Community and outreach projects in medical school

It is Saturday morning at a public school on the outskirts of town. A group of second-year students has set up three tables in the courtyard: at one, they check blood pressure; at another, they teach children how to brush their teeth; at the third, they talk with mothers about vaccinating their children. A woman says she stopped taking her blood pressure medicine because she ran out and the health unit had none. One of the students writes it down, not quite sure what to do with the information. On the way back, the group debates whether that was care, a class or just a good deed.

This question is the starting point of this guide. Community and extension projects exist at medical schools in many countries, under different names, and in some of them they are already a required part of the curriculum. But not every project teaches, and not every project helps the community. Here you will understand what extension is, what international research on service learning and student clinics shows, how to choose a project that is worth your time, what ethical care it requires and how to use the experience to learn clinical reasoning.

Key points

• Community and extension projects bring the school together with the community, and in the international literature they appear as service learning and community-based education.
• A systematic review found little emphasis on reciprocity between schools and communities, the point that defines a good project (Hunt et al., 2011).
• Education alongside the community can improve empathy and understanding of the social determinants of health (Plessas et al., 2024).
• Student-run clinics show positive results for patients with various conditions, though the studies still have weak designs (Broman et al., 2022).
• In studies in Brazil and the United Kingdom, improving the curriculum appears among the main motivations of students for activities outside the grid (Oliveira et al., 2024; Nikkar-Esfahani et al., 2012).
• A good project has supervision, continuity, feedback to the community and room for reflection.

Summary

• What community and extension projects are
• What the research shows about service learning
• Student clinics and what happens to patients
• How to choose an extension project
• Ethical care in extension
• Extension as clinical reasoning training
• Clinical cases on NEXO for leagues and projects
• Frequently asked questions
• Checklist for joining an extension project

What community and extension projects are

At many universities, especially in Latin America and in Portuguese- and Spanish-speaking countries, the mission rests on three pillars: teaching, research and extension. Elsewhere, the same work appears as a community project, service learning or a community placement. In every case, it is the part that takes the university beyond its walls, in actions with the community that at the same time train the student and respond to real needs. In medicine, it appears in varied formats: health campaigns, education in schools, actions in rural or Indigenous communities, academic leagues with open activities, joint efforts, student clinics and long-term projects with a defined territory.

Some countries have made this experience mandatory by national rule, and others leave the decision to each school. One example of a rule is Brazil: Resolution CNE/CES No. 7 of December 18, 2018 established that extension activities must make up at least 10% of the curricular workload of undergraduate courses (Brasil, 2018). At many schools, especially in the United States, community experience comes as service learning, a community placement or a student clinic, in formats that vary greatly from school to school (Stewart e Wubbena, 2015). Where it is mandatory, the student's question changes: it is no longer whether to take part but which project to choose and how to make the most of the time.

What a national rule describes

The text of the Brazilian resolution serves as an example of what a regulation can say about what counts as extension and what is expected of it. Extension is defined as an activity integrated into the curriculum and into research, which promotes an interaction that changes both the institution and other sectors of society, in permanent articulation with teaching and research. Among the principles listed are dialogical interaction with the community, through the exchange of knowledge, and the student's civic education, built in an interprofessional and interdisciplinary way. The document also names the possible modalities: programs, projects, courses and workshops, events and service provision (Brasil, 2018).

Two points in this wording matter to anyone choosing a project. The first is the word dialogical: the regulation does not describe extension as delivering a service to a passive community, but as an exchange, in which the university also learns. The second is the mention of the interprofessional character, which brings extension close to the teamwork you will find in the health network. In any country, each school defines, in its pedagogical project, how the hours are distributed and recorded, so it is worth reading your course's document and talking to the coordination before planning the semester.

