patient outcomes Seeking impact of medical schools on health: meeting the challenges of social accountability

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1 patient outcomes Seeking impact of medical schools on health: meeting the challenges of social accountability Bob Woollard & Charles Boelen CONTEXT The acquisition of sums of knowledge and mastery of sophisticated technologies by medical graduates is insufficient for their responsibilities to recognise and adapt to people s evolving needs. RESPONSE A Global Consensus on Social Accountability for Medical Schools brought together 130 organisations and individuals from around the world with responsibility for health education, professional regulation and policy making to participate for 8 months in a three-round Delphi process leading to a 3-day consensus development conference which included weighted representation from all regions of the world. The resulting Consensus reflects agreement on 10 strategic directions to enable a medical school to be socially accountable. RESULTS The list of 10 directions embraces a system-wide scope from identification of health needs to verification of the effects of medical schools on those needs, all driven by the quest for positive impact on peoples health status. This includes an understanding of the social context, an identification of health challenges and needs and the creation of relationships to act efficiently (directions 1 and 2). Within the spectrum of the health workforce required to address health needs, the anticipated role and competences of the doctor are described (direction 3) serving as a guide to the education strategy (direction 4), which the medical school is called to implement along with consistent research and service strategies (direction 5). Standards are required to steer the institution towards a high level of excellence (directions 6 and 7), which national authorities need to recognise (direction 8). While social accountability is a universal value (direction 9), local societies will be the ultimate appraisers of the achievements of the school and its graduates (direction 10). Medical Education 2012: 46: doi: /j x Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada Correspondence: Bob Woollard, Department of Family Practice, University of British Columbia, # University Boulevard, Vancouver, BC, Canada V6T 1Z3. Tel: ; Fax: ; woollard@familymed.ubc.ca ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46:

2 B Woollard & C Boelen THE UNFINISHED QUEST FOR THE STATE OF THE ART The crisis of our time relates not to technical competence, but to a loss of the social and historical perspective, to the disastrous divorce of competence from conscience. 1 To those seeking ever more effective ways of shaping and evaluating the development of future medical practitioners, this reflection by Ernest Boyer in 1990 is a reminder that equal care must be taken to ensure that such development progresses in the right direction. 1 Boyer was tasked by the Association of American Medical Colleges (AAMC) to examine the continued relevance of medical scholarship in a changing world and cautioned that excellence must be carefully defined as we dedicate ourselves to its pursuit. In the search for right priorities in health care and medical education, we should be guided above all by the interests of those who are to be served: patients, families, communities, as well as nations. At the same time, we have a collective moral obligation to work towards building a health service delivery system that can sustainably support the values of person-centred care and equity. In their challenging task of preparing future generations of doctors, medical schools must maintain these values as beacons to guide their development and landmarks against which to gauge their achievements. An international meeting of medical education experts in 1994, called jointly by the World Health Organization (WHO) and the Educational Commission for Foreign Medical Graduates (ECFMG), affirmed, in a remarkable blend of altruism and science, that serving the specific needs of populations and individuals is an essential characteristic defining the quality of medical education and should be an important goal of all medical schools. 2 More recently, the notion of professionalism, advocated internationally in calls for doctors to be good care providers, to be respectful of patient autonomy and to be advocates of social justice, represents another important reference for the adjusting of the missions and educational functions of medical schools. 3 7 Recognition of and adaptation to people s evolving needs and societal challenges require more than the acquisition of sums of knowledge and mastery of sophisticated technologies by medical graduates. Referring to the US context, Jordan Cohen notes: medical students too often graduate without all of the knowledge and skills that 21st century physicians need and without fully appreciating the role that professional values and attitudes play in sustaining medicine as a moral enterprise and that All medical schools have an obligation to educate future physicians who are prepared both to assess and to meet the health needs of the public. 