stage inclusion criteria process resulted in articles (n D 32) on service-learning and Doctor of Medicine or Doctor of Osteopathic Medicine being included for both coding and analysis. Focused and selective coding were employed to identify recurring themes and subthemes from the literature. Findings: The findings of the qualitative thematic analysis of service-learning variation in medical education identified a total of seven themes with subthemes. The themes identified from the analysis were (a) geographic location and setting, (b) program design, (c) funding, (d) participation, (e) program implementation, (f) assessment, and (g) student outcomes. Insights: This systematic review of literature confirmed the existence of program heterogeneity among service-learning program in medical education. However, the findings of this study provide key insights into the nature of service-learning in medical education building a framework for which to organize differences among service-learning programs. A list of recommendations for future areas of inquiry is provided to guide future research. Keywords
service-learning, curriculum development, medical education, experiential learning, community service
INTRODUCTION In the United States, the emerging paradigm of population perspective healthcare recognizes that patient well-being does not exist within a vacuum, nor can it be simply condensed into a collection of signs and symptoms searchable in a database. With the passage of the Affordable Care Act, practitioner competence and preparation will be partially defined by an ability Correspondence may be sent to Trae Stewart, Texas State University, ASBS 316, 601 University Drive, San Marcos, TX 78666, USA. E-mail: [email protected]
to address the needs of an economically underserved and racially diverse population. Physicians will need to obtain a broader set of knowledge and skills, rather than focus solely on the specialized knowledge that dominates healthcare today. Issues of significance in this movement will be the reform of medical education curricula to match the reconfiguring healthcare system and the preparation of practitioners for primary-care medicine. Traditional, institution-based pedagogical models will need to transition to more communitycentered models, in which healthcare professionals will accommodate contemporary life-styles and care for the community’s health. Service-learning is a pedagogy of engagement wherein students address a genuine community need by engaging in volunteer service that is connected explicitly to the academic curriculum through structured ongoing reflections.1–3 The philosophical roots of service-learning are attributed to John Dewey, who posited that the key to learning is the interaction of knowledge and skills with experience.4,5 Dewey focused on the tendency of students to acquire stores of knowledge that were useless in new situations.6 Through experiential education, however, students discover relationships among ideas, rather than passively receiving information.7 Dewey argued that discovering relationships is a wholehearted affair, linking emotions and intellect by capturing student interest and passion. Such learning is intrinsically valued because it incites students’ curiosity to address problems.8 Under Dewey’s pragmatism, the community is a laboratory for addressing problems because it provides a venue for the application of knowledge. Reflection serves as a critical component in this process because it helps students bridge knowledge incorporated from volunteer service and academic coursework.2,3 Researchers, students, and instructors need an informed inquiry exploring the intersection of service-learning and medical education. As Cook and West9 suggested, systematic reviews that synthesize the strengths and weaknesses of research are needed for the field of medical education. Currently, the literature lacks clarity regarding the sources of heterogeneity among service-learning programs in medical schools.1,2 The purpose of this inquiry was to identify the
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sources of heterogeneity among service-learning programs in medical education.1 Three questions were posed to guide this systematic review of the literature: 1. How has service-learning been used/implemented in medical education? 2. What structural elements underpin different servicelearning programs? 3. What recommendations can be made about future training and research?
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METHODS Search Strategy Queries on the keywords “service-learning,” “service learning,” “medicine,” “medical education,” and “medical school” were submitted via PubMed, Google Scholar, the library function on the National Service-Learning Clearinghouse website, and various academic search engines available through our university library (e.g., ProQuest, EBSCOHost, ERIC/CSA, JSTOR, Education Source, Dissertation Abstracts). When the term “service-learning” was replaced with “community service” or “experiential education,” more articles were available. However, service-learning is unique among engagement and experiential education models in that reflection is a central, required pedagogical component in service-learning and not necessarily featured in the other forms of engagement and experiential learning.1–3 Articles that named other forms of community engagement and/or associated pedagogies were, therefore, not applicable to the study.2,3,10
Inclusion Criteria A method was developed for screening articles for inclusion or exclusion at two separate stages. At the first stage, the title, abstract, and keywords of each article were reviewed for terminology related to service-learning and Doctor of Medicine or Doctor of Osteopathic Medicine programs. Then, the second stage of screening included an independent full-text review of each article according to the aforementioned criteria. Articles were excluded at either of the two stages if they included other types of experiential education (e.g., community service, community-based learning, and community-based research) and/or other healthcare disciplines (e.g., dentistry, nursing, or physician assistant). Articles meeting the inclusion criteria, at both stages, were included in the data abstraction and analysis steps. The criterion of reflection was not explicitly part of the inclusion and exclusion criteria because we assumed reflection was part of the service-learning courses even if it was not reported in the studies reviewed. The use of the term “service-learning,” without reflection, is otherwise misappropriated.
Trial Flow The initial literature search identified 63 manuscripts for review, of which 47 were eligible for full screening after Stage 1. Figure 1 shows a flow diagram of the manuscript selection process.11 After Stage 2, 32 manuscripts spanning the years 1998 to 2012 were included for the final analysis (see Figure 2). The interrater agreement of the article selection process was 100%. The high level of interrater agreement may be attributable to the straightforward, and concrete, selection criterion used. In addition, the two-stage screening allowed for collaboration to refine and clarify the selection criterion iteratively. The 32 articles included 20 empirical articles, four theoretical/conceptual articles, three review articles, one monograph, one capstone report, one editorial, and two dissertations.
Data Abstraction Qualitative and quantitative data were abstracted from each article and structured into a chart. The data were organized in the chart according to the following categories: type of article, author(s), objective(s), context, methods, outcomes, limitations, and recommendations for further research. The data from the chart were then used for conducting a thematic analysis.
Thematic Analysis Recurring themes and subthemes based on the data from the chart were identified through focused and selective coding. Focused coding permitted a refining of categories and connections between concepts.12 New categories within each theme were developed, obliging the rereading of each text. Then, the last stage of coding was selective coding;13 here, subcategories of each theme were identified. Overall, the coding process resulted in the identification of seven themes: (a) geographic location and setting, (b) program design, (c) funding, (d) participation, (e) program implementation, (f) assessments, and (g) student outcomes.
RESULTS Geographic Location and Setting The geographic representation of publications about servicelearning reflected a concentration of programs in the United States14–25 (80%), but with an emerging trend in Canada26 (6.7%), Singapore27 (6.7%), and Taiwan28 (6.7%). Among these locations existed a within-location tendency for service-learning implementation in urban (73%)14–23,27 as opposed to rural settings (13%).24,26 An exemplary service-learning model in Canada exposed students to a geographic triad of experiences (i.e., urban, rural, international) while integrating a foreign language
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FIG. 1.