The names the literature uses

Anyone looking for articles on the topic will find other names. The international literature speaks of service learning, which combines community service with learning objectives and structured reflection, and of community-based medical education, which takes part of the teaching outside the hospital. There is also a large literature on student-run clinics, common in the United States, and on the social accountability of medical schools, which discusses the school's commitment to the health needs of the population it serves (Woollard, 2006).

These traditions overlap, but they are not identical. Extension, in the Latin American definition, must work both ways: the university learns from the community, and does not only bring knowledge to it. This point, as we will see, is precisely what is most lacking in the programs described in the literature.

What the research shows about learning in service

A systematic review on service learning in medical education, covering studies from 1998 to 2012, confirmed a great heterogeneity among programs and organized the differences into categories such as setting, design, funding, participation, implementation, assessment and outcomes for the student (Stewart and Wubbena, 2015). In other words, there are many different projects under the same name, and the outcome depends on the design.

Another systematic review examined the objectives of these programs. The authors found a focus on benefits for the student, such as understanding the social determinants of health, and many articles that treated the community placement as equivalent to the traditional curriculum, but little emphasis on the reciprocal character of partnerships between schools and communities (Hunt et al., 2011). They proposed that the principle of community partnership should train students prepared for a health system with an agenda of accountability to the community.

Gains described for the student

The studies describe varied gains. The most frequent are:

• Empathy and cultural sensitivity: in a mixed-methods review, education alongside the community helped students understand local needs, overcome stereotypes and improve empathic communication (Plessas et al., 2024).
• Applied public health: in a service learning program, students acquired skills such as diagnosing community needs, searching for evidence and designing an assessment, with grades comparable to those of the previous year (Essa-Hadad et al., 2015).
• Systems-based practice: student clinics teach how to solve problems and navigate the health system to serve vulnerable populations (Meah et al., 2009).
• Teamwork: clinics run by students from several professions help each one understand their own role and that of the others (Hopkins et al., 2022).
• Personal and professional development: in a community project abroad, students reported gains in communication, adaptability, ethics, leadership and resilience (Nadarajan et al., 2024).
• Career choice: volunteer activities and involvement with the team are among the curricular factors that influence the choice of specialty (Schoon and Kötter, 2024).

What is still missing

Most of this evidence comes from student reports, qualitative studies and before-and-after assessments, without a control group. A narrative review on social accountability in undergraduate education found that the student experience was the most studied outcome, followed by career choice, and that a truly socially accountable curriculum should also measure the impact on the community (Mihan et al., 2022). Almost nobody measures whether the community got better.

Student clinics and what happens to patients

In the United States, free clinics run by students, with physician supervision, serve people without health insurance. They offer a good laboratory for understanding what a student project can deliver. An integrative review found positive results for patients in conditions such as diabetes, hypertension, depression, quality of life and vaccination, but called for studies with more rigorous, prospective designs (Broman et al., 2022).

In a scoping review of patient-centered outcomes research in these clinics, 36.8% of the studies reported improvement in the indicators after an intervention and 20.7% reported performance equal to or better than the national targets (Silvestri et al., 2023). In a student clinic in New York, the quality of care reached or exceeded the national benchmarks in 16 of 18 indicators assessed (Jiang et al., 2024).

The lesson for other health systems

In countries with a universal public system, such as Brazil, Canada or the United Kingdom, the model of a free clinic for those without insurance does not transfer directly. The lesson that does transfer is another one: a student project can offer quality care when it has supervision, protocol and continuity, and it can do harm when it does not. Integration with the local public network, especially with primary care and community health workers, is what allows the woman who stopped her medication in the opening scene to be referred to someone who will follow up with her after Saturday.

How to choose an outreach project

With so many options, the choice weighs heavily. A study with medical students in Brazil showed that participation in extracurricular activities is broad and diverse, motivated above all by the desire to enrich the curriculum and develop skills, and that time management and academic adaptation are important challenges, especially early in the course (Oliveira et al., 2024). In the United Kingdom, a survey on student participation in research and audit outside the curriculum found curriculum improvement cited as a motivation by 51% of them (Nikkar-Esfahani et al., 2012). The question, therefore, is not only whether the project is good, but whether it fits into your life.

