Education for Primary Care

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Medical students as service learners:

opportunities, risks and recommendations

Felicity Lalloo, Nichola Hawkins, Rachel Lindley & Sonia Kumar

To cite this article: Felicity Lalloo, Nichola Hawkins, Rachel Lindley & Sonia Kumar (2021) Medical
students as service learners: opportunities, risks and recommendations, Education for Primary
Care, 32:3, 135-139, DOI: 10.1080/14739879.2020.1869589

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Published online: 14 Feb 2021.

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EDUCATION FOR PRIMARY CARE
2021, VOL. 32, NO. 3, 135–139
https://doi.org/10.1080/14739879.2020.1869589

LEADING ARTICLE

Medical students as service learners: opportunities, risks and recommendations

a a
Felicity Lalloo , Nichola Hawkins , Rachel Lindleyb and Sonia Kumara
a
Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK; bDivision of Medical Education,
Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK

ABSTRACT ARTICLE HISTORY

Service learning is a form of experiential education that is being implemented internationally Received 26 August 2020
within undergraduate primary care, with the potential to significantly enhance clinical practice Revised 13 December 2020
whilst simultaneously facilitating medical students’ learning. Though the benefits of service learn­ Accepted 23 December 2020
ing are widely acknowledged within the literature, there is little documentation of the associated KEYWORDS
challenges. Drawing on reflections from our own practice, and those of colleagues from a variety of Medical education;
institutions across the UK, we propose four key areas of risk associated with the integration of undergraduate; primary care;
service learning into undergraduate medical education: unsafe encounters, patient disempower­ general practice
ment, inequality of experience and misalignment of service and learning priorities. Considering
each area in turn, we identify contributory factors alongside practical recommendations to miti­
gate these risks. Acknowledgement of this subject is timely as medical schools develop their
curricula to reflect evolving service and patient priorities in light of the COVID-19 pandemic. We
aim to encourage discussion and debate amongst the medical education community at a time
where emphasis is being increasingly placed on medical students as being active participants in
the delivery of patient care. In doing so, faculty may reduce associated risks and maximise the
benefit of opportunities for all stakeholders.

Introduction
Service learning can be defined as ‘a form of experiential
education in which students engage in activities that
address community needs, together with structured
opportunities for reflection to achieve desired outcomes’
[1]. Highly valued in the education of healthcare profes­
sionals, it is thought to promote a symbiotic relationship
between the learning needs of students and the healthcare
needs of the local population, with benefit to both [2].
Experiential learning of this nature is considered key
to the professional identity formation of students in
wider healthcare education, including nursing, dentis­
try, pharmacy, and medicine. Research highlights the
significance of ‘experimenting’ within one’s own voca­
tion [3], fostering the development of undergraduates
that are able to ‘think, act and feel’ like a member of
their future profession [4,5]. This, alongside exposure to
the increased levels of complexity and uncertainty asso­
ciated with ‘real life’ learning outside of the classroom, is
believed to support healthcare undergraduates in the
‘holistic transition’ from student to independent practi­
tioner [4,6]. More specifically, immersive service learn­
ing experiences where students work within
a community of practice, with increasing levels of active
participation, have been shown to foster professional
identity formation in medical students [5,7].
Incorporating service learning and associated reflec­
tive opportunities into undergraduate medical curricula
enables students to develop the professional knowledge,
skills and behaviours expected of UK graduates as set
out by the General Medical Council (GMC) [8]. Indeed,
medical students’ engagement in service learning has
been shown to support the development of skills includ­
ing critical thinking, collaboration and problem solving,
as well as advancing their understanding of social
responsibility [9].
In conjunction with the student benefits of service
learning described, communities gain not only direct
support in addressing their specific current health
needs but the additional future benefit of having
a better trained and more competent medical workforce.
Furthermore, it offers communities novel opportunities
to collaborate and network, which may enhance outputs
and enable more individuals to benefit [2].
Service learning is incorporated into the education of
healthcare professionals in different forms. Within under­
graduate primary care medical education, opportunities
commonly include community research projects, where