8 SOCIAL PRESSURE AND THE CHALLENGES AHEAD The aspirations of people and societies for greater transparency, democracy, participatory management, accountability for returns on investments and explicit contributions to public wealth are growing worldwide. These are further enhanced by globalisation and its correlating quest for a fair balance between economic growth and social justice. Medical schools cannot stand aside from using their considerable intellectual and physical resources to assist in that quest. The search for health, at any scale from the individual to the global, is simultaneously a search for social justice. One of the greatest challenges to be imposed on medical schools in the future will require them to strive for and demonstrate greater impact on health through tied bonds with society. This is precisely the purpose of social accountability. An etymological reference tells us this: social is derived from the Latin word socius, meaning an ally, and accountable indicates something that is both measured and reported back. 9 It is this extended sense of accountability that challenges medical schools in the 21st century. Too often, a medical school looks like an island in the midst of an archipelago of a complex health system, and its communications with other islands are generally uncertain. The medical school island educates the future medical workforce, conducts research into a variety of health-related issues, and provides services. Likewise, other islands, such as those represented by practitioners in many specialties (each of which may inhabit their own small islet), health delivery settings of different sizes, health insurance companies, social services, workplaces, educational institutions, civil society organisations, and so forth contribute in their own ways to alleviate suffering, prevent risks and promote healthy living. Although all belong to a common territorial entity and share a common culture, they have yet to establish solid bridges among themselves to build the most productive and sustainable project for the islanders well-being. 22 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46: 21 27

3 Seeking impact of medical schools on health The impact of medical schools on people s health is tied to stakeholders commitment to share a common vision of health (i.e. a complete state of physical, mental and social well-being) and a common set of values such as quality, equity, relevance and efficiency in service delivery. 10 For instance, the three-tier statement that people s health needs should determine which type of doctors should be trained, that doctors need to acquire appropriate competencies during their training and that doctors should practise where they are most needed is an equation that demands the commitment of three different values (relevance, efficiency, equity) and five different groups of stakeholder (policymakers, medical educators, health managers, doctors and citizens themselves). Theoretically, from an economic standpoint, the medical school could be viewed as a hub coordinating the three functions of sounding out market needs, producing a product and dispatching it to consumers. Practically, it essentially focuses on the production of graduates and displays less concern for the context of their future practice. If we are to contribute to an ever-increasing effectiveness of medical education in preparing practitioners, educators and scientists for an uncertain future, it is clear that such education must embrace adaptability and the capacity to manage new knowledge and develop new skills as graduates pursue a course of lifelong learning. That is easy to say. It is another matter to recognise, develop and teach adaptability in the context of the values that must underpin those adaptations. In an increasingly multicultural and distressingly inequitable 11 global society, it becomes challenging to describe, let alone set learning objectives for the core axis around which both professional development and the education enterprise must turn. THE EMERGENCE OF THE CONCEPT OF SOCIAL ACCOUNTABILITY Medical schools obligation to society is encapsulated in the term social accountability, defined by the WHO as: the obligation to direct their education, research, and service activities towards addressing the priority health concerns of the community, the region, or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organisations, health professionals and the public. 12 This implies that medical schools must effectively engage with collaborative partners in pursuit of people s wellbeing. By this action they build a new definition of academic excellence that moves beyond the current model and assesses, not just the stature of ongoing scholarship, but the manner in which it can be seen to apply to the social obligation to improve the health status of all. The broad contours of social responsiveness were established decades ago when concepts of community-based and community-oriented medical education were promoted by the WHO and the Network of Community-Oriented Educational Institutions in Health Sciences, now called the Network towards Unity for Health. 13 A more recent focused network called THEnet (Training for Health Equity Network; http: has further amplified, supported the development of and attempted to assess this. 14 This work proceeded from the assumption that innovative approaches in educational processes would result in a proportionate impact on people s health. The concept of social accountability widens the scope of innovations to include the relevant planning of human resources for health and the proper insertion of graduates in a supportive working environment. The term social responsibility, applied to an institution, implies awareness of duties regarding society; the term social responsiveness implies engagement in a course of actions that respond to social needs. Social accountability, in turn, implies a justification for the scope of the actions undertaken and asserts that the attaining of anticipated outcomes and results will be verified. Although the general principles of social accountability have been well established for over a decade, 9,11,15 its application in the lived history of medical schools has been slower to achieve. 16 By contrast, excellent examples are present in most regions of the world, but in their focus on the precise needs and priorities of their communities and societies, they often stand out as exceptions IMPLICATIONS FOR MEDICAL EDUCATION What then does this mean for medical education? In a very real sense it means that medical schools must demonstrate a consistent commitment to social accountability in their formal programmes and in their hidden curricula. Through effective engagement with collaborative partners, they must focus their education, research and service resources on the pursuit of understanding and addressing the priority health concerns of their societies. By these ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46:

