From campus to community: the Loving Spoonful Service Learning Project
By Steven Bae and Lauren Wilson, MEDS 2019
“Let food be thy medicine, and medicine be thy food” – Hippocrates
Food. It is a vital part of our existence, and is a focal point in many cultures. Over the course of one year, a person who eats three meals a day consumes 1092 meals. It plays such a large role in everyday life that sometimes it is easy for us to overlook.
The importance of food security to one’s overall health is well known. Food security is defined as “all people, at all times, have physical and economic access to sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active healthy life.”  A recent JAMA study reported that suboptimal intake of nutrients and healthy foods was associated with over 45% of deaths due to heart disease, stroke, or type 2 diabetes.  Yet for too many people, adequate access to nutritious food is out of reach. Some of these people live right in our community.
The neighbourhoods in North Kingston make up 20% of the total population, and their average income is 22% lower than the city average.  The people living in North Kingston are twice as likely not to have completed high school, and twice as likely to be living on low incomes.  Many physicians that know their patients may not always be able to afford food ask their patients at appointments if they have enough food. Some family health teams even have an emergency supply cupboard in their office for extra food to give to patients who need it.
To increase awareness of these issues, we became closely involved in helping develop a service learning project in partnership with Loving Spoonful, an organization that works to achieve a healthy, food-secure community. The project is structured around community cooking programs for low-income Kingston residents with medical students as volunteers. On top of building food literacy and confidence in preparing healthy foods among class participants, the goals of the project were to expose medical students to the Kingston community, provide information about food security in Kingston, and encourage them to create a dialogue with the participants in order to learn more about what they can do as future physicians.
The project also allows for students to accompany a physician from the Kingston Community Health Centres to visit the home of a patient living on a fixed income. The students have found that this experience has been eye-opening to appreciate firsthand the ways in which barriers can be specific to individuals. For example, if an individual has difficulty standing, the food s/he buys has to be prepared quickly, which limits his or her choices. Underpinning all of these experiences is a facilitated debrief and written reflection at the end, which allows students to share and document their insights, challenges, and surprises.
Ten medical students have participated in the service learning project thus far, with more students registered for this fall. All of the students have enjoyed this project in many aspects, from improving their own food preparation skills, to developing rapport with the local Kingston residents.
Overall, we are walking away with a greater appreciation for the social determinants of health. As future physicians, the social inequities that underlie many chronic diseases may seem insurmountable. However, this work is not solely our own. Organizations like Loving Spoonful play an important role in our community to address upstream factors that we eventually see presenting as illness. Being knowledgeable about the resources available in our community is a small but helpful step we can take to help our patients address challenging socio-economic circumstances.
Thank you to Loving Spoonful for your invaluable partnership in developing this project and the Kingston Community Health Centres health team for contributing to student learning. We would also like to gratefully acknowledge the City of Kingston and United Way for their Community Investment Fund, as well as the Kaufman Endowment fund, which helped fund this program.
 Micha R, Penalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA 2017;317(9):912-924.
 Kingston Community Health Centres. A community needs assessment of North Kingston neighbourhoods. June 2010
Navigating multiple paths to service-learning projects
Anyone with their ear to the medical education ground in the past year will know that service learning is a very, very hot topic. Ever since the Committee on Accreditation of Canadian Medical Schools (CACMS) endorsed service-learning as an important (but optional) element of the education of future physicians, medical schools across the country have sought to incorporate this as a feature of their curriculum. However, service-learning, by its very nature, can leave students feeling uncomfortable: it’s structured but open-ended.
Consulting with community members to set goals and design projects is not always as straight forward as mastering the objectives of a standard medical course. Unlike other curricular and co-curricular activities, service-learning projects often start with pretty broad objectives. Add in consultation with multiple community stakeholders and the projects themselves can seem quite nebulous at the start.
We’ve written about service-learning on the blog before (here and here) as we’ve continued to develop our approach to encouraging and supporting our students in engaging in service-learning. Service-learning projects are one way our medical students (and pre-medical students, in the case of QuARMS) enhance their understanding of working with community members, explore intrinsic physician roles, and contribute in a very real way to our medical school’s social accountability to our communities.
On a national level, the Canadian Alliance for Community Service Learning (CACSL) provides support and networking opportunities for students, educators and communities engaged in these endeavors. At their recent biennial conference held in Calgary, multiple presenters addressed students’ issues with the ambiguity of service-learning projects compared to other learning activities.
When students have the autonomy to define what is happening with a project in cooperation with an organization, they can feel a little lost, one presenter, Chelsea Willness, an assistant professor at the Edwards School of Business at University of Saskatchewan, noted.