CONTACT Sonia Kumar sonia.kumar@imperial.ac.uk Department of Primary Care and Public Health, School of Public Health, Imperial College London,
London W6 8RP, UK
© 2021 Informa UK Limited, trading as Taylor & Francis Group
136 F. LALLOO ET AL.
students identify local needs, design and deliver
a sustainable intervention before evaluating and presenting
their work [2]. Other examples include health education
and promotion work with schools and participation in
longitudinal follow-up of a specific panel of patients [9].
These varied learning opportunities encourage students to
take on active and meaningful roles within the multi-
disciplinary healthcare team across a variety of settings;
underpinned by community collaboration, authentic
learning occurs synergistically with patient care.
The evolving COVID-19 pandemic has acutely
emphasised the value of service learning. Clinical teach­
ing capacity globally has been compromised as the
demands on the healthcare system have significantly
increased. Aware of the benefits that service learning
potentially offers both students and patients, particularly
at this time of global crisis, many medical schools are
looking to integrate increased service learning approaches
into their curricula. In the UK, the Medical Schools
Council has encouraged faculty to reconsider learning
opportunities on placements, supporting ‘the idea of stu­
dents wherever possible being active participants in the
delivery of care rather than simple observers’ [10].
As students take on more meaningful service-led
roles, a ‘paraprofessional’ role emerges for medical stu­
dents where they take on responsibilities that benefit the
community in addition to their own learning [11]. It
therefore feels timely to pause to consider the potential
risks of service learning alongside possible strategies
that may be employed to maximise benefits and ensure
safety for students, patients, and the healthcare system.
In November 2019, at the ‘Service Learning in
Healthcare conference’ hosted by the University of
Manchester, we ran a workshop entitled ‘ABC of bring­
ing service learning into your curriculum’. This was
attended by 24 colleagues involved in healthcare educa­
tion across a variety of UK institutions.
Building on discussions during the workshop, and
reflections from our own practice, we present
a framework to outline and address some of the risks
and challenges that service learning could pose in med­
ical education, alongside possible strategies to mitigate
these. Whilst the focus of this article considers service
learning from an undergraduate primary care perspec­
tive, many of the fundamental principles could also
apply to undergraduate secondary care settings and
medical education more broadly.
Potential risks and recommendations
Service learning can be seen as the intersection between
three key stakeholders: the health service, students and
the community. It is here, at this point of intersection,
that we propose there are four key areas of risk to
consider: unsafe encounters, disempowerment of stake­
holders, inequality of experience and misalignment of
service and learning priorities (Figure 1). Considering
each area in turn, we identify contributing factors along­
side practical recommendations to navigate these risks.
Safety
Risks
With patient safety at the heart of the medical profes­
sion, it is essential that students can recognise, and
practice within, the limitations of their own competen­
cies [8]. There is a danger that the ‘paraprofessional’
student may take on, or feel pressured into taking, more
responsibility than they are able to manage safely. In
doing so there is not only a risk to patients but also a risk
to students and tutors with the potential for significant
emotional burden and burnout.
Recommendations
Conducting an initial, shared assessment between student
and supervisor ensures that both are aware of the level of
the individual student’s skills, competencies and confi­
dence, the potential safety risks that could arise and how
to mitigate these where possible. The use of a Student
Charter offers one opportunity to clearly outline expecta­
tions of both tutor and student, and specifically highlight
the importance of students working within their limita­
tions. Furthermore, continuity and familiarity between
student and supervisor could enable the effective use of
Entrustable Professional Activities (EPAs) – tasks
entrusted to a student to perform due to agreed sufficient
competence [12], relevant across different health profes­
sions [13,14]. Alongside adequate and timely debriefs
after patient encounters, these measures can safeguard
students working beyond their own capabilities.
Faculty support is also key here, with clear guidance
for students, tutors and patients of what can be expected
of the student at each stage of training, alongside exam­
ple activities. Outlining students’ levels of expertise and
managing patient expectations in this way, alongside the
other measures described, will all contribute to main­
taining patient safety.
Patient disempowerment
Risks
Service learning provides valuable opportunities for the
development of strong and mutually beneficial student–
patient relationships. However, there is a potential for
power imbalances. Student involvement may inadver­
tently result in over-medicalisation of patients, for
 EDUCATION FOR PRIMARY CARE 137

Figure 1. Framework to consider the risks of service learning and strategies to mitigate against these. Service learning lies at the
intersection between the health service, students and the community. Within this critical intersection we highlight four key areas of
risk with potential contributing factors, alongside practical recommendations.