4 B Woollard & C Boelen actions they build a new definition of academic excellence that moves beyond the current model and assesses, not just the stature of ongoing scholarship, but the manner in which it can be seen to apply to the social obligation to improve the health status of those they purport to serve. Examples of this are emerging and are subject to reflection, 20,21 with attendant implications for the professoriate and the conduct of scholarship. Although some accreditation systems have turned their attention to social accountability 22 or important aspects thereof, 23 many have not and distressingly large (and growing) numbers of medical schools are not subject to any meaningful accreditation assessment. Even those that are tend to be assessed primarily on the basis of their conformity with standards that are almost exclusively focused on the conduct of the medical programme during the time students attend the school. This rather narrow view has been challenged as inadequate to address the social accountability of medical schools. 24 Instead, what has been proposed is a model that sees medical schools accountable for ensuring that existing standards in medical education are revisited and enriched with new standards so that their scope extends beyond processes to encompass inputs (who is trained and from where), outcomes (what graduates actually do once in practice) and impact (how the graduates activities improve the health of citizens). LINKING PROCESS TO IMPACT The issue of linking process to impact was explicitly explored in 1998 by a panel of experts gathered in another joint conference sponsored by the WHO and ECFMG with the task of reviewing strategies used worldwide to improve the social responsiveness of medical schools and measure their effects. 15 A recent initiative towards accreditation in Indonesia 25 developed a model of the quality cascade to illustrate the issues at hand (Fig. 1). Figure 1 The quality cascade Although the potential for confounding influences to exist at each level of this quality cascade is fully recognised, the intent and responsibility of medical schools to initiate the cascade and participate with collaborators in advancing it in this direction are clear. The relationship between medical school innovative work and improved performance in the health care system is difficult to establish, let alone extend to improved health status. Nevertheless, the essence of social accountability demands that participants engage in directions and processes that are most likely to lead in that direction. For instance, we may assume that graduates are more likely to settle in underserved areas if their school has actively worked with health authorities on strategies to attract them to such areas rather than simply imposing a 1-month supervised practicum in a poor community centre or offering only an optional course on disparities in health. Although the value of equity can be enhanced at various degrees of intensity by different schools, the thrust for social accountability calls for the most engaged and far-reaching interventions. Table 1 provides examples of interventions by a socially accountable institution with regard to the values of the health system in which its graduates are expected to function. Table 1 Examples of the commitments of a socially accountable institution Value Efficiency Relevance Quality Equity Intervention Research in health care reforms to ensure the optimal use of graduates consistent with a primary health care model Negotiation with a wide range of health professionals and others to establish the most appropriate roles for doctors Promotion of multi-professional and policy partners in teamwork to address major social determinants of health Engaging student learners with minority groups and facilitating their settlement in vulnerable areas 24 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46: 21 27

5 Seeking impact of medical schools on health In line with the concept of social accountability, academic excellence may be interpreted as the manner in which an institution demonstrates an ethos that is inspired by the health needs of the people and society it serves and the challenges they impose and by the manner in which, through a variety of short- and long-term actions in education, research and service, it extends its practice to impact on those needs. A sample of medical schools in regions ranging from northern Canada to the southern Philippines has demonstrated the benefits of applying the concept of social accountability, which include the retention of graduates working in primary health care settings in underserved communities. 