The table below helps compare projects based on criteria that appear in the literature and in practice:

Criterion	Sign of a strong project	Warning sign
Supervision	A professor or professional present and responsible	Students alone performing clinical procedures
Continuity	A bond of months or years with the same territory	One-off actions with no follow-up
Reciprocity	The community takes part in planning	The project alone decides what the community needs
Integration with the network	Referral arranged with the health unit	Findings with no destination
Reflection	Meetings to discuss what was seen	Only the action, with no conversation afterward
Evaluation	Some record of the effect on the community	Only a count of appointments
Workload	A clear commitment compatible with the course	Demands that override exams and rest

Types of project and what each one teaches

It is worth knowing the most common formats, because each one trains different skills. One-off actions, such as campaigns and task forces, are a good entry point: they require little time, put you in contact with many people and teach you to approach someone you do not know, to explain a simple guidance and to recognize when a finding needs referral. The limit is the lack of continuity, since you rarely meet the same person again.

Health education projects, in schools, associations or patient groups, teach you to translate technical knowledge into accessible language. Explaining to a class of teenagers why treatment for an infection cannot be interrupted forces you to understand the subject for real. It is communication training that will serve you in every future consultation.

Community projects, with a long-term bond to a community or a health unit, are the ones that come closest to the ideal of reciprocity. In them you follow families over months, learn about housing, work and access conditions, and see how the same disease has different courses depending on the context. They require more time and commitment, and usually teach more.

Supervised care projects, when they exist, are the ones that train clinical reasoning the most: history, examination, hypotheses, management and follow-up, with discussion with the supervisor. They are also the ones that require the most ethical care, because they involve decisions about someone's health. Finally, there are research projects with the community, which combine outreach and investigation and teach you to formulate a question from a local problem, to collect data with respect and to return the results to those who took part.

No format is absolutely better. The ideal is to combine different experiences throughout the course, starting with simpler actions in the basic cycle and moving on to community or supervised care projects in the clinical cycle. This progression follows your own development and prevents you from taking on responsibilities before you are prepared. The post on how to choose a medical specialty recalls that these experiences also help you discover affinities.

Questions to ask before joining

Before signing up, talk to people who already take part and ask a few direct questions. Who supervises and how often? What happens to the people served after the action? Was the community heard about what it needs? Are there meetings to discuss the cases? How much time per week does the project really require? The answers say a lot about what you will learn and about what the community will gain.

It is also worth thinking about what you are looking for. If you want to learn clinical reasoning, prefer projects with supervised care and case discussion. If you want to learn public health, prefer projects with community diagnosis and evaluation. If you want to do research, look for projects that already have a question and a supervising professor, a topic the post on research in the Medicine undergraduate course develops.

Outreach and curriculum

Outreach projects count in the academic curriculum and, in many countries, in residency selection processes. The post on the academic curriculum of the Medicine student explains how to record your participation. But be careful with the logic of collecting certificates. An integrative review on extracurricular activities in medical education discussed the results in terms of academic growth, career development and psychological experiences, and suggested ways to improve the quality of these activities to maximize the educational effect (Kim et al., 2023). A project experienced in depth usually teaches more than several done in passing.

Ethical care in outreach

Projects with the community involve real people, often in situations of vulnerability. A narrative review on preventive care in student clinics recalled that the principles of beneficence and non-maleficence should guide the choice of services offered, and that actions such as screening require well-organized follow-up (Vu et al., 2024). Detecting a problem without guaranteeing care afterward can cause more harm than benefit.

Some precautions every project should have:

1. Real clinical supervision whenever there is health assessment or guidance.
2. A clear limit on what students do, agreed with the responsible team.
3. Referral flow agreed with the health unit before the activity.
4. Consent and privacy, including for photos and records.
5. Feedback to the community on what was done and what was found.
6. Respect for local culture, with the community as a partner, not an audience.