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Flow diagram illustrating the manuscript selection process.
component.26 Service-learning was also implemented to address community needs after natural disasters (13%).25,28
Program Design Service-learning opportunities for students included elective-based (33%)14,17,18,21,25,27,29,30 and selection-based programs (37.5%).17,18,20,22,24,26,30–32 Elective-based courses are for students interested in participating in an optional service-
FIG. 2. Distribution of service-learning and medical education articles from 1998 to 2012.
learning activity to earn elective credit, whereas other students (perhaps in the same year of medical school) are free to enroll in non-service-learning electives. Another type of servicelearning course was selection-based. Selection-based courses are for students that desire to participate in service-learning but must first apply and be selected; there are often more applications submitted than available spots. Selection-based service-learning courses are often based on student merit. The limitation regarding self-selection of students into servicelearning was that students who participated often had an altruistic predisposition to provide service.30,33 An alternative approach to student-chosen participation in service-learning was requisite-based programs (29%).15,16,19,23,28,30,34 All students are required to enroll in requisite-based service-learning courses, which often are linked to the core medical school curriculum. Packet et al.30 suggested that students who volunteered and were assigned self-reported positive outcomes, but the assigned students returned to provide further service in the community. The long-term benefits for medical schools adopting requisitebased service-learning as part of their core curriculum was that service-learning projects could be sustained through a renewable pool of students each year. Also, students had an opportunity to experience the altruistic benefits of service that they may not have otherwise experienced.14,16,35
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Funding Funding was a main limitation to implementing and sustaining service-learning.13,29 Funding was provided from institutions (53%)19,21,24,25,27–30 or externally through grants (46.7%).14–16,20,23,31,34 The availability of funding impacted the functionality of the service-learning programs by placing constraints on resources, including staff, space, and location.30 Ironically, McNeal and Buckner20 found student teams that submitted proposals for minigrant funding frequently spent less than their awarded funds, which ranged from $100 to $200. Organizing home-based service-learning projects, rather than clinic based, was a way to alleviate the funding limitation. A key goal of home-based service-learning was for students to understand the determinants of health in patients’ home settings.36 Thus, students can bypass intermediary organizations that may misrepresent community needs.28 Based on research on a Singapore service-learning program designed to expose medical students to the health determinants of both homebased and clinic-based settings, Wee et al. suggested that home-based service-learning had significantly greater effects for both students and patients, in part, because students spent more time with fewer clients in their homes.24 Veronesi and Gunderman37 reported that from 2004 to 2012, an annual service-learning music concert enabled $560,000 to be raised for a children’s hospital. This study is an example of how a sustained service-learning program can generate its own funding while benefiting the community. Sustained service-learning also allows new students to have an opportunity to build on existing service activities to minimize the resources and costs for program preparation, startup, implementation, and maintainance.38 Participation Medical students in Years 1 (46%)14–23,26,31,33 and 2 (21%)16,20,25,26,33,34 often engaged in nonclinical servicelearning,14–23,25,26,31,33,34 whereas students in Years 3 (17.8%)20,24,30,31,34 and 4 (14%)20,24,31,34 often took part in clinical service-learning.20,24,30,31,34 Several service-learning programs occurred during the summer, or over multiple years.16,20,24,26,29,31,34 There was a tendency for service-learning to be offered to students entering medical school, so that these students could carry a community-based perspective throughout their medical education.16 Brush39 linked the degree of service-learning participation to students’ performance in medical school. Their findings suggested that student performance was affected by the level of student involvement in service-learning. Students in the lower quartiles (i.e., 33%) and higher quartiles (i.e., 99%) of class rank were less likely to engage in service-learning, whereas students in the middle quartiles (i.e., 66%) of class rank were more likely to participate in service-learning.39
Program Implementation Cene, Peek, Jacobs, and Horowitz40 developed an algorithm that categorized three types of service-learning programs. Educational/training programs (52%) included the implementation of health behavior interventions in communities14,15,17,20,23,24,29,31 and local K-12 schools.16,19,21,33,34 These programs addressed issues such as diet, exercise, impact of health decisions, stress and relaxation,14 sexual health,15 self-esteem,16 drug and alcohol addiction,33 and shelter life.30 Clinical-based programs (24%) included service-learning activities in Alzheimer patient care,18,29 prenatal care,22 and general clinic-based care.16,25,30 Last, medical schools implemented service-learning activities within the social justice and philanthropic paradigms (24%), including health-community advocacy,17,31 community outreach,25,30,31 and fund-raising.16 Two methods for determining the most appropriate servicelearning activities for a community included needs-based assessments,14,15,20,24,28,31 which focused on the deficits of the community, and assets-based assessments,33,34 which focused on leveraging community resources to address community needs. Regardless, relying on indirect assessments of the community may misguide service-learning activities. For example, during the mobilization of a service-learning program to a disaster area, medical school faculty received evaluations of community needs from disaster relief organizations. Rather than reflecting the needs of the community, these evaluations reflected the needs of the relief organization.28 Assessment of Service-Learning Qualitative and quantitative assessments were used to evaluate the effectiveness of service-learning and place the impact of outcomes in context.38 Written reflections were the most frequented assessment method (37%).14,15,17,18,23,25,26,28,30,33 Reflection occurred before, during, and after service-learning courses. Reflection activities included written reflection by students and group discussions among students, instructors, and community members.28 Quantitative assessments were aimed at measuring students’ professional/academic knowledge through the use of pre-/postspecialty tests or board exams (37%).8,22,23 Assessed topics included Alzheimer’s patients, prenatal care, and use of a genogram tool. Student involvement and learning were also evaluated by student projects,23,31,34 attendance,15 interviews,34 questionnaires, (26%)16,17,19,20,22,25,30,31,33 service hour documentation,16 and poster presentations.20,24 Questionnaires (33%),23,33 interviews (50%),14,33,34 and behavioral tests (17%)21 were used to measure communityperceived benefits of service-learning projects. There was limited research on the assessment of faculty involvement in service-learning activities. Although available research noted end-of-course evaluations were used to assess faculty effectiveness.3,33
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Student Outcomes Table 1 shows the themes for three categories of outcomes: (a) intra-/interpersonal skills, (b) academic knowledge and professional skills, and (c) civic engagement and social responsibility. Outcomes were culled from both objective and subjective measures. Objectively measured outcomes (16%), for example, included board shelf exams and performance tasks. The majority of outcomes (84%) were drawn from
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subjective assessments, most commonly service-learners’ selfreported responses to reflections and open-ended questionnaires. Intra-/interpersonal skills. Student reports via reflections and questionnaires evidenced the development of intra-/interpersonal skills (25%).14,15,23,25,27,29 Positive outcomes related to leadership, teamwork, collaboration, communication skills, and comfort in working with people from diverse backgrounds
Table 1 Outcome themes from service-learning in medical education Intra-/Interpersonal skills
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Teamwork and Collaboration Leadership Communication Diversity
Improved teamwork skills and functioning23,24,28 Developed community partner collaboration14, Increased likelihood to take leadership roles27 Developed leadership skills28 Improved personal communication with diverse patients14,16,18,24,27–28 Increased compassion, respect, and comfort for underserved16,29
Academic and Professional Skills Clinical Skills and Subject-Specific Knowledge
Problem Analysis and Critical Thinking Self-confidence and Efficacy
Physician Role and Working Environment/ Specialty
Understanding of Public Health Determinants and Policy
Enacted behavioral interventions/health education14–17,19,20,21,23,26,31,33,34 Learned clinical skills of dementia and Alzheimer’s,18 PPD testing for TB, Blood Pressure (BP) readings,16,22 and prenatal care22 Increased knowledge: disease management24 and sexual education14,21 Identified community needs14,19,26,28,31 and assets33,34 Need to develop students’ critical thinking27 Increased comfort using health-related technology26,41 Increased teaching and presentation skills19,21 Less confident providing care alone27 Played a meaningful role in childrens’ lives16 Increased importance of patient-physician relationships25 Mixed decisions regarding professional specialty choice25,30 Increased likelihood of working with geriatric patients18 Increased understanding of rural resources and medicine26 Developed multicultural health understanding25 Understanding of legal issues and bureaucratic barriers30 Awareness of home-based factors/social determinants of health20,23–25,28 Recognized challenges faced by community organizations28 Understand how communities cope with natural disasters28 Understand factors affecting Alzheimer’s patients18
Civic Engagement and Social Responsibility Social Justice and Support for Community
Increased need for social justice for underserved communities21,25,27,30 Increased service hours beyond course requirment14,16,30 Recognized need to change community living habits25 Increased understanding of health disparities that can be addressed by interventions, community partnerships, and policy/legislative measures20
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by showing compassion and respect for members from an underserved community.14,16,18,20,25,27–29 Students also reported working with each other and community members when designing, developing, and implementing service-learning activities.20,25,28 Academic knowledge and professional skills. Servicelearning participation also evidenced an increase in academics and professional skills (60.05%), as determined by both student self-reports and validated exams and preceptor feedback after structured clinical observations. Objectively measured outcomes evidenced improved clinical skills and subject-specific knowledge.15,16,18,21,22,27 Student reports via reflections and questionnaires noted positive outcomes related to analyzing problems,14,15,19,24,25,31,33,34 self-confidence/self-efficacy,15,16,19,21,24,28,41 understandings the roles and responsibilities of physicians18,24,26,29,30 and the determinants of health.18,20,23,25–27,29,30 Student reports indicated mixed impact on specialty choice28 and no change in critical thinking.28 Civic engagement and social responsibility. The third theme identified was civic engagement and social responsibility (14%). For example, service-learners’ reflections and course open-ended questionnaire responses specifically mentioned their development of a social justice framework, 21,26,28,29,30 including awareness of the needs to resolve health disparities present in poor communities and recognition of the role of policy in community health interventions.20,26 Objective documentation of service hours suggested that students without a predisposition to volunteer documented hours in excess of the minimum hours required and continued their service after completing the required course.14,16,30 DISCUSSION Our systematic review of the literature on service-learning in medical education suggested that service-learning has been integrated into elective, selective, and required programs; basic science courses; and clinical rotations, with favorable objective and self-reported outcomes in terms of student learning and community impact within each configuration. Integrating mandatory service-learning during the 1st year of medical school appears beneficial. A community-based pedagogy of engagement can support students’ hands-on experiences and help build their mental schema to scaffold future concepts. Therefore, required service-learning programs offering inclusive choice provides an opportunity for all students to participate while also allowing them the choice to select/create their own service-learning activity, which is in alignment with the course objectives. Unfortunately, faculty involvement16,28,35 and funding25 remain interrelated barriers to implementing mandatory service-learning in medical education. Faculty may benefit from time release to support service-learning design, space to meet with students and community members, or recognition in the
form of awards, promotions, and tenure policies. The need for funding can be reduced by students who find their own service-learning placements and take responsibility for planning, decision making, problem solving, and assessing their learning.42 Another way to reduce the need for funding is to utilize home-based service-learning where students spend individualized time with patients.27 Last, philanthropic fundraising can create self-sustainable service-learning programs.20 A goal is for students and faculty to engage in “service” linked to course objectives. Service in this review was categorized into direct, indirect, advocacy, and philanthropic activities. Research was peripheral when present. Therefore, students may benefit from opportunities to design, implement, and analyze projects, either under the auspices of a required research program or as part of an independent elective. A value-added element to a research project is the opportunity for students to present their findings to the community. Student presentations may show the impact of service on the community while also providing recommendations for action. An open dialogue and stakeholder shared governance about the plans for action are key to successful and sustainable servicelearning, as well as healthy campus–community partnerships. A triad of settings—urban, rural, and international—can extend campus–community partnership opportunities and expose students to the unique health needs of diverse populations.26 Service-learning in the urban setting currently predominates, most likely because of the proximity of medical programs to urban populations, which are densely populated, are accessible, and provide diverse pathologies to study. Also, urban settings more readily provide opportunities for university–community partnerships due to nonprofit service organizations’ locations close to large populations. Service-learning in rural, natural disaster, and international settings was limited; thus, programs should expand beyond adjacent urban locations. Students engaging in service-learning in rural and natural disaster areas may gain an understanding of what it is like to work with limited resources; students who engage in international service-learning can learn ways to overcome language barriers and learn new languages while having the opportunity to develop their global citizenship, cross-cultural awareness, and cosmopolitanism. Overall, reflection, as a central component of service-learning, is the conduit between volunteer service, academic coursework, and civic intentions—the glue holding service and learning together.43 Reflection activities should be continuous (i.e., before, during, after), connected to academic and real-life needs (i.e., learning objectives), challenging to prompt critical thinking, contextualized within the course and service setting, and involve communication with all relevant members.2 Reflection complements quantifiable measurements.27,28 However, attempts to quantify outcomes as a trade-off for reflection is cautioned. Sole reliance on quantitative assessments limits the benefits of service-learning for students and community members—indeed, innovation in general stems from
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unexpected learning outcomes.44 The following barriers to reflection should be avoided: reflection as an extra activity, end-of-the-semester reflection, reflection as a log of events, and students not taking a critical stance.
