Pedja Stojicic

Project Director

What did you say you do for a living? You are working on population health? Hm, now I get it, you are trying to pay doctors less for the hard work that we do.

Those were the words of my friend, a well-known neurologist from Boston. I was trying to explain to him why it is important to shift and reinvest some of the resources from health care delivery to address some of the social determinants of health. Doing so will help us achieve better health outcomes for all.

As the conversation continued, I (a fellow medical doctor) realized he didn’t see our profession as even partially responsible for the overall health of this nation nor responsible for acting as good stewards of existing available resources. His words conveyed that his sense of social responsibility, which I know he practices in other areas of life, was somehow less important than his fears about the future of his profession. I was not surprised by this, knowing how little we invest in making sure that civic virtues (and specific skills) are part of the professional medical training.

With current shifts in priorities toward population health, there is a growing awareness of the need to bridge the gap between institutions (especially health care) and the people they serve or affect. That’s one of the reasons why many multi-sector partnerships (MSPs)–created to find new approaches to better health–have been fostering the rise of new professions such as community health workers, patient navigators, peer educators, and other “community liaison” positions. But as my all-too-typical conversation with my neurologist friend suggests: as MSPs continue to demonstrate the value of some of these positions, we should also be intentional about providing the space for “citizenization” of both new and existing professionals.

Citizenization is a term I made up to describe an intentional process of creating the conditions for professionals and other community members to flex their civic muscle (i.e., develop and practice social responsibility) and become active agents in health system transformation. Imagine the possibilities if professionals were intentionally using 10 percent of their time to activate the communities they serve and if they were trained on how to do it as part of their core professional curriculum. Imagine if health professionals were engaged to create a culture of health, by being intentional in how they use their time and resources on an everyday basis, in the interest of community health. That is citizenization.

Citizenization can help alleviate unintended consequences

A major challenge to citizenization is that MSPs, in seeking to solve problems by professionalizing community roles, often are not aware that professionalization can have unintended consequences. These consequences actually work against health transformation–what MSPs are ultimately trying to achieve. Yet when MSPs pay conscientious attention to citizenization, the consequences can be overcome.

We see one unintended consequence when people in secure, professional roles do not use the opportunity to act as champions of system transformation for the public good, but rather act as champions of the status quo (despite the evidence of the need for change). In 19th century health care, for example, professionals strongly resisted women becoming doctors. More recently, there have been turf battles around who has the authority and power to prescribe certain drugs or medical devices.

Paul Starr, a sociologist from Princeton University, suggests that this is typical. He writes that professionalization has to be understood as a cultural and political process that involves power and conflict. Citizenization, however, could help professionals become more aware of these tendencies and provide them with specific tools and skills they need to benefit both the people they serve and their profession.

Another unintended consequence is that people in health care roles, once professionalized, tend to have a client/consumer orientation with patients. While this can be important in some cases, in others it creates a transactional relationship between patients and health professionals that can lead to problems for patients who need to make substantial long-term lifestyle changes. Being a “client” who relies on others for services can make people less inclined to exercise their agency and activate their existing individual skills, abilities, and community resources. People are more capable of managing their own health than they think (see this short piece about people taking at home strep tests rather than making a trip to the ER, for example). Engaging people is a huge untapped strategy that can help us solve some of the most complex problems  affecting people’s health, like chronic disease or social determinants of health. Citizenization might help professionals find new ways to become true partners with people in co-production of health.

MSPs can support professionalization AND citizenization

Over the last five years at ReThink Health, my colleagues and I have been testing ways for MSPs to support citizenization alongside professionalization. The most promising strategies create the conditions for professionals to become aware of the need to intentionally develop critical skills for practicing their civic responsibility. We’ve found two approaches that have been quite useful:

  1. Provide specific training to show professionals how meeting their social responsibilities can be part of their job.

Professionals can engage with communities in new and different ways as part of their job. ReThink Health has created processes for successfully training leaders and staff of Quality Improvement Networks and Organizations (QIN-QIOs) in applying those skills for the purpose of achieving Centers for Medicare and Medicaid Services’s ambitious quality improvement agenda. This is one of the largest federal programs dedicated to improving health quality at the local level. We developed a 22-week, long-distance learning program, called Leadership, Organizing and Action, which trains leaders to craft their motivating vision, develop community relationships, organize teams and structures for their community initiatives, and develop collective action. We’ve watched first hand as these processes lead professionals to reclaim their roles and responsibilities as a citizens and take action steps to restore trust between institutions and communities.

For example, one of our trainees from Birmingham, Alabama used the skills to start a local care coordination coalition with a specific goal to reduce unnecessary hospital readmissions. Her initial goal was to have 10-15 institutions involved, mostly health care providers. However, new leadership skills enabled her to recruit and organize more than 70 local institutions (from above and beyond health care), as well as patients and community organizations. The coalition leadership decided to expand its scope of work to improving various aspects of health in the region. The group is now in the process of becoming a 501(c)3 and will continue to serve people beyond the original project agenda.

  1. Provide professionals with the opportunity to use their time to serve groups, not just individuals.

Professionals need to be intentional about creating conditions for the community members they engage with to lead and participate in collective actions and build shared responsibility for the health outcomes of their community. The professionals should be given opportunities to use their time to create, serve, and build the capacity of peer groups, teams, neighborhood circles, and clubs not just individuals.

In 2016, with the support from the New York State Health Foundation, we  designed and led a six-month long leadership development program for Niagara Falls residents that led to the activation of more than 100 people in the community to improve healthy food access, create opportunities for physical activities, and reclaim public spaces to help improve community health. The initiative, Creating A Healthier Niagara Falls Collaborative, is now led by a group of local volunteers who have developed the capacity to train others and partner with and influence local institutions. One of the original project team members was working in a local medical center and was impressed by the collaborative group’s power, solidarity, and ability to achieve results.

Based on her experience with the project, she transformed her approach through other hospitals’ community initiatives. She was also lucky enough to receive support and time for this new approach from her own institution. Looking forward, if health professionals had an explicit option to allocate their time (schedules/day/timesheets) toward serving and developing groups and individuals, then perhaps it could serve as an incentive to further this type of engagement work.

ReThink Health is committed to continuing to research this topic this year so we can learn more promising practices and create practical tools that can help multi-stakeholder partnerships build civic muscle within their institutions and in communities they serve. We’ve learned from our experience that there is an enormous appetite from professionals to learn these skills and practices. Are you aware of other ways to help professionals build their civic muscle?

The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis.

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