example during a low-risk pregnancy. Formation of
a close student-patient friendship could also result in
emotional dependency and subsequent feelings of ‘aban­
donment’ on completion of the student’s placement or
project; this is consistent with research highlighting the
sense of loss experienced by panel patients when students
reach the end of their longitudinal clerkship [15]. Overall,
patients may become increasingly disempowered due to
over-reliance on their student’s presence [18].
Recommendations
Guidance from faculty to all parties can help set appro­
priate expectations and raise awareness of the different
stakeholder roles. Taking this further, the development of
shared, co-created ‘ground rules’ between students and
their patients in a collaborative relationship can lead to
avoidance of the power imbalance described. Coaching
approaches can also be used by students with their
patients to increase patient empowerment and activation
with their health [16]; existing research is supportive of
this approach amongst wider health professions includ­
ing nursing, pharmacy and allied health professions [17].
Additionally, it is important to consider the sus­
tainability of these community relationships.
Undergraduates repeatedly move between placements
and therefore facilitating effective patient handover
between students could help to mitigate the sense of
loss that may be experienced.
Inequality of experience
Risks
Both students and patients may be affected by unequal
experiences on service learning placements. For students,
variation across placements may affect the learning oppor­
tunities presented, and quality of service provision can
differ.
Certain patient groups may also be excluded from
selection, for example those with mental health diag­
noses, where English is not their first language, com­
plex needs or no fixed abode. These patients arguably
stand to gain significantly from the service learning
collaboration, and it may be considered inequitable
that only certain patients who are seen to be ‘good’
for student learning are selected to participate in such
partnerships.
Recommendations
Supervisors should be encouraged and supported to
offer service learning opportunities in all clinical
138 F. LALLOO ET AL.
Figure 2. The balance of service learning (adapted from Furco [10]).
settings, as well as to involve more complex patients in
student-led care where appropriate. A solid quality
assurance process is important, whereby faculty focus
on consistency of experience for both students and
patients. Whilst we acknowledge that some variation
in opportunities is inevitable, ongoing evaluation from
the perspectives of all stakeholders can help to identify
and address key areas of inequality.
Misalignment of learning and service priorities
Risks
Ideally, service learning should offer equal opportunities
for student learning and service provision, mutually
benefiting both. It is useful to consider the spectrum of
opportunities that exists between the two (Figure 2).
Should students’ learning be prioritised, there is a risk of
bias, whereby patients are specifically selected for the stu­
dents’ educational priorities; here, there may be little ben­
efit to the patient themselves and they may not truly
represent the local community. For example, supervisors
may seemingly exclude patients who are non-English
speaking or have less ‘interesting’ (although more com­
mon) conditions. Furthermore, patients may feel pressured
into participation and unable to subsequently withdraw,
and there is a risk that a self-selected student group may be
more motivated by their own learning objectives than by
patient needs. Overall, patients and communities could feel
they are being ‘used’ by the medical education system.
Conversely, where emphasis is placed on service,
learning opportunities may not directly align with
intended learning outcomes and assessments dictated
by medical school curricula; time spent by students
working on a project could therefore be disproportion­
ate to the medical school assessed educational out­
comes. As a result, students may disengage with the
process, negatively impacting their academic studies
and patient care.
Recommendations
Whilst it is recognised that an exact balance between
service and learning at all times may be unrealistic, this
should remain the aim of these programmes. Here,
education and collaboration are key. Faculty should out­
line the service learning model from the outset to
patients, students and tutors, to set expectations and
encourage shared responsibility. Stakeholder remunera­
tion and formal recognition for community collaborators
could also be considered. These in turn should promote
‘buy-in’ from all stakeholders and drive true collabora­
tion, enabling effective application of principles into the
development and delivery of a balanced project.
Conclusion
Service learning has significant educational and com­
munity benefits, but its integration within undergradu­
ate education is not without risk. Through
acknowledgement of these risks, we aim to encourage
discussion and debate within the medical education
community around how they may be mitigated and, in
doing so, maximise the benefit for all involved.
This discussion is key and timely as medical schools
develop their curricula to reflect evolving priorities dur­
ing the COVID-19 pandemic, and the role of service
learning progresses from a novel addition to the curri­
culum to a core component of medical students’ under­
graduate clinical placements.
Acknowledgments
Medical Education Innovation and Research Centre (MEdIC).
Disclosure statement
No potential conflict of interest was reported by the authors.
Contributorship
FL and NH wrote and finalised the article. RL and SK revised
the draft and provided critical feedback. The final version of
the article was approved by all authors.
ORCID
Felicity Lalloo http://orcid.org/0000-0002-5698-4120
Nichola Hawkins http://orcid.org/0000-0001-9535-7616

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