CONCLUSIONS AND FUTURE INQUIRIES This systematic review was framed by the need to synthesize published literature related to the heterogeneity of service-learning programs in medical schools.1,9 The significance of this study was supported by the recent passage of the Affordable Care Act. Also relevant internationally, servicelearning may be used to reform medical curricula to match the reconfiguring needs of the healthcare system and to equip future physicians with an understanding of the health needs of diverse communities. However, opportunities for future research exist and need to be explored. Six recommendations for future inquiry are offered next: 1. Increased rigor in service-learning research in general is necessary. Therefore, future examinations of servicelearning in medical education should make purposeful attempts to address previous methodological limitations. Increased validity of findings will depend on the use of established cognitive and behavioral assessments (e.g., Compendium of Assessment & Research Tools, Project STAR, The Measure of Service Learning45) instead of relying on self-reporting mechanisms. However, it is important to note that because the philosophical roots of service-learning contrast with sole reliance on psychometric measurement, mixed-methodologies combining qualitative and quantitative data sources are recommended. 2. Related to the need for increased validity are self-selection and nonexperimental studies. Because electivebased service-learning courses seem to be the most popular, medical educators may design a quasi-experimental control group study between two different elective sections. This design will help verify whether outcomes are linked to the service-learning activity or to other unknown variable(s). In addition, between-group studies, between requisite and nonrequisite models, may help establish a clearer answer regarding the most effective program model for medical education. 3. One-shot studies are limited both in scope and reliability. Longitudinal, time-series studies will permit a clearer picture of the immediate and long-term impact of service-learning on students’ academic achievement, use of knowledge and skills gained, descriptions of reflection activities, choice of specialty and community of practice, demographic characteristics, perceptions of the experience, and intentions to serve when not required, particularly after medical school (e.g., provision of pro bono services).14–16
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4. To ensure reciprocity in service-learning, the impact of service-learning on the host community needs to be investigated. Initial planning should begin with community assessments of needs and/or assets to guide the research questions. Interventions, then, should be linked explicitly to curricula and community findings. These engagement activities should be focused on the host community’s health and habits, as a result of both shortterm and long-term student interventions and campuscommunity partnerships.15,16 Regression analyses may be used to link findings back to specific program structure and service activities. 5. International service-learning, typically linked to study abroad community service activities, is currently neglected in the medical education literature. Medical schools with international programs have a unique opportunity to determine if these experiences resulted in transformative learning for the participating students, or if these experiences increased students’ sense of global citizenship, cosmopolitanism, self-efficacy, and social dominance orientation. For those programs currently without international programs, unplanned service events may provide parallel opportunities for students and research. For example, natural disasters and rural and border programs create chances to engage students with the “Other,” both in population and setting. 6. Last, the field of service-learning and medical education can still benefit from descriptions of program structures and implementation steps, examples of successful institutionalization, models of sustainability, political maneuvering around faculty workload, and reflection assignments/activities that lead to impact. Further, given the interdisciplinary nature of the future health profession and service-learning’s viability as a transformative pedagogy, future research should review service-learning literature in other healthcare disciplines (e.g., dentistry, occupational and physical therapy). An understanding of service-learning in these other disciplines will assist our understanding of the convergence between other fields of healthcare and medical education.
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5. Dewey J. The child and the curriculum. Chicago, IL: University of Chicago Press, 1956. 6. Eyler J, Giles D. Where’s the learning in service-learning? San Francisco, CA: Jossey-Bass, 1999. 7. Dewey J. Democracy and education. New York, NY: Macmillan, 1916. 8. Giles D, Eyler J. The theoretical roots of service-learning in John Dewey: Toward a theory of service-learning. Michigan Journal of Community Service-learning 1994;1:77–85. 9. Cook D, West C. Conducting systematic reviews in medical education: A stepwise approach. Medical Education 2012;46:943–52. 10. Furco A. Service-learning: A balanced approach to experiential education. Expanding Boundaries: Serving and Learning 1996;1:1–6. 11. Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Annals of Internal Medicine 2009;151:264–9. 12. Charmaz K, Mitchell R. Grounded theory in ethnography. In P. Atkinson (Ed.), Handbook of ethnography (pp. 160–74). London, UK: Sage, 2001. 13. Charmaz, K. Loss of self: A fundamental form of suffering in the chronically ill. Sociology of Health & Illness 1983;5:168–95. 14. Averill N, Sallee J, Robinson J, Mcfarlin J, Montgomery A, Burkhardt G, et al. A first-year community-based service-learning elective: Design, implementation, and reflection. Teaching and Learning in Medicine 2007;19:47–54. 15. Buckner A, Ndjakani Y, Banks B, Blumenthal D. Using service-learning to teach community health: The Morehouse School of Medicine community health course. Academic Medicine 2010;85:1645–51. 16. Burrows M, Chauvin S, Lazarus C, Chehardy P. Required service-learning for medical students: Program description and student response. Teaching and Learning in Medicine 1999;11:223–31. 17. Long J, Lee R, Federico S, Battaglia C, Wong S, Earnest M. Developing leadership and advocacy skills in medical students through service-learning. Journal of Public Health Management and Practice 2011;17:369–72. 18. Jefferson A, Cantwell N, Byerly L, Morhardt D. Medical student education program in Alzheimer’s disease: The PAIRS program. BMC Medical Education 2012;12:1–8. 19. McConnell E, Clasen C, Stolfi A, Anderson D, Markert R, Jaballas E. Community service and the pediatric exam: An introduction to clinical medicine via a partnership between first year medical students and a community elementary school. Teaching and Learning in Medicine 2010;22:187–90. 20. McNeal M, Buckner A. Using mini-grants and service-learning projects to prepare students to serve underserved populations. Journal of Health Care for the Poor and Underserved 2012;23:20–6. 21. Sakai D, Fukuda M, Nip I, Kasuya R. School health education at the Queen Emma clinics: A service-learning project at the John A. Burns School of Medicine. Hawaii Medical Journal 2002;61:14–7. 22. Switzer C. Service-learning in a medical school: Psychosocial and attitudinal outcomes. Doctor of Philosophy. Pittsburgh, PA: University of Pittsburgh, 1999. 23. Waddell R, Davidson R. The role of the community in educating medical students: Initial impressions from a new program. Education for Health 2000;13:69–76. 24. Stearns J, Stearns M, Glasser M, Londo R. Illinois RMED: A comprehensive program to improve the supply of rural family physicians. Family Medicine 2000;32:17–21.
