Leveraging Community Psychology Competencies to Advance Medical Education and Improve Obesity Healthcare

In this manuscript, the author draws from her experiences on a South Carolina educationalresearch obesity initiative to describe the important value that community psychology (CP) brings to medical education and healthcare organizations. The article describes the set of CP competencies that were most influential to the initiative and discuss how those competencies shaped the course of the initiative. More specifically, the author discusses: 1) how the use of a participatory action research approach helped ground project efforts in the practical realities of the participating practices, 2) how the team developed sociocultural and cross-cultural competence to better understand the complexity of weight-related issues in healthcare, and 3) how using an ecological perspective facilitated practice-wide improvements in obesity management. Through a series of examples, the article highlights specific ways medical education organizations can leverage community psychology competencies to move beyond traditional continuing medical education (CME) methods. In her mid-50s, Brittany woke up one morning and noticed a dull pain in her left knee. She shrugged it off and continued her weekday routine of getting ready for work. Over the course of six months, the knee pain gradually intensified. Brittany began avoid stairs and hills, which seemed to make her knees hurt even more. Already obese and self-conscious about her weight, Brittany noticed that she had gained eight pounds since her left knee started to hurt. After talking with a friend about the knee pain and her weight gain, she decided to schedule an appointment with her primary care doctor. Brittany’s time in the waiting room was longer than she would have liked; however, her appointment with Dr. Bradley was quick and easy. He told her knee pain was a common symptom for persons who were heavy set, prescribed painkillers, and asked her to schedule a follow-up visit for two weeks out. Brittany was not happy to learn that her weight was impairing her left knee, but she was glad to have a remedy for the pain. Two weeks later, Brittany had to reschedule her doctor’s appointment due to an unexpected change in her work schedule. Dr. Bradley was booked three weeks out, and so Brittany scheduled to see another physician at the primary care practice. During the follow-up appointment, Brittany met with Dr. Vera. She was surprised by Dr. Vera’s interest in her weight. Dr. Vera asked about her lifestyle, what she ate, the kind of neighborhood she lived in, and what she liked to do for physical activity. She asked Brittany how she felt about her weight and how motivated she was to lose weight. Although Brittany was generally very private about her weight-related concerns, she found it surprisingly easy to talk with Dr. Vera. After the conversation, Dr. Vera gave Brittany an exercise prescription and took her off the painkillers. Dr. Vera believed that Brittany’s knee pain would dissipate with exercise and weight loss. Brittany was relieved to be able to talk with a professional about her weight. She was unsure about stopping the painkillers, but excited about starting a swimming routine. One month later, Brittany had dropped seven pounds She had almost lost all the weight that was put on since the knee pain started, but was frustrated to still have the pain in her left knee. She called the doctor’s office again. The receptionist scheduled her to see Dr. Bradley. During the appointment, Dr. Bradley was flushed with annoyance to learn that Brittany Global Journal of Community Psychology Practice Volume 7, Issue 4 December 2016 Global Journal of Community Psychology Practice, http://www.gjcpp.org/ Page 3 had stopped taking her pain medication. She proudly shared her new exercise regime and weight loss with Dr. Bradley. Dr. Bradley responded indifferently. He told Brittany that she should stay on her pain medication if she wanted the pain to go away. He explained that trying to lose weight at her age was very difficult, and that most obese patients are not successful with maintaining weight loss. Brittany left the doctor’s office feeling confused and deflated. Should she bother to exercise? Should she start her pain medication again? Why were the doctors giving her such conflicting messages and prescriptions? Nearly three-quarters of adults in the United States (U.S.) are overweight or obese, with obesity affecting more than one-third of this population (National Center for Health Statistics, 2015). South Carolina has the tenth highest adult obesity rate in the nation at 32% (Levi, Segal, Rayburn, & Martin, 2015). Given the diverse set of medical problems associated with obesity, primary healthcare settings are critical for the successful proactive management of obesity; however, many primary care physicians report feeling uncomfortable or insufficiently competent to talk with patients about their weight-related issues (Kaminsky & Gadaleta, 2002; Anderson et al. 2001; Davis, Shishodia, Taqui, Dumfeh, & Wylie-Rosett, 2008). For example, a study of 620 family physicians revealed that 51% felt they lacked the knowledge and skill to discuss weight-related behavior changes with their patients (Huang et al., 2004). Additionally, providers vary widely in their attitudes about obesity, including whether they believe their patients can successfully lose and maintain weight loss (Anderson et al., 2001; Block, DeSalvo, & Fisher, 2003). As in the case with Drs. Bradley and Vera in the opening scenario, disparate physician attitudes about obesity complicate obesity management and interfere with desired patient health outcomes. Enactment of the Patient Protection and Affordable Care Act (P.L.11-148) has catalyzed significant and rapid changes in the healthcare landscape in the United States. Healthcare systems have elevated their interest in improving care quality, lowering healthcare costs, and achieving patient and population health outcomes (Mann, 2010). In addition, rather than volume-based care models, pay-for-performance structures are now driving reimbursement levels as a means of promoting quality outcomes. To evolve with changing industry demands, healthcare systems across the nation are re-examining their practices and embracing alternative approaches. For example, services are shifting from provider-led to patient-centered care. Healthcare settings are adopting and using electronic healthcare records to track and measure patient outcomes. And the philosophy of quality improvement and lean management is more vigilantly applied across operational levels. These sweeping changes are directly impacting medical education organizations, compelling medical educators to re-assess the way they go about their work and to question the adequacy of existing continuing medical education (CME) structures, supports, and methods for preparing physicians to provide safe, quality patient care. Along these lines, medical educators are moving away from traditional approaches to education--where educational activities are largely didactic, episodic, in the classroom, and focused on the individual--to approaches that promote ongoing, team-based learning in settings that simulate or represent real work conditions. Medical educators are turning to implementation science to better understand what educational interventions work where, when, how, and for whom (Carney et al., 2016; Price et al., 2015). They are asking fundamental questions about ways medical education can contribute to more meaningful educational outcomes. In tandem with these shifts has been an increased recognition of the value that interdisciplinary education and Global Journal of Community Psychology Practice Volume 7, Issue 4 December 2016 Global Journal of Community Psychology Practice, http://www.gjcpp.org/ Page 4 multi-organizational collaboration can bring to quality improvement efforts. In 2011, the University of South Carolina School of Medicine CME Organization partnered with the Medical University of South Carolina CME Organization to implement a multi-year educational-research initiative aimed to improve the quality of obesity healthcare. Referred to as the South Carolina Initiative for Quality Overweight/Obesity Care (SCIQOC), this pilot initiative was designed to move beyond traditional CME formats (i.e., didactic lectures, case conferences) toward an educational approach targeting organizational-level improvements. During this exploratory journey, the competencies of community psychology played a pivotal role in designing, planning, and implementing SCIQOC. In this manuscript, the author draws from her experiences with SCIQOC to describe the important value that community psychology (CP) skills bring to medical education and healthcare organizations. Specifically, this article focuses on three community psychology competencies that critically influenced the course of the initiative: participatory action research, sociocultural and cross-cultural competence, and ecological perspectives. Through a series of examples, the article highlights specific ways medical education organizations can leverage community psychology competencies to move beyond traditional CME methods. Figure 1. SCIQOC Design Global Journal of Community Psychology Practice Volume 7, Issue 4 December 2016 Global Journal of Community Psychology Practice, http://www.gjcpp.org/ Page 5 Background: SCIQOC Participants and Project Design The obesity initiative included two primary care practices situated in urban settings of South Carolina. At project start, Primary Care Practice A included 15 clinicians, 24 clinical staff members (nurses, nurse assistants), and 15 patient service representatives (front staff). Primary Care Practice B had 5 clinicians, 2.5 clinical staff members, and 3 front staff. SCIQOC involved a two-stage assessment phase (exploratory assessment and needs assessment), followed by an intervention phase (see Figure 1). The exploratory assessment entailed a l