The risk of health tourism

Projects in distant communities, in your own country or abroad, can become experiences that are more useful to the student than to the population. The risk grows when the project arrives, provides care and leaves, with no continuity and no link to the local network. A well-structured project abroad can bring learning aligned with the competencies of systems-based practice and professionalism, when there is reflection and follow-up of patients over time (Nadarajan et al., 2024). The post about internships abroad and exchanges discusses how to choose experiences outside the country with this care.

Outreach as clinical reasoning training

Outreach is often seen as a social activity, separate from clinical study. It can be much more than that. Each person seen in an activity brings a story, a context and a clinical question. The woman who stopped her blood pressure medication is an example: behind the simple complaint there is a question of adherence, access, understanding of the disease and cardiovascular risk. Thinking about this methodically is clinical reasoning applied to the territory.

A script for after the activity

After each activity, set aside a few minutes to turn what you saw into learning:

• Choose one person you saw and describe the situation in three sentences.
• List what you did not know and need to study.
• Think about the context: which social factors weigh on the problem.
• Discuss with your supervisor what the ideal next step would be and what is possible.
• Record what changed in the way you see that problem.

This habit connects with the idea of active learning and reflection on experience, the theme of the post about active learning in medicine. It also helps you see that the patient in the community is no different from the patient in the hospital: it is the same person, seen before becoming seriously ill.

Engagement as an outcome

There is a less visible effect of outreach: engagement with your own course. A scoping review on student engagement in undergraduate medical education showed that it can be encouraged when learning seems relevant, when there are good relationships with colleagues and teachers and when the student feels autonomy and competence (Kassab et al., 2022). A good outreach project brings these conditions together. For many students in the basic cycle, it is the first time the classroom content gains a face.

Clinical cases on NEXO for student leagues and projects

NEXO can be a complement for outreach projects and academic leagues. In the case of the day, the diagnosis arrives in up to six clues, one at a time, and the proximity in ICD-10 shows how far each guess was from the answer. The cases are fictional with a real clinical presentation, which allows you to train reasoning before and after activities without exposing anyone.

One way to use it is to open each reflection meeting of the project with the case of the day, discussed as a group, and then return to the people seen during the week. The exercise helps the group practice the same question in both contexts: which hypotheses make sense and what is missing. The guide on what NEXO is explains the whole game, the limits of use are on the NEXO economy page, and the NEXO blog gathers other texts about life in medical school.

If you coordinate a medical school, a student league or an outreach project and want cases for the group meetings, learn about NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Physicians who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is an outreach project in medical school?

It is a university activity with the community that trains the student and responds to the population's health needs, under the supervision of professors.

Is extension mandatory?

It depends on the country and the school. In some places it is: in Brazil, for example, Resolution CNE/CES No. 7/2018 requires that extension make up at least 10% of the curricular workload of undergraduate courses (Brazil, 2018). In many schools in other countries, community experience is a mandatory course or an optional activity defined by the school itself.

What does the student learn in extension?

Studies describe gains in empathy, understanding of social determinants, applied public health and teamwork (Plessas et al., 2024; Essa-Hadad et al., 2015).

Do student projects make a difference for patients?

Student clinics show positive results in various conditions, but the studies still have weak designs (Broman et al., 2022).

How to choose a good project?

Look for supervision, continuity, partnership with the community, integration with the health network and reflection meetings (Hunt et al., 2011).

How many projects should I do?

There is no right number. Time management is the challenge most cited by students (Oliveira et al., 2024), and one project experienced in depth usually teaches more than several done in passing.

Checklist for joining an extension project

• Supervision: know who is responsible for the project and when they are present.
• Destination of findings: confirm the referral flow with the network.
• Partnership: see whether the community takes part in planning.
• Reflection: look for meetings to discuss what was seen.
• Time: agree on a workload compatible with the course and with rest.