25. Steiner B, Sands R. Responding to a natural disaster with service-learning. Family Medicine 2000;32:645–9. 26. Meili R, Fuller D, Lydiate J. Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project. Medical Teacher 2011;33:659–66. 27. Wee L, Xin Y, Koh G. Doctors-to-be at the doorstep-comparing servicelearning programs in an Asian medical school. Medical Teacher 2011;33:471–8. 28. Leung K, Liu W, Wang W, Chen C. Factors affecting students’ evaluation in a community service-learning program. Advances in Health Sciences Education: Theory and Practice 2007;12:475–90. 29. Elam C, Musick D, Sauer M, Skelton J. How we implemented a servicelearning elective. Medical Teacher 2002;24:249–53. 30. Packer C, Carnell R, Tomcho P, Scott J. Development of a four-day service-learning rotation for third-year medical students. Teaching and Learning in Medicine 2010;22:224–8. 31. O’Toole T, Kathuria N, Mishra M, Schukart D. Teaching professionalism within a community context: Perspectives from a national demonstration project. Academic Medicine 2005;80:339–43. 32. Stoltenberg M, Rumas N, Parsi K. Global health and service-learning: Lessons learned at US medical schools. Medical Education Online 2012;17:1–5. 33. Elam C, Sauer M, Stratton T, Skelton J, Crocker D, Musick D. Servicelearning in the medical curriculum: Developing and evaluating an elective experience. Teaching and Learning in Medicine 2003;13:194–203. 34. Hufford L, West D, Paterniti D, Pan R. Community-based advocacy training: Applying asset-based community development in resident education. Academic Medicine 2009;84:765–70. 35. Vogel A. Advancing service-learning in health professions education: maximizing sustainability, quality, and co-leadership. Doctor of Philosophy. Baltimore, MD: Johns Hopkins University, 2009. 36. Brown R, Marcus M. Bearing witness: The political agenda of community-based service-learning. Substance Abuse 2005;26:3–4. 37. Veronesi M, Gunderman R. Perspective: The potential of student organizations for developing leadership: One school’s experience. Academic Medicine 2012;87:226–9. 38. Farr N. Service-learning curriculum evaluation and proposal. Master of Public Health. Galveston, TX: The University of Texas Medical Branch, 2010. 39. Brush D, Markert R, Lazarus C. The relationship between service-learning and medical student academic and professional outcomes. Teaching and Learning in Medicine 2006;18:9–13. 40. Cene C, Peek M, Jacobs E, Horowitz C. Community-based teaching about health disparities: Combining education, scholarship, and community service. Journal of General Internal Medicine 2009;25:130–5. 41. Lazarus C, Krane K, Bowdish B. An innovative partnership in service. Academic Medicine 2002;77:755–6. 42. Morgan W, Streb M. First do no harm: The importance of student ownership in service-learning. Metropolitan State Universities 2003;14:36–52. 43. Eyler J, Eyler J, Giles D, Schmeide A. A practitioner’s guide to reflection in service-learning. Nashville, TN: Vanderbilt University, 1996. 44. Haji F, Morin MP, Parker K. Rethinking programme evaluation in health professions education: Beyond ‘did it work?’ Medical Education 2013;47:342–51. 45. Bringle R, Phillips M, Hudson M. The measure of service learning: Research scales to assess student experiences. Washington, DC: APA, 2004.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
A Systematic Review of Service-Learning in Medical Education: 1998–2012 a
a
Trae Stewart & Zane C. Wubbena a
Department of Counseling, Leadership, Adult Education and School Psychology, Texas State University, San Marcos, Texas, USA Published online: 20 Apr 2015.
Click for updates To cite this article: Trae Stewart & Zane C. Wubbena (2015) A Systematic Review of Service-Learning in Medical Education: 1998–2012, Teaching and Learning in Medicine: An International Journal, 27:2, 115-122, DOI: 10.1080/10401334.2015.1011647 To link to this article: http://dx.doi.org/10.1080/10401334.2015.1011647
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Teaching and Learning in Medicine, 27(2), 115–122 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011647
GROUNDWORK A Systematic Review of Service-Learning in Medical Education: 1998–2012 Trae Stewart and Zane C. Wubbena
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Department of Counseling, Leadership, Adult Education and School Psychology, Texas State University, San Marcos, Texas, USA
Phenomenon: In the United States, the Affordable Care Act has increased the need for community-centered pedagogy for medical education such as service-learning, wherein students connect academic curriculum and reflections to address a community need. Yet heterogeneity among service-learning programs suggests the need for a framework to understand variations among service-learning programs in medical education. Approach: A qualitative systematic review of literature on service-learning and medical education was conducted for the period between 1998 and 2012. A two-stage inclusion criteria process resulted in articles (n D 32) on service-learning and Doctor of Medicine or Doctor of Osteopathic Medicine being included for both coding and analysis. Focused and selective coding were employed to identify recurring themes and subthemes from the literature. Findings: The findings of the qualitative thematic analysis of service-learning variation in medical education identified a total of seven themes with subthemes. The themes identified from the analysis were (a) geographic location and setting, (b) program design, (c) funding, (d) participation, (e) program implementation, (f) assessment, and (g) student outcomes. Insights: This systematic review of literature confirmed the existence of program heterogeneity among service-learning program in medical education. However, the findings of this study provide key insights into the nature of service-learning in medical education building a framework for which to organize differences among service-learning programs. A list of recommendations for future areas of inquiry is provided to guide future research. Keywords
service-learning, curriculum development, medical education, experiential learning, community service
INTRODUCTION In the United States, the emerging paradigm of population perspective healthcare recognizes that patient well-being does not exist within a vacuum, nor can it be simply condensed into a collection of signs and symptoms searchable in a database. With the passage of the Affordable Care Act, practitioner competence and preparation will be partially defined by an ability Correspondence may be sent to Trae Stewart, Texas State University, ASBS 316, 601 University Drive, San Marcos, TX 78666, USA. E-mail: [email protected]
to address the needs of an economically underserved and racially diverse population. Physicians will need to obtain a broader set of knowledge and skills, rather than focus solely on the specialized knowledge that dominates healthcare today. Issues of significance in this movement will be the reform of medical education curricula to match the reconfiguring healthcare system and the preparation of practitioners for primary-care medicine. Traditional, institution-based pedagogical models will need to transition to more communitycentered models, in which healthcare professionals will accommodate contemporary life-styles and care for the community’s health. Service-learning is a pedagogy of engagement wherein students address a genuine community need by engaging in volunteer service that is connected explicitly to the academic curriculum through structured ongoing reflections.1–3 The philosophical roots of service-learning are attributed to John Dewey, who posited that the key to learning is the interaction of knowledge and skills with experience.4,5 Dewey focused on the tendency of students to acquire stores of knowledge that were useless in new situations.6 Through experiential education, however, students discover relationships among ideas, rather than passively receiving information.7 Dewey argued that discovering relationships is a wholehearted affair, linking emotions and intellect by capturing student interest and passion. Such learning is intrinsically valued because it incites students’ curiosity to address problems.8 Under Dewey’s pragmatism, the community is a laboratory for addressing problems because it provides a venue for the application of knowledge. Reflection serves as a critical component in this process because it helps students bridge knowledge incorporated from volunteer service and academic coursework.2,3 Researchers, students, and instructors need an informed inquiry exploring the intersection of service-learning and medical education. As Cook and West9 suggested, systematic reviews that synthesize the strengths and weaknesses of research are needed for the field of medical education. Currently, the literature lacks clarity regarding the sources of heterogeneity among service-learning programs in medical schools.1,2 The purpose of this inquiry was to identify the
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sources of heterogeneity among service-learning programs in medical education.1 Three questions were posed to guide this systematic review of the literature: 1. How has service-learning been used/implemented in medical education? 2. What structural elements underpin different servicelearning programs? 3. What recommendations can be made about future training and research?