“Students are very uncomfortable with the ambiguity: ‘What do you mean, I don’t know what I’m going to be doing?’”
They want templates and checklists because that’s familiar, she added.
It’s clear that while many students are excited about the opportunity to engage with community partners, they both need and want support. Equally important is providing them with reassurances that each project will have its own path – which includes some levels of uncertainty.
Here’s the Queen’s UGME operational definition of service-learning (as there are multiple interpretations of this term):
“Service-learning is a structured learning experience that combines community service with preparation and reflection. Medical students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided, the connection between their service and their academic coursework, and their roles as citizens and professionals.”
One key word in that definition is structured. Providing as much structure as possible can help ease students’ discomfort with some of the ambiguous nature of service-learning. To that end, the Teaching, Learning, and Integration Committee (TLIC) has been assigned oversight of service-learning for undergraduate medical students and has implemented three possible avenues students may use to have a service-learning project recorded on their MSPR.
To launch this, a one-hour session on service-learning was added to the first-year Professional Foundations course earlier this year. This learning event included information on why we’re deliberately supporting extra-curricular and co-curricular service-learning activities as well as information on potential service-learning avenues. As part of this session, members of the Class of 2019 were polled to see what types of service-learning projects they might be interested in and how these might fit in the three paths.
Here are the three paths to a recognized service learning project:
- Participate in an existing student-led volunteer initiative and complete the additional tasks necessary to extend this to a service-learning project
- Complete an individual service-learning project, which meets the requirements (including consultation and reflection)
- Take part in a service-learning pilot project brokered by the TLIC
Dr. Lindsay Davidson (Director of the TLIC) and I have met with representatives from several established student groups whose existing activities were quite close to our service-learning definition and threshold to map out ways their participants could extend their volunteer service into a service-learning project (this is always optional). Typically, this meant documenting some form of consultation and implementing some form of reflection on learning. These groups include SwimAbility (formerly Making Waves) and Jr. Medics. Other groups can be added to this list (email me: firstname.lastname@example.org to set up a meeting about this if your group might fit).
The two initial pilot projects are with Loving Spoonful (an organization with the goal of enhancing access to healthy food) and the Social Planning Council (with a focus on social housing in the Kingston area). These will be longer-term projects with sequential groups of students completing phases of a larger, continuing project. (The first participants have already been identified through the PF class poll. Recruitment of UGME students will be through the TLIC, not through the agencies).
For each of the three paths, students must submit evidence of meeting the threshold for each aspect, using forms provided by the TLIC. These will be made widely available in September using a MEdTech community page. Here are the requirements for any project to be recognized:
- The project must serve the needs of a group in the wider community (i.e., not medical school-focused)
- Complete some form of consultation with community participants and/or stakeholders (this will look different depending on the type of project and service)
- Complete between 15-20 hours of service (with no more than 20% devoted to training)
- Completed a required reflection on learning
In the future, as more students engage in formal service-learning projects, students’ reflections on their learning may be presented at a service-learning showcase, similar to the Undergraduate Research Showcase that is held each year.
While having three different routes to recognized projects may seem to add to the ambiguity of “what does a service-learning project look like”, providing multiple avenues for recognition was important.
“Our students have many different interests and we wanted to leverage that by providing multiple avenues for service-learning projects to be completed and recognized by the school,” Dr. Davidson said.
We’re never going to completely eliminate the ambiguous nature of service-learning projects, but we’re working to put structures in place that can meet a variety of students’ interests and community needs.
With thanks to Dr. Davidson for her contributions to writing this post.
June Curricular Leaders Retreat held: EPAs, Remediation and Feedback, oh my!
After bringing another busy semester to a close, UGME curricular leaders took time to reflect on the past year and take part in workshops and discussion groups on a number of areas of the curriculum at their semi-annual Curricular Leaders Retreat on June 19. The aim of the retreat was to share information and to generate ideas and solutions to address teaching and assessment challenges.
In his end of year report, Associate Dean Anthony Sanfilippo highlighted accomplishments of the past year as well as announced new faculty appointments.
After providing an entertaining and informative review of the process of curriculum renewal that UGME has undergone over the last several years, including the development of the “Red Book” objectives, Dr. Sanfilippo discussed how the emerging use of Entrustable Professional Activities (EPAs) will relate to and refine our existing curriculum and assessment processes.
Dr. Sue Moffatt presented an information session on how the three classroom-based “C” courses relate to both clerkship and the rest of the curriculum.
In a discussion about Service-Learning, led by Dr. Sanfilippo, faculty brainstormed ways additional service-learning opportunities could be created for medical students and others as well as ways they could support and encourage students in these endeavours. The Service Learning Advisory Panel will consider their suggestions and recommendations.
