Clinical community health: revisiting "the community as patient"

A little over fifty years ago, Edward McGavran, Dean of the University of North Carolina School of Public Health, articulated the concept of treating the community as if it were a patient. Although McGavran was addressing public health practitioners, the concept has applicability in academic medicine and reflects contemporary thought in patient care, research, and education. The goals of this paper are (1) to present a framework through which clinicians can conceptualize the community as an appropriate level of intervention to improve health, to conduct research and to educate students, and (2) to illustrate the framework by presenting information on how programs at Morehouse School of Medicine have used it to organize community-focused initiatives. The concept may be called Clinical Community Health.

Health problems of communities are more readily understood by clinicians when analyzed in the same way that clinicians analyze the health problems of individual patients: by gathering subjective and objective data, formulating an assessment that is expressed as a problem list, and developing a plan ("SOAP"). The plan is created in consultation with the community, much as a modern physician engages in shared decision-making with a patient rather than issuing "doctor's orders." Similarly, community-based participatory research creates a relationship between the researcher and the community that parallels the relationship between the researcher and the individual research participant in traditional clinical research. When viewed through this lens, the education of students in the community resembles the education of students in the hospital or clinic--both are a type of service-learning. Hence, the community work of faculty is best evaluated and rewarded in a fashion that parallels evaluation of faculty work in the clinic or hospital. This paper reports on our experiences at Morehouse School of Medicine (MSM), a historically black institution in the United States whose mission focuses on primary care and the health of the underserved. We report on our efforts to apply the model in service, research, and education.

Viewing the community as a patient provides a useful conceptual framework for primary care physicians and other clinicians, since it allows them to recognize that it is not necessary to learn a different conceptual framework to diagnose and treat the community; rather, one can think of the community as a patient and apply a similar approach to that used in the care of individuals.