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METHODS Search Strategy Queries on the keywords “service-learning,” “service learning,” “medicine,” “medical education,” and “medical school” were submitted via PubMed, Google Scholar, the library function on the National Service-Learning Clearinghouse website, and various academic search engines available through our university library (e.g., ProQuest, EBSCOHost, ERIC/CSA, JSTOR, Education Source, Dissertation Abstracts). When the term “service-learning” was replaced with “community service” or “experiential education,” more articles were available. However, service-learning is unique among engagement and experiential education models in that reflection is a central, required pedagogical component in service-learning and not necessarily featured in the other forms of engagement and experiential learning.1–3 Articles that named other forms of community engagement and/or associated pedagogies were, therefore, not applicable to the study.2,3,10
Inclusion Criteria A method was developed for screening articles for inclusion or exclusion at two separate stages. At the first stage, the title, abstract, and keywords of each article were reviewed for terminology related to service-learning and Doctor of Medicine or Doctor of Osteopathic Medicine programs. Then, the second stage of screening included an independent full-text review of each article according to the aforementioned criteria. Articles were excluded at either of the two stages if they included other types of experiential education (e.g., community service, community-based learning, and community-based research) and/or other healthcare disciplines (e.g., dentistry, nursing, or physician assistant). Articles meeting the inclusion criteria, at both stages, were included in the data abstraction and analysis steps. The criterion of reflection was not explicitly part of the inclusion and exclusion criteria because we assumed reflection was part of the service-learning courses even if it was not reported in the studies reviewed. The use of the term “service-learning,” without reflection, is otherwise misappropriated.
Trial Flow The initial literature search identified 63 manuscripts for review, of which 47 were eligible for full screening after Stage 1. Figure 1 shows a flow diagram of the manuscript selection process.11 After Stage 2, 32 manuscripts spanning the years 1998 to 2012 were included for the final analysis (see Figure 2). The interrater agreement of the article selection process was 100%. The high level of interrater agreement may be attributable to the straightforward, and concrete, selection criterion used. In addition, the two-stage screening allowed for collaboration to refine and clarify the selection criterion iteratively. The 32 articles included 20 empirical articles, four theoretical/conceptual articles, three review articles, one monograph, one capstone report, one editorial, and two dissertations.
Data Abstraction Qualitative and quantitative data were abstracted from each article and structured into a chart. The data were organized in the chart according to the following categories: type of article, author(s), objective(s), context, methods, outcomes, limitations, and recommendations for further research. The data from the chart were then used for conducting a thematic analysis.
Thematic Analysis Recurring themes and subthemes based on the data from the chart were identified through focused and selective coding. Focused coding permitted a refining of categories and connections between concepts.12 New categories within each theme were developed, obliging the rereading of each text. Then, the last stage of coding was selective coding;13 here, subcategories of each theme were identified. Overall, the coding process resulted in the identification of seven themes: (a) geographic location and setting, (b) program design, (c) funding, (d) participation, (e) program implementation, (f) assessments, and (g) student outcomes.
RESULTS Geographic Location and Setting The geographic representation of publications about servicelearning reflected a concentration of programs in the United States14–25 (80%), but with an emerging trend in Canada26 (6.7%), Singapore27 (6.7%), and Taiwan28 (6.7%). Among these locations existed a within-location tendency for service-learning implementation in urban (73%)14–23,27 as opposed to rural settings (13%).24,26 An exemplary service-learning model in Canada exposed students to a geographic triad of experiences (i.e., urban, rural, international) while integrating a foreign language
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FIG. 1.
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Flow diagram illustrating the manuscript selection process.
component.26 Service-learning was also implemented to address community needs after natural disasters (13%).25,28
Program Design Service-learning opportunities for students included elective-based (33%)14,17,18,21,25,27,29,30 and selection-based programs (37.5%).17,18,20,22,24,26,30–32 Elective-based courses are for students interested in participating in an optional service-
FIG. 2. Distribution of service-learning and medical education articles from 1998 to 2012.
learning activity to earn elective credit, whereas other students (perhaps in the same year of medical school) are free to enroll in non-service-learning electives. Another type of servicelearning course was selection-based. Selection-based courses are for students that desire to participate in service-learning but must first apply and be selected; there are often more applications submitted than available spots. Selection-based service-learning courses are often based on student merit. The limitation regarding self-selection of students into servicelearning was that students who participated often had an altruistic predisposition to provide service.30,33 An alternative approach to student-chosen participation in service-learning was requisite-based programs (29%).15,16,19,23,28,30,34 All students are required to enroll in requisite-based service-learning courses, which often are linked to the core medical school curriculum. Packet et al.30 suggested that students who volunteered and were assigned self-reported positive outcomes, but the assigned students returned to provide further service in the community. The long-term benefits for medical schools adopting requisitebased service-learning as part of their core curriculum was that service-learning projects could be sustained through a renewable pool of students each year. Also, students had an opportunity to experience the altruistic benefits of service that they may not have otherwise experienced.14,16,35
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Funding Funding was a main limitation to implementing and sustaining service-learning.13,29 Funding was provided from institutions (53%)19,21,24,25,27–30 or externally through grants (46.7%).14–16,20,23,31,34 The availability of funding impacted the functionality of the service-learning programs by placing constraints on resources, including staff, space, and location.30 Ironically, McNeal and Buckner20 found student teams that submitted proposals for minigrant funding frequently spent less than their awarded funds, which ranged from $100 to $200. Organizing home-based service-learning projects, rather than clinic based, was a way to alleviate the funding limitation. A key goal of home-based service-learning was for students to understand the determinants of health in patients’ home settings.36 Thus, students can bypass intermediary organizations that may misrepresent community needs.28 Based on research on a Singapore service-learning program designed to expose medical students to the health determinants of both homebased and clinic-based settings, Wee et al. suggested that home-based service-learning had significantly greater effects for both students and patients, in part, because students spent more time with fewer clients in their homes.24 Veronesi and Gunderman37 reported that from 2004 to 2012, an annual service-learning music concert enabled $560,000 to be raised for a children’s hospital. This study is an example of how a sustained service-learning program can generate its own funding while benefiting the community. Sustained service-learning also allows new students to have an opportunity to build on existing service activities to minimize the resources and costs for program preparation, startup, implementation, and maintainance.38 Participation Medical students in Years 1 (46%)14–23,26,31,33 and 2 (21%)16,20,25,26,33,34 often engaged in nonclinical servicelearning,14–23,25,26,31,33,34 whereas students in Years 3 (17.8%)20,24,30,31,34 and 4 (14%)20,24,31,34 often took part in clinical service-learning.20,24,30,31,34 Several service-learning programs occurred during the summer, or over multiple years.16,20,24,26,29,31,34 There was a tendency for service-learning to be offered to students entering medical school, so that these students could carry a community-based perspective throughout their medical education.16 Brush39 linked the degree of service-learning participation to students’ performance in medical school. Their findings suggested that student performance was affected by the level of student involvement in service-learning. Students in the lower quartiles (i.e., 33%) and higher quartiles (i.e., 99%) of class rank were less likely to engage in service-learning, whereas students in the middle quartiles (i.e., 66%) of class rank were more likely to participate in service-learning.39