As a follow-up to last year’s popular workshop on remediation strategies, Michelle Gibson, Richard Van Wylick and Renee Fitzpatrick presented “Remediation 2” with additional cases and strategies.
For the afternoon, participants chose between a session on writing narrative feedback or one on making ExamSoft work for you.
Designed in particular for faculty working in clerkship, clinical skills and facilitated small group learning (FSGL), for the workshop on narrative feedback, Cherie Jones and Andrea Winthrop provided concrete examples and solutions to situations faculty routinely encounter when needing to provided constructive feedback to students. This included a discussion of ways in which oral and written feedback differ.
In the ExamSoft workshop, Michelle Gibson, Eleni Katsoulas and Amanda Consack worked with faculty to show how to tag mid-term and final assessments to match to assigned MCC presentations and Red Book objectives as well as coding for author and key word. Using these ExamSoft tools upfront makes it possible to use built-in reports to blueprint assessments, rather than having to do so manually. (For more on ExamSoft, check out the team’s poster from CCME at this link.)
To wrap up the day’s activities, pre-clerkship and clerkship course directors brainstormed with competency leads for ways the milestones identified for these intrinsic roles can be met throughout the curriculum. How to highlight and incorporate patient safety in different courses was also considered.
Documents from the Retreat are available to curricular leaders under “Retreats” on the Faculty Resources Community Page.
Balancing service and learning in service-learning
Formalizing opportunities for service-learning is increasingly important to schools of medicine, both for the inherent merits of service-learning itself (for both learners and communities), as well as for accreditation considerations.
The Future of Medical Education in Canada (FMEC) report places a strong emphasis on social accountability, and service-learning is integral to carrying out this mandate: “Central to these social accountability initiatives is the provision of a comprehensive education for physicians that will enable them to respond directly to the ever-changing health care needs of the communities they serve” (FMEC, p. 16).
Ways forward suggested in the FMEC document include:
- Provide greater support to medical students and faculty as they work in community advocacy and develop closer relationships with the communities they serve.
- Provide students with opportunities to learn in low-resource and marginalized communities as well as international settings. To emphasize student and patient safety in a socially and ethically accountable framework, students should experience adequate training and preparation prior to working in these communities and should have adequate support throughout. (p. 17).
As well, service-learning projects can provide students with opportunities to develop many aspects of the CanMEDS competencies in community settings, enhancing our existing classroom and hospital-based curriculum.
But what, exactly, is service-learning? There are many definitions of service-learning (one reference points to 147 definitions in the literature) and many interpretations of what service-learning may look like.
The LCME has defined service-learning as “a structured learning experience that combines community service with preparation and reflection. Medical students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided, the connection between their service and their academic coursework, and their roles as citizens and professionals.”
It’s also helpful to consider this chart (from Marquette University in Milwaukee) which illustrates the differences among community service, service-learning, and internships.
Regardless of variations in definitions, service-learning is always a three-part process which incorporates preparation, service, and reflection.
The core components of service learning include:
- Formal, deliberate preparation, which includes consulting with the members of the community who will be served by a project and which may include classroom instruction or another form of mentorship/coaching. A plan, detailing both the intended service and learning outcomes is created.
- The “service” and “learning” are completed
- The learner reflects on the process, the service and the learning. (This may occur throughout the project or period of service). The learner provides evidence of learning. (This could be provided in different ways, for example, through written reflections or an interview with a preceptor).
Some things to consider when thinking about incorporating a service-learning project into an existing course or a student-developed learning plan:
- Time & Scope: Is this in addition to, or as a replacement for, an existing project or assignment? There may be ways to extend or expand existing assignments to allow for service-learning. How much time can students realistically devote to the project both to make it a success and in light of other academic and personal responsibilities?
- Goals: How does the project relate to curricular objectives and individual students’ learning goals? How does the project serve the community group or agency’s goals? An individual or group of students may have short-term goals that feed into an agency’s long-term planning: A particular cohort could complete a component of a larger service-learning endeavor with subsequent cohorts carrying on with other components of the same over-arching project.
- Mentoring & Accountability: How will students be guided and supervised during the project? Is this responsibility shared between an instructor and community member or does one person have the lead? How will students’ learning be assessed and documented?
Encouraging opportunities for service-learning should in no way suggest that other, equally-worthy, voluntary service is not valued by the School of Medicine, Queen’s or the wider Kingston community (and other communities in which our students find themselves). However, because of the integrated nature of service-learning, it has the potential to provide unique opportunities for our students and our communities. The Professional Foundations Committee is exploring ways to address service-learning formally in the UGME Curriculum.
If you’re interested in incorporating service-learning in your course, the Education Team is available to help with your planning. Please feel free to get in touch.