Scholars work toward healthy communities

When Oni Blackstock, M.D., arrived in New Haven in the summer of 2010 to begin her fellowship as a Robert Wood Johnson Foundation (RWJF) Clinical Scholar, she and some of the other fellows took a walking tour of the city’s West River neighborhood—home to many of the patients treated by Yale physicians.

“I was really excited,” says Blackstock. “I know a lot of people who have spent years in New Haven and have never gone to these communities. I think it’s really important to get a sense of the reality of your patients’ lives. You don’t get that just seeing them in the office.”

The tour served its purpose. Blackstock saw the urban neglect, the effects of unemployment, lack of access to healthy foods, limited recreational facilities, and the residents’ reliance on public transportation. She also saw, in the community leaders who led the tours, the neighborhood’s strength and resiliency. What Blackstock didn’t see, at least initially, was how what she learned on the tour would dovetail with her own clinical interests, inform her work as an RWJF fellow, and most likely influence her medical career well into the future.

As the tour was winding down, the scholars were taken to a meeting of the West River Neighborhood Services Corporation. Community residents had gathered to discuss a number of issues, including where they were going to buy their food now that the Shaw’s Supermarket chain had closed its store on Whalley Avenue.

“As a primary care doctor I care a lot about food insecurity and its health consequences, and I knew that we would be able to help the West River residents in some capacity,” says Blackstock, who attended Harvard Medical School.

With the loss of Shaw’s, community organizers were weighing other food distribution options—possibly a food co-op, another supermarket, or a buyers’ club—but first they needed to figure out what neighborhood residents want and would be prepared to support. Blackstock and Jed Barash, M.D., a first-year scholar, worked with neighborhood corporation members to develop a survey tool to gauge community needs and feelings.

Although a Stop & Shop supermarket has recently opened in the old Shaw’s site, Blackstock says strong support remains for an alternative. Their survey specifically asked whether Stop & Shop satisfies the neighborhood’s grocery needs. Noting that some residents expressed concern about Stop & Shop’s prices, she said, “We believe affordable quality food remains a need, even with the presence of Stop & Shop.”

This finding is something that wouldn’t be known without engaging the community. Replacing one large supermarket with another would seem to be the ideal solution—but when residents were surveyed, a different picture emerged.

“When the research is generated by the community, it’s a more holistic, honest, and genuine way to approach research,” says Blackstock. “Forming these partnerships helps community members understand what research is, and it builds a bond between academia and the community.”

This bonding, administrators of the Yale RWJF Clinical Scholars Program would say, is exactly how their program is supposed to work. “What we’re aiming for is alignment of the scholars’ passions and the needs of the community they are serving,” says Marjorie Rosenthal, M.D., M.P.H., the program’s assistant director.

Such community-based participatory research is an important facet of the program, says Program Director Harlan M. Krumholz, M.D., the Harold J. Hines Jr. Professor of Internal Medicine. “We have maintained our traditional commitment to teaching core competencies in research and enriched our curriculum with this work. We are a program that trains people for a variety of roles in a range of organizations, but we are trying to change the paradigm of research too—with an emphasis on thinking about the end-user of the knowledge.”

People who ask the next question

In 1973, Yale was one of the founding sites for the nascent RWJF Clinical Scholars Program, a two-year fellowship that teaches research skills, health policy, leadership, media/communication skills, and community health. The other three sites are the University of Michigan, the University of Pennsylvania, and the University of California, Los Angeles.

Young doctors apply for RWJF fellowships after they’ve completed their residencies, with seven or eight scholars a year being accepted into the Yale program. Upon successful completion of the program, they receive the degree of Master of Health Sciences Research.

Rosenthal said that the ideal clinical scholar candidate is someone who is interested in the interplay between research and policy. “We’re looking for people who, when they’re on rounds, are continually asking the next question,” she says. “If the patient has anemia, they’re not satisfied asking, ‘How should we treat this?’ They want to know why the patient has it; is there something about the social structure that contributed to this?”

Krumholz adds that the successful RWJF scholar is willing to challenge the conventional wisdom. “Just because that’s the way things have been done for a long time doesn’t mean it’s the right thing,” he says. “The inclination is to just go along. We want critical thinkers who have the courage of their convictions.”

The program is divided into a didactic year followed by a year devoted to research. Coursework includes training in clinical epidemiology, community-partnered research, health economics, health policy, health systems management, organizational behavior, and leadership development. The four foundational courses are biostatistics; clinical and health services research methods; principles and processes of community-based research approaches; and principles of health policy and management.

Central to scholars’ training is the expectation that they will conduct two or more health services research projects during their fellowship and contribute to scholarship in clinical research. They are encouraged to undertake at least one project that involves primary data collection and tackle projects that use different methodological approaches. Scholars are also expected to maintain their clinical skills through interactions with patients at Yale-New Haven Hospital, the VA Connecticut Healthcare System in West Haven, or affiliated clinic, hospital, or community-based health centers.