Program Implementation Cene, Peek, Jacobs, and Horowitz40 developed an algorithm that categorized three types of service-learning programs. Educational/training programs (52%) included the implementation of health behavior interventions in communities14,15,17,20,23,24,29,31 and local K-12 schools.16,19,21,33,34 These programs addressed issues such as diet, exercise, impact of health decisions, stress and relaxation,14 sexual health,15 self-esteem,16 drug and alcohol addiction,33 and shelter life.30 Clinical-based programs (24%) included service-learning activities in Alzheimer patient care,18,29 prenatal care,22 and general clinic-based care.16,25,30 Last, medical schools implemented service-learning activities within the social justice and philanthropic paradigms (24%), including health-community advocacy,17,31 community outreach,25,30,31 and fund-raising.16 Two methods for determining the most appropriate servicelearning activities for a community included needs-based assessments,14,15,20,24,28,31 which focused on the deficits of the community, and assets-based assessments,33,34 which focused on leveraging community resources to address community needs. Regardless, relying on indirect assessments of the community may misguide service-learning activities. For example, during the mobilization of a service-learning program to a disaster area, medical school faculty received evaluations of community needs from disaster relief organizations. Rather than reflecting the needs of the community, these evaluations reflected the needs of the relief organization.28 Assessment of Service-Learning Qualitative and quantitative assessments were used to evaluate the effectiveness of service-learning and place the impact of outcomes in context.38 Written reflections were the most frequented assessment method (37%).14,15,17,18,23,25,26,28,30,33 Reflection occurred before, during, and after service-learning courses. Reflection activities included written reflection by students and group discussions among students, instructors, and community members.28 Quantitative assessments were aimed at measuring students’ professional/academic knowledge through the use of pre-/postspecialty tests or board exams (37%).8,22,23 Assessed topics included Alzheimer’s patients, prenatal care, and use of a genogram tool. Student involvement and learning were also evaluated by student projects,23,31,34 attendance,15 interviews,34 questionnaires, (26%)16,17,19,20,22,25,30,31,33 service hour documentation,16 and poster presentations.20,24 Questionnaires (33%),23,33 interviews (50%),14,33,34 and behavioral tests (17%)21 were used to measure communityperceived benefits of service-learning projects. There was limited research on the assessment of faculty involvement in service-learning activities. Although available research noted end-of-course evaluations were used to assess faculty effectiveness.3,33
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Student Outcomes Table 1 shows the themes for three categories of outcomes: (a) intra-/interpersonal skills, (b) academic knowledge and professional skills, and (c) civic engagement and social responsibility. Outcomes were culled from both objective and subjective measures. Objectively measured outcomes (16%), for example, included board shelf exams and performance tasks. The majority of outcomes (84%) were drawn from
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subjective assessments, most commonly service-learners’ selfreported responses to reflections and open-ended questionnaires. Intra-/interpersonal skills. Student reports via reflections and questionnaires evidenced the development of intra-/interpersonal skills (25%).14,15,23,25,27,29 Positive outcomes related to leadership, teamwork, collaboration, communication skills, and comfort in working with people from diverse backgrounds
Table 1 Outcome themes from service-learning in medical education Intra-/Interpersonal skills
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Teamwork and Collaboration Leadership Communication Diversity
Improved teamwork skills and functioning23,24,28 Developed community partner collaboration14, Increased likelihood to take leadership roles27 Developed leadership skills28 Improved personal communication with diverse patients14,16,18,24,27–28 Increased compassion, respect, and comfort for underserved16,29
Academic and Professional Skills Clinical Skills and Subject-Specific Knowledge
Problem Analysis and Critical Thinking Self-confidence and Efficacy
Physician Role and Working Environment/ Specialty
Understanding of Public Health Determinants and Policy
Enacted behavioral interventions/health education14–17,19,20,21,23,26,31,33,34 Learned clinical skills of dementia and Alzheimer’s,18 PPD testing for TB, Blood Pressure (BP) readings,16,22 and prenatal care22 Increased knowledge: disease management24 and sexual education14,21 Identified community needs14,19,26,28,31 and assets33,34 Need to develop students’ critical thinking27 Increased comfort using health-related technology26,41 Increased teaching and presentation skills19,21 Less confident providing care alone27 Played a meaningful role in childrens’ lives16 Increased importance of patient-physician relationships25 Mixed decisions regarding professional specialty choice25,30 Increased likelihood of working with geriatric patients18 Increased understanding of rural resources and medicine26 Developed multicultural health understanding25 Understanding of legal issues and bureaucratic barriers30 Awareness of home-based factors/social determinants of health20,23–25,28 Recognized challenges faced by community organizations28 Understand how communities cope with natural disasters28 Understand factors affecting Alzheimer’s patients18
Civic Engagement and Social Responsibility Social Justice and Support for Community
Increased need for social justice for underserved communities21,25,27,30 Increased service hours beyond course requirment14,16,30 Recognized need to change community living habits25 Increased understanding of health disparities that can be addressed by interventions, community partnerships, and policy/legislative measures20
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by showing compassion and respect for members from an underserved community.14,16,18,20,25,27–29 Students also reported working with each other and community members when designing, developing, and implementing service-learning activities.20,25,28 Academic knowledge and professional skills. Servicelearning participation also evidenced an increase in academics and professional skills (60.05%), as determined by both student self-reports and validated exams and preceptor feedback after structured clinical observations. Objectively measured outcomes evidenced improved clinical skills and subject-specific knowledge.15,16,18,21,22,27 Student reports via reflections and questionnaires noted positive outcomes related to analyzing problems,14,15,19,24,25,31,33,34 self-confidence/self-efficacy,15,16,19,21,24,28,41 understandings the roles and responsibilities of physicians18,24,26,29,30 and the determinants of health.18,20,23,25–27,29,30 Student reports indicated mixed impact on specialty choice28 and no change in critical thinking.28 Civic engagement and social responsibility. The third theme identified was civic engagement and social responsibility (14%). For example, service-learners’ reflections and course open-ended questionnaire responses specifically mentioned their development of a social justice framework, 21,26,28,29,30 including awareness of the needs to resolve health disparities present in poor communities and recognition of the role of policy in community health interventions.20,26 Objective documentation of service hours suggested that students without a predisposition to volunteer documented hours in excess of the minimum hours required and continued their service after completing the required course.14,16,30 DISCUSSION Our systematic review of the literature on service-learning in medical education suggested that service-learning has been integrated into elective, selective, and required programs; basic science courses; and clinical rotations, with favorable objective and self-reported outcomes in terms of student learning and community impact within each configuration. Integrating mandatory service-learning during the 1st year of medical school appears beneficial. A community-based pedagogy of engagement can support students’ hands-on experiences and help build their mental schema to scaffold future concepts. Therefore, required service-learning programs offering inclusive choice provides an opportunity for all students to participate while also allowing them the choice to select/create their own service-learning activity, which is in alignment with the course objectives. Unfortunately, faculty involvement16,28,35 and funding25 remain interrelated barriers to implementing mandatory service-learning in medical education. Faculty may benefit from time release to support service-learning design, space to meet with students and community members, or recognition in the