13 Yet, the challenge to clearly correlate social accountability with outcome and impact remains. Conceptual and applied research will be necessary to sharpen ideas and vivify approaches to quality improvement. Table 2 The 10 strategic directions of the Global Consensus for Social Accountability of Medical Schools 1 Anticipating society s health needs 2 Partnering with the health system and other stakeholders 3 Adapting to evolving roles of doctors and other health professionals 4 Fostering outcome-based education 5 Creating responsive and responsible governance of the medical school 6 Refining the scope of standards for education, research and service delivery 7 Supporting quality improvement in education, research and service delivery 8 Establishing mandated mechanisms for accreditation 9 Balancing global principles with context specificity 10 Defining the role of society GLOBAL CONSENSUS The timeliness of this trend was confirmed in 2010 by an initiative entitled Global Consensus for Social Accountability of Medical Schools (GCSA) that brought together 130 organisations and individuals with responsibility for health education, professional regulation and policymaking, selected in a manner that ensured weighted representation of all regions of the world, to participate for 8 months in a three-round Delphi process that led to a 3-day consensus development conference ( The participants are enumerated on the website and represent major international, regional and national bodies with responsibility for education, regulation, accreditation and population health from all continents. Included were perspectives from other health professions. The Delphi and meeting processes were conducted using qualitative research methods such that the categories of agreement emerged from an initial feedback of 43 pages. The process is outlined on the website. The subsequent process of distillation went through three rounds of validation and refinement. Although the working language was English, the Consensus has been translated into French, Spanish, Russian and Arabic. With appropriate deference to the fact that each nation must adapt the material to its own context and priorities, the resulting Consensus reflects agreement on 10 strategic directions to enable a medical school to become socially accountable (Table 2). Social accountability embraces a system-wide scope of purpose The list of 10 directions embraces a system-wide scope of purpose that ranges from the identification of health needs to the verification of the effects of medical schools on those needs, all driven by the quest to ensure a positive impact on people s health status. It is a logical sequence; it starts by highlighting the need to understand the social context, and identify the health challenges and needs in that context and the relationships that must be created to ensure efficient action (directions 1 and 2). The enumeration of the spectrum of health care personnel required to address health needs includes a description of the anticipated role and competences of the doctor (direction 3), which serves as a guide to the education strategy (direction 4) the medical school is called upon to implement along with consistent research and service strategies (direction 5). Standards are required to steer the institution towards a high level of excellence (directions 6 and 7), which must be recognised by national authorities (direction 8). Although social accountability is a universal value (direction 9), the ultimate appraisers of achievements will be local societies (direction 10). The 10 directions advance the discourse and promote the practicality of social accountability by providing a more precise definition of the interwoven components of this overarching idea. Drawing upon the ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46:

6 B Woollard & C Boelen wisdom of crowds, 26 they define a distillation across languages and cultures of a large group of thoughtful perspectives delivered by representatives of institutions that must daily wrestle with the selection of students, the delivery of curricula, research into education, the administration of accreditation systems, the delivery of health services, and the multitude of other tasks that represent the health enterprise in both high- and low-resource countries. They thus carry the potential to move beyond the rhetoric and look at how each sector can reflect on its own policies and procedures, as well as contribute towards the development of the thoughtful partnerships necessary to pursue our common goal of enhancing the health of our fellow citizens. The power of its contribution rests in the collective wisdom that spawned and wove the Consensus. Thus, in the various institutional, national and international venues in which discussion and decision making must take place, emphasis can be focused on the facility for appropriate contextual adaptation that is built into the Consensus, rather than on continual wrangling over definitions. For example, a curriculum might develop learning objectives and pedagogic opportunities to be addressed by the student in each of the 10 areas by weaving them together into a longitudinal experience of true community-based service learning (such as that implied by the US Liaison Committee on Medical Education s standard on service learning) so that the educational experience reflects the very idea of social accountability. 23 The fulfilment of the 10 strategic directions and the specific guidelines under each direction also provide a basis upon which to re-define academic excellence. This attempt was informed by the Conceptualise Produce Usability (CPU) model for the design of standards to evaluate and accredit medical schools, and hence improve their quality. 