To date, 151 scholars have graduated from the Yale program, with seven more graduating in 2011. Graduates work in a wide range of jobs in academia and politics as well as holding other positions in the public, private, and nonprofit sectors. Stephen Cha, M.D., FW ’06, is the chief health care policy advisor to U.S. Representative Henry Waxman, D-Calif.; Katherine Goodrich, M.D., FW ’10, is the chief medical officer of the Office of Planning and Evaluation at the U.S. Department of Health and Human Services; David M. Krol, M.D., FW ’01, is the team director and senior program officer of human capital at the Robert Wood Johnson Foundation; Eric S. Holmboe, M.D., Ph.D., FW ’98, is the chief medical officer and senior vice president of the American Board of Internal Medicine; and Anu Gupta, M.D. ’97, HS ’00, FW ’02, oversees the HIV/AIDS philanthropic portfolio of Johnson &; Johnson’s Corporate Contributions Division.

A move to community-based research

The original program’s stated mission, according to Krumholz, was training fellows to be “skilled in clinical research to the same extent that people were in basic sciences,” and to understand research methods, develop fluency in the language of clinical research, and become astute readers of the scientific literature. “Our ulterior motive,” he adds, was to sharpen critical thinking skills. “We wanted them to be able to pinpoint the key leverage points in medicine and make a difference.”

The founding director of Yale’s clinical scholars program was the late Alvan Feinstein, M.D., Sterling Professor of Medicine and Epidemiology. Under his direction the Yale program developed a reputation for excellence in training its scholars in clinical research methods. As the RWJF program matured both nationally and at Yale, however, its mission evolved. In the most recent funding cycle, which began in 2005, national directors maintained the rigorous training in re-search methods, but added a new emphasis on community-based participatory research.

“We fully embraced the idea,” says Krumholz. “Too often we’re doing research without soliciting input from the people we’re seeking to help.” Krumholz calls the result “confetti papers”—research papers that are published, maybe even attract some press coverage, but generate “no conversation.” He says this lack of feedback usually occurs because there wasn’t enough front-end work with the end-users. “Other researchers may cite the paper,” he said, “but that doesn’t matter if it doesn’t lead to action.”

Now, six years into the latest funding cycle, Krumholz calls Yale’s community-based participatory research initiative “the jewel of our program.” At least 15 percent of the scholars’ time is devoted to research in partnership with organizations serving New Haven. The work is guided by the Steering Committee on Community Projects, composed of a cross-section of community representatives and Yale affiliates working with the New Haven community. So far, seven projects have been completed and disseminated; another 10 are either under way or being planned.

Yet in the beginning it was far from a given that community leaders would agree to partner with the scholars. “People were suspicious when we proposed this,” Krumholz recalls. “They’d had people like us approach them before and write them into their grants, only to lose interest in them as soon as the grant came through. I made a personal promise that we wouldn’t abandon them—that this was a sincere, genuine offer.”

New Haven’s size and demographics make it an ideal place to conduct community-based participatory research, says Georgina Lucas, M.S.W., deputy director and steering committee chair of the Yale RWJF clinical scholars program. “It’s a microcosm of a much larger urban area,” she said. “You can get your arms around it, and it’s small enough that you can build relationships and disseminate information.”

The challenge, she adds, is completing a project within the two years the scholars are in the program. “People don’t realize how much time community research takes,” she says. “You need to engage your stakeholders to get complete and accurate information and to create effective and sensitive interventions, but that means building relationships and trust—which takes time.”

Gun violence and motorcycle helmets

When Chisara N. Asomugha, M.D., M.P.H., FW ’09, was in the program, her community-based participatory research focused on youth-related gun violence in New Haven. Working with the New Haven Family Alliance, she used an established research approach called Photovoice to collect data. New Haven youths between the ages of 14 and 19 were given cameras and asked to photograph scenes reflecting their community’s strengths and challenges. The photographs were then used as a stimulus for focus group discussions with an eye toward gaining insights into local policy and service needs.

After the project was completed, the photographs were displayed in the New Haven Public Library, while Asomugha, who attended the Duke University School of Medicine, shared her final report with Mayor John DeStefano Jr. Soon afterward she was hired as New Haven’s deputy mayor for community services.

Gregg Furie, M.D., drew inspiration for his community research project from the city’s plan to remove the Route 34 Connector in an effort to reconnect the medical campus and adjacent neighborhoods with the rest of the city. He’s been working with fellow scholar and pediatrician Clara Filice, M.D., and the city’s health, planning, and economic development departments to conduct a health impact assessment that will focus on pedestrian and bicycle safety, activities for walkers, and reducing accidents. “It’s a way to introduce health as a consideration in public policy decision making,” says Furie, who got his medical degree from Harvard. “City planning and public health have different objectives, so we’re trying to make sure the public health impact doesn’t get lost.”