form of awards, promotions, and tenure policies. The need for funding can be reduced by students who find their own service-learning placements and take responsibility for planning, decision making, problem solving, and assessing their learning.42 Another way to reduce the need for funding is to utilize home-based service-learning where students spend individualized time with patients.27 Last, philanthropic fundraising can create self-sustainable service-learning programs.20 A goal is for students and faculty to engage in “service” linked to course objectives. Service in this review was categorized into direct, indirect, advocacy, and philanthropic activities. Research was peripheral when present. Therefore, students may benefit from opportunities to design, implement, and analyze projects, either under the auspices of a required research program or as part of an independent elective. A value-added element to a research project is the opportunity for students to present their findings to the community. Student presentations may show the impact of service on the community while also providing recommendations for action. An open dialogue and stakeholder shared governance about the plans for action are key to successful and sustainable servicelearning, as well as healthy campus–community partnerships. A triad of settings—urban, rural, and international—can extend campus–community partnership opportunities and expose students to the unique health needs of diverse populations.26 Service-learning in the urban setting currently predominates, most likely because of the proximity of medical programs to urban populations, which are densely populated, are accessible, and provide diverse pathologies to study. Also, urban settings more readily provide opportunities for university–community partnerships due to nonprofit service organizations’ locations close to large populations. Service-learning in rural, natural disaster, and international settings was limited; thus, programs should expand beyond adjacent urban locations. Students engaging in service-learning in rural and natural disaster areas may gain an understanding of what it is like to work with limited resources; students who engage in international service-learning can learn ways to overcome language barriers and learn new languages while having the opportunity to develop their global citizenship, cross-cultural awareness, and cosmopolitanism. Overall, reflection, as a central component of service-learning, is the conduit between volunteer service, academic coursework, and civic intentions—the glue holding service and learning together.43 Reflection activities should be continuous (i.e., before, during, after), connected to academic and real-life needs (i.e., learning objectives), challenging to prompt critical thinking, contextualized within the course and service setting, and involve communication with all relevant members.2 Reflection complements quantifiable measurements.27,28 However, attempts to quantify outcomes as a trade-off for reflection is cautioned. Sole reliance on quantitative assessments limits the benefits of service-learning for students and community members—indeed, innovation in general stems from
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unexpected learning outcomes.44 The following barriers to reflection should be avoided: reflection as an extra activity, end-of-the-semester reflection, reflection as a log of events, and students not taking a critical stance.
CONCLUSIONS AND FUTURE INQUIRIES This systematic review was framed by the need to synthesize published literature related to the heterogeneity of service-learning programs in medical schools.1,9 The significance of this study was supported by the recent passage of the Affordable Care Act. Also relevant internationally, servicelearning may be used to reform medical curricula to match the reconfiguring needs of the healthcare system and to equip future physicians with an understanding of the health needs of diverse communities. However, opportunities for future research exist and need to be explored. Six recommendations for future inquiry are offered next: 1. Increased rigor in service-learning research in general is necessary. Therefore, future examinations of servicelearning in medical education should make purposeful attempts to address previous methodological limitations. Increased validity of findings will depend on the use of established cognitive and behavioral assessments (e.g., Compendium of Assessment & Research Tools, Project STAR, The Measure of Service Learning45) instead of relying on self-reporting mechanisms. However, it is important to note that because the philosophical roots of service-learning contrast with sole reliance on psychometric measurement, mixed-methodologies combining qualitative and quantitative data sources are recommended. 2. Related to the need for increased validity are self-selection and nonexperimental studies. Because electivebased service-learning courses seem to be the most popular, medical educators may design a quasi-experimental control group study between two different elective sections. This design will help verify whether outcomes are linked to the service-learning activity or to other unknown variable(s). In addition, between-group studies, between requisite and nonrequisite models, may help establish a clearer answer regarding the most effective program model for medical education. 3. One-shot studies are limited both in scope and reliability. Longitudinal, time-series studies will permit a clearer picture of the immediate and long-term impact of service-learning on students’ academic achievement, use of knowledge and skills gained, descriptions of reflection activities, choice of specialty and community of practice, demographic characteristics, perceptions of the experience, and intentions to serve when not required, particularly after medical school (e.g., provision of pro bono services).14–16
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4. To ensure reciprocity in service-learning, the impact of service-learning on the host community needs to be investigated. Initial planning should begin with community assessments of needs and/or assets to guide the research questions. Interventions, then, should be linked explicitly to curricula and community findings. These engagement activities should be focused on the host community’s health and habits, as a result of both shortterm and long-term student interventions and campuscommunity partnerships.15,16 Regression analyses may be used to link findings back to specific program structure and service activities. 5. International service-learning, typically linked to study abroad community service activities, is currently neglected in the medical education literature. Medical schools with international programs have a unique opportunity to determine if these experiences resulted in transformative learning for the participating students, or if these experiences increased students’ sense of global citizenship, cosmopolitanism, self-efficacy, and social dominance orientation. For those programs currently without international programs, unplanned service events may provide parallel opportunities for students and research. For example, natural disasters and rural and border programs create chances to engage students with the “Other,” both in population and setting. 6. Last, the field of service-learning and medical education can still benefit from descriptions of program structures and implementation steps, examples of successful institutionalization, models of sustainability, political maneuvering around faculty workload, and reflection assignments/activities that lead to impact. Further, given the interdisciplinary nature of the future health profession and service-learning’s viability as a transformative pedagogy, future research should review service-learning literature in other healthcare disciplines (e.g., dentistry, occupational and physical therapy). An understanding of service-learning in these other disciplines will assist our understanding of the convergence between other fields of healthcare and medical education.
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