Want to train clinical reasoning between one activity and another? Play the case of the day on NEXO.

References

1. Woollard RF. Caring for a common future: medical schools' social accountability. Med Educ. 2006. PubMed
2. Stewart T, Wubbena ZC. A systematic review of service-learning in medical education: 1998-2012. Teach Learn Med. 2015. PubMed
3. Hunt JB, Bonham C, Jones L. Understanding the goals of service learning and community-based medical education: a systematic review. Acad Med. 2011. PubMed
4. Plessas A, Paisi M, Ahmed N, Brookes Z, Burns L, Witton R. The impact of community engaged healthcare education on undergraduate students' empathy and their views towards social accountability; a mixed methods systematic review. BMC Med Educ. 2024. PubMed
5. Essa-Hadad J, Murdoch-Eaton D, Rudolf MC. What impact does community service learning have on medical students' appreciation of population health? Public Health. 2015. PubMed
6. Meah YS, Smith EL, Thomas DC. Student-run health clinic: novel arena to educate medical students on systems-based practice. Mt Sinai J Med. 2009. PubMed
7. Hopkins S, Bacon R, Flynn A. Student outcomes for interprofessional education in student led clinics: a rapid review. J Interprof Care. 2022. PubMed
8. Nadarajan GD, Rasappan K, Ng JSY, Junchen ML, Yoon S. Medical students' experience and learning outcomes of overseas community involvement project: a qualitative study. BMC Med Educ. 2024. PubMed
9. Schoon B, Kötter T. Intracurricular factors influencing medical students' specialty choice: a systematic review. Adv Med Educ Pract. 2024. PubMed
10. Mihan A, Muldoon L, Leider H, Tehfe H, Fitzgerald M, Fournier K, et al. Social accountability in undergraduate medical education: a narrative review. Educ Health (Abingdon). 2022. PubMed
11. Broman P, Tokolahi E, Wilson OWA, Haggie M, Andersen P, Brownie S. Patient outcomes from student-run health services: an integrative review. J Multidiscip Healthc. 2022. PubMed
12. Silvestri F, Mellgard G, Goldstein J, Chennareddy S, Tang J, Tran M, et al. How are we doing? A scoping review of published patient-centered outcomes research in United States student-run free clinics. Teach Learn Med. 2024. PubMed
13. Jiang JJ, Link K, Mellgard G, Silvestri F, Qian D, Chennareddy S, et al. Evaluation of patient health outcomes of a student-run free clinic in East Harlem. BMC Med Educ. 2024. PubMed
14. Nikkar-Esfahani A, Jamjoom AA, Fitzgerald JE. Extracurricular participation in research and audit by medical students: opportunities, obstacles, motivation and outcomes. Med Teach. 2012. PubMed
15. Oliveira NM, Viana DA, Santos JR, Quintanilha LF, de Jesus RF, Avena KM, et al. Engagement in extracurricular activities during medical school: a cross-sectional study on student motivations and challenges. J Med Educ Curric Dev. 2024. PubMed
16. Kim S, Jeong H, Cho H, Yu J. Extracurricular activities in medical education: an integrative literature review. BMC Med Educ. 2023. PubMed
17. Vu A, Hsu AR, Baumel NM, Holthe J, Ho JY, Goldberg SY, et al. Preventative care in student-run free clinics: a narrative review on feasibility, ethics, and recommendations. BMC Med Educ. 2024. PubMed
18. Kassab SE, El-Sayed W, Hamdy H. Student engagement in undergraduate medical education: a scoping review. Med Educ. 2022. PubMed
19. Brazil. Ministry of Education. National Council of Education. Higher Education Chamber. Resolution No. 7, of December 18, 2018. Official Gazette of the Union. 2018. Ministry of Education (PDF)