In talking about their research projects, all the scholars say they are gratified to have the opportunity to contribute to addressing real health needs; but they also recognize that through the cultivation of personal relationships with community members and the process of consensus building—which is so important for the success of a community project—they are developing other skills that will be valuable in their later careers.

Adam Landman, M.D., FW ’10, wanted to do a research project on the correlation between wearing a motorcycle helmet and serious injuries. Krumholz questioned whether the topic might be too obvious—of course wearing a helmet reduces the likelihood of serious injury.

“One of the most beneficial parts of the program,” Landman says, “is learning to clearly articulate the importance and value of the research you’re doing.” In the case of the helmet study, Landman and Michael Phipps, M.D., his RWJF partner, were able to persuade their professors and colleagues that the project was worthwhile. “We knew from the outset that the results wouldn’t be novel,” Landman says, “but we were okay with that. There had been discussions in the past about making helmet use mandatory in Connecticut, but there was no recent data to inform the decision making. Our goal was to use our research skills and rigorous methodology to inform an important public health topic.”

In her new job as deputy mayor, Asomugha is already seeing the value of acquiring a deeper understanding of the social determinants of health that she gained through her training as a clinical scholar. She cites an incident she says is not atypical, concerning a woman who had been scrupulous about getting her daughter to her medical appointments. “They rode their bikes and were always on time,” Asomugha says. “After one appointment, the doctor gently told the mother that her child should wear a helmet when bike riding. The woman missed her next appointment, and the doctor didn’t know what had happened.” Upon hearing the story, Asomugha quickly understood—the mother couldn’t afford a helmet. Embarrassed and unwilling to risk what she saw as further rebuke, she skipped her appointment. “It’s the unintended consequences of trying to do a good thing,” Asomugha says. “It’s very common, and it’s something we need to try to anticipate and avoid.”

Peggy Chen, M.D., FW ’10, learned a similar lesson during her time in the clinical scholars program. She was helping the New Haven Healthy Start Program Consortium develop a brochure about obesity and the importance of exercise and healthful eating.

“We came up with an initial draft and thought, ‘This is great. They’re going to love it,’ ” Chen says. “They changed every word and all the photos.” The problem, Chen came to learn, was that the brochure, complete with photos of overweight women standing on scales, had the scolding tone of a finger-wagging gym teacher. “You’ll get high blood pressure; you’ll get diabetes, blah, blah, blah. These women have gotten negative messages from everywhere else. They didn’t need another one from us.” The new draft, which emphasizes all the positive things that can happen when one lives a healthful lifestyle, was quickly approved.

The community takes notice

It’s not just the scholars who see the value in the program’s community research component; community partners in New Haven and RWJF’s national program office have also taken notice.

Rebecca Allen, director of programs and services for the Columbus House homeless shelter, remembers when Ryan Greyson, M.D., a RWJF scholar, contacted the shelter’s executive director, Alice Cunningham. Greyson’s project was to find ways to improve communication between the shelter and Yale-New Haven Hospital. “We get lots of people coming through here wanting to talk or do research,” she says, “but Ryan brought it to a whole new level. He partnered with clients and staff. He gave us feedback and held our hand every step of the way. Usually doctors don’t speak our language, but Ryan does. He’s always very understandable and approachable.”

Desmond Runyan, M.D., D.P.H., the RWJF national program director, was even more effusive. “The Yale program is doing exceptional work in the community,” he says. “Harlan and his staff are doing a superb job.” This finding is all the more noteworthy, he adds, because Yale hasn’t always enjoyed the most collaborative relationship with its host city. “Yale has a reputation for having a town/gown split, so it’s remarkable how strong the ties are now, how invested people have become. Overall, the success of community-based research is best exemplified in Yale.”

Runyan also cites Yale’s leadership component as an area where it excels. About four years ago, under the stewardship of Irwin Birnbaum, J.D., the medical school’s former chief operating officer, and David Berg, Ph.D., clinical professor of psychiatry, the clinical scholars program began offering seminars in leadership development and organizational management. Scholars are given an opportunity to shadow health industry leaders and attend group discussions when such leaders come to campus.

But in this latest iteration of the clinical scholars program, it is the commitment to community-based participatory research that is exciting the scholars, winning over hearts and minds in the community, and impressing the program’s national administrators who make those all-important funding decisions.

Whether it’s helping establish Project Access, a new program that helps the uninsured gain access to health specialists; helping Integrated Refugee and Immigrant Services assess the health needs of new refugees and develop interventions; or designing a method to evaluate the progress made on Mayor DeStefano’s Teen Pregnancy Prevention Council, Yale’s clinical scholars are collaborating with community members to address their neighbors’ health needs in the hope of changing their circumstances. If their work proves to be valuable beyond New Haven, so much the better.

“At the end of our lives and careers, to just look back on a big curriculum vitae would be a shame,” Krumholz says. “We should strive to leave a legacy of better health in the community.”