To truly improve lives, researchers in academic medicine need to leave the ivory tower and engage directly with the communities in which people live.
Carol M. Mangione, MD, MSPH, has been on the faculty of the David Geffen School of Medicine at UCLA since 1994. She is a health-services researcher, director of the UCLA/Drew Resource Center for Minority Aging Research, associate director of the UCLA Clinical Translational Science Institute, and co-director of the UCLA Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program, which concentrates on teaching postdoctoral fellows how to conduct community-partnered research. She spoke with U Magazine editor David Greenwald about the Community Engagement component of the Strategic Plan for the David Geffen School of Medicine at UCLA and UCLA Health.
Community engagement is a broad term. What, specifically, are we speaking of when we talk about community engagement?
Dr. Mangione: Community engagement spans all of the missions of both the David Geffen School of Medicine at UCLA and UCLA Health System - teaching, patient-care and research. Through community engagement - partnering with organizations outside of the university - we have access to venues where we can train the next generation of healthcare professionals, and where they can more directly learn about our communities and how best to improve the health of the people living in those communities. We conduct community-partnered research with these organizations, and we deliver primary-care services to the broad spectrum of people living throughout this region, as well as tertiary and quaternary care that engages with an even larger global community. So when we speak of community engagement, what we are speaking about truly does not have geographic boundaries; it is all of those people we provide patient-care to; it involves people working within our various service-learning and research partnerships; it involves our donor community, whose creativity and generosity are what's going to help us maintain excellence and stay nationally competitive as our state faces huge financial shortfalls.
As you mention, UCLA Health System and the David Geffen School of Medicine at UCLA have three core missions: teaching, research and care delivery. The Strategic Plan now lists community engagement as a core mission as well.
Dr. Mangione: Yes. There are a number of reasons why community engagement has been elevated to this level. First, it is clear that if a part of our mission at UCLA is to improve the health of the people of Los Angeles, then we have to be able to not only develop new models and best-practices for healthcare based on laboratory and clinical research but also to deliver on them more quickly. To do that, we have to engage our communities. We have to understand what the barriers to care are in some instances, and also what are the facilitators of care in others. The reality of care delivery can't really be appreciated unless you train doctors, nurses and allied health professionals in settings where you see the full spectrum of people and the challenges that they face when managing their conditions.
It is well recognized that it takes, on average, about 17 years from the time a scientific discovery is made to when clinical practice changes so that patients can benefit from discoveries. Our goal at UCLA is to shorten that time line to get the best treatments into the hands of our community doctors faster. The only way that we can really accomplish that is by engaging our community and understanding how best to disseminate information to patients and community physicians. Right now, there is this enormously leaky conduit between what we know and how we practice clinical medicine. The Community Engagement-implementation team of the Strategic Plan believes that it is through robust community engagement that we will patch up the conduit and get the best knowledge and best treatments into the hands of more doctors and patients faster.
A key component of this engagement is to increase the healthcare workforce and to create more of a pipeline through the education system to feed into the needs of healthcare.
Dr. Mangione: That is correct. Historically, schools of medicine have thought about the workforce in terms of doctors. But we need to have a broader view. We are thinking about physicians, of course, but we're also thinking about nursing, pharmacy and then a whole group of people in the allied-healthcare fields - the pharmacy technicians, the phlebotomists, the medical assistants, the physical therapists and others. If you look at current projections, our hospitals in Westwood and Santa Monica are going to face very severe shortages of people in the allied-healthcare professions. The need right now in our state and nationally well outstrips the number of people being trained in these fields. So that is the problem we face here on the Westside of Los Angeles. And if we travel 10 miles east and south, we would be in communities with some of the highest unemployment rates in the country. We know that lower socioeconomic status and unemployment create tremendous barriers to receiving healthcare services. So if we think creatively, we can solve these two problems simultaneously.
What we have proposed in the Strategic Plan is to partner with the schools that train allied-healthcare professionals - the community colleges, the Cal State system - and to create within our hospital system really high-quality internships and clinical experiences for their students. We also will work with schools in underserved areas, reaching all the way down to the elementary schools in some places, to try to make sure that young people in these communities understand how much opportunity there is in the allied-health professions. Our goal is to elevate the visibility of these career paths in some of the most vulnerable communities, to really try to help with the pipeline of bringing those young people into the programs, and then to try to create here at UCLA high-quality internships so that when these students come and work at our institutions, we can offer the best of them jobs with us after they complete their training programs.
Community engagement has been a focus at UCLA for many years. How does this effort, within the context of the Strategic Plan, differ from what has been done previously?
Dr. Mangione: I think it represents something of a major sea change. For one thing, one of our priorities is to create a new career path that will reward faculty who do community-partnered research. Traditionally, the person working in an academic medical center who gets the most reward is the bench scientist - the very smart individual tackling a small problem, thinking creatively, testing things out in the lab, and coming up with a cure or a new way to find or treat a serious condition. That single-scientist model historically has been at the top of the pyramid in academic medical centers, and will continue to be highly valued. But that is not the way community-partnered research works. Community-partnered research is highly collaborative. Generally, it deals with such things as getting the care efficiently to the people who need it most. For example, we have all these great scientific discoveries and we've learned so much about how to take care of people, but we still have an obesity epidemic in this community and some of the highest rates of infant mortality in the country within 10-to-15 miles from UCLA. Why is that? Community-partnered researchers are deeply dedicated to finding out what is driving the huge disparities in access and outcomes for so much of our population. These scientists ask, why, when we know so much about how best to take care of people, most patients are not benefitting? This kind of science engages a very broad spectrum of disciplines. You can't just sit in an office and develop the world's best diabetes self-management intervention and put it in a nice little booklet and then go out to the senior centers and say here, do this. You have to sit in the room with the clients and with the center directors, and you have to understand barriers, the facilitators; you build programs together, test them together, and evaluate them together. This type of carefully performed, community-engaged research is a pretty big paradigm shift for most academic medical centers, but is essential if we are going to improve the health of people in Los Angeles.
At the end of this process, what do you hope to see accomplished?
Dr. Mangione: I hope that we have excited our students about the possibilities of working in a community-engaged setting, and that our students have plenty of role models from whom they can learn. I hope we have engaged donors and philanthropists to partner with us on the community-engagement mission, so they see themselves as a part of the multidisciplinary team needed to successfully do this work. I hope in the academic promotion process, faculty who spend hundreds of hours working on partnered projects are as valued as the bench scientists and that there's a viable promotion track for them. And I hope I will never again go into a community and hear stories about how some previous UCLA researchers came in, like they dropped in off a helicopter, made a bunch of promises that they didn't keep, took the data away and never shared the results with the people who generously participated in their research. I hope in all of our efforts in the future, the first people who hear about our results and who benefit from them are those who are the altruistic partners who joined us in our studies to improve the health of everyone in our community.