23 Through a series of 31 parameters, the model invites schools to anticipate and conceptualise the kinds of professionals needed to address priority health needs, produce lifelong learners dedicated to understanding and addressing health priorities, and support and steward the ongoing usability of their graduates in service to the people and populations they serve. Under the auspices of THEnet (http: an international sample of schools has undertaken to design an evaluation framework in which appropriate indicators derived from the CPU model will measure their compliance with social accountability principles. Stimulating and demanding work lies ahead as aspirations for greater social accountability in health and academic institutions must be brought to life through the enactment of explicit policies, the engagement of committed policymakers and fundholders, imaginative research in developing valid and reliable metrics, the creation of adequate accreditation systems at national and regional levels, and the building of a global consortium to advocate and support norms and procedures of universal relevance. In 1910, Flexner intended to revive medical education on strong scientific grounds and alluded implicitly that it might benefit society to do so. A century after the publication of his report, 27 the GCSA articulates explicitly the scope of reforms that will enable academic institutions to improve their impact on people s health status, essentially by weaving strong ties with society. The CPU model and new perspectives established by the GCSA represent two steps in that direction. Contributors: both authors contributed to the conception and development of this paper and to the drafting and critical revision of the manuscript. Acknowledgements: the work of the Global Consensus for Social Accountability of Medical Schools was supported by a grant from The Atlantic Philanthropies (SA) (Proprietary) Limited, Johannesburg, South Africa. Funding: none. Conflicts of interest: none. Ethical approval: not applicable. REFERENCES 1 Boyer E. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching Gastel BA. Toward a global consensus on the quality of medical education: serving the needs of populations and individuals. Acad Med 1995;70 (7 Suppl): American Board of Internal Medicine Foundation. Medical Professionalism Project. Medical professionalism in the new millennium: a physicians charter. Lancet 2002;359: General Medical Council. Good Medical Practice. year. practice.asp. [Accessed 6 February 2011.] 5 World Medical Association. Ethics and Medical Professionalism. year. 20activities/10ethics/50professionalism/index.html. [Accessed 6 February 2011.] 6 Whitcomb ME. Professionalism in medicine. Acad Med 2007;82 (11): ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46: 21 27

7 Seeking impact of medical schools on health 7 Stanton E, Lemer C, Marshall M. An evolution of professionalism. J R Soc Med 2011;104: Cohen JJ. Chairman s Summary of the Conference. In: Hager M, ed. Revisiting the Medical School Educational Mission at a Time of Expansion. Charleston, SC: Josiah Macy Jr Foundation foundation.org/docs/macy_pubs/macy_medschool Mission_proceedings_06-09.pdf. [Accessed 5 March 2010.] 9 myetymology.com. english/social.html. [Accessed 29 June 2011.] 10 Boelen C. Towards Unity for Health: Challenges and Opportunities for Partnership in Health Development. Geneva: World Health Organization www. who.int/hrh/documents/en/tufh_challenges.pdf. [Accessed 15 November 2008.] 11 Marmot M. Health in an unequal world. Lancet 2006;368: Boelen C, Heck J. Defining and Measuring the Social Accountability of Medical Schools. Geneva: World Health Organization Hrdj_no1/charles.html. [Accessed 15 November 2008.] 13 Schmidt H, Neufeld V, Nooman Z, Ogunbode T. Network of community-oriented educational institutions for the health sciences. Acad Med 1991;66 (5): Pálsdóttir B, Neusy A-J. Transforming medical education: lessons learned from THEnet. year. MedEd.pdf. [Accessed 29 October 2010.] 15 Gary N, Boelen C, Gastel B, Ayers W. Improving the social responsiveness of medical schools: proceedings of the 1998 Educational Commission for Foreign Medical Graduates World Health Organization invitational conference. Acad Med 1999;74 (8 Suppl): Woollard RF. Caring for a common future: medical schools social accountability. Med Educ 2006;40: Suleiman AB. Missions of a medical school: an Asian perspective. Acad Med 1999;74 (8 Suppl): Kaufman A. Measuring social responsiveness: a casestudy from New Mexico. Acad Med 1999;74: George C. Measuring social responsiveness: a view from the United Kingdom. Acad Med 1999;74: Schofield A, Bourgeois D. Socially responsible medical education: innovations and challenges in a minority setting. Med Educ 2010;44: Woollard B. Many birds with one stone: opportunities in distributed education. Med Educ 2010;44: Association of Faculties of Medicine of Canada, Committee on the Accreditation of Continuing Medical Education. Future of Medical Education in Canada, [Accessed 7 February 2011.] 23 Liaison Committee on Medical Education Committee on the Accreditation of Canadian Medical Schools. Functions and Structure of a Medical School. [Accessed 7 February 2011.] 24 Boelen C, Woollard RF. Social accountability and accreditation: a new frontier for educational institutions. Med Educ 2009;43: Health Professional Education Quality Project (HPEQ). From Idea to Action: the Creation of a National Accreditation Agency for Indonesia. Jakarta: Directorate General of Higher Education, Ministry of National Education, Government of Indonesia year. hpeq.dikti.go.id. [Accessed 24 November 2011.] 26 Surowiecki J. The Wisdom of Crowds: Why the Many are Smarter than the Few and How Collective Wisdom Shapes Business, Economies, Societies and Nations. Mississauga, Ontario, Canada: Anchor Books Doubleday 2004; Flexner A default/files/elibrary/carnegie_flexner_report.pdf [Accessed 24 November 2011] Received 15 February 2011; editorial comments to authors 26 April 2011; accepted for publication 17 May 2011 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2012; 46: