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Social Accountability: A Framework for Medical Schools to Improve the Health of the Populations They Serve

Rourke, James, MD, MClinSc, FCFP(EM), LLD

doi: 10.1097/ACM.0000000000002239
Invited Commentaries
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Social accountability has gained importance and greater acceptance in the ever-increasing complexity and interconnectivity of patient care, education, and research that is the threefold mission of academic health science centers and networks. In this Invited Commentary, the author provides a brief overview of the development of the concept of social accountability and the criteria for the Association for Medical Education in Europe ASPIRE-to-Excellence Award for Social Accountability, which provide a useful framework for medical schools to consider when examining their own social accountability. Per these criteria, schools are expected to document social accountability plans in their organization and functions; document social accountability actions in their education and research program activities; and demonstrate positive impacts of their education, research, service, graduates, and partnerships on the health care and health of their community, region, and nation. Award-winning schools integrate social accountability into the school’s mission, planning, and day-to-day management. The health needs and diversity of the school’s community, region, and nation are reflected in the school’s admissions, curriculum, learning experiences, research activities, health care partnerships, and graduates. The author also describes three award winners as exemplars of social accountability and concludes by challenging every medical school and graduate medical education program to focus on meeting the needs of the populations it serves, especially those who are marginalized, vulnerable, and underserved.

J. Rourke is professor of family medicine and former dean of medicine (2004–2016), Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada, and chair, ASPIRE-to-Excellence Panel on Social Accountability, Association for Medical Education in Europe; ORCID: http://orcid.org/0000-0001-8019-0294.

Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on social justice, health disparities, and meeting the needs of our most vulnerable and underserved populations.

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s website (http://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=61), follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the November 2017 issue for submission instructions and for more information about this feature).

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to James Rourke, Faculty of Medicine, Discipline of Family Medicine, Health Sciences Centre, Memorial University of Newfoundland, 300 Prince Philip Dr., St. John’s, NL A1B 3V6, Canada; e-mail: Jrourke@mun.ca.

Academic Medicine’s current New Conversations series focuses on justice, disparities, and how to meet the needs of vulnerable and underserved populations; these are closely tied to the social accountability of medical schools. Social accountability has been an important part of the mission and activities of some medical schools from their very beginning, and many have made remarkable contributions to improving the health of the populations they serve. For other schools, however, social accountability seems to be an unimportant consideration, which leads us to this conversation.

In this Invited Commentary, I provide a brief overview of the development of the concept of social accountability and the criteria for the Association for Medical Education in Europe (AMEE) ASPIRE-to-Excellence Award for Social Accountability. I then enumerate the major common themes among the medical schools that have earned the award and describe three award winners as exemplars of social accountability. I conclude by challenging every medical school and graduate medical education (GME) program to focus on meeting the needs of the populations it serves.

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Background

By permit of legislation, regulation, and accreditation as well as the social contract, medical schools are entrusted to educate tomorrow’s doctors and conduct medical research to serve the needs of society; thus, social accountability is the foundation of both medical practice and medical schools.1,2 Social accountability should, therefore, be expected throughout every medical school’s plans, actions, and impact. However, every medical school’s context is different, so how each school can best engage with, partner with, and respond to the needs of its community, region, and nation will vary.

The concept of social accountability as developed and defined for the World Health Organization by Boelen and Heck3 in 1995 states:

[Medical schools have] the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.

This definition3 and the accompanying partnership pentagon diagram,2 depicting a health system based on people’s needs, have gained importance and greater acceptance in the ever-increasing complexity and interconnectivity of patient care, education, and research that is the threefold mission of academic health science centers and networks.

Canadian medical schools became early adopters of social accountability with the 2001 report “Social Accountability: A Vision for Canadian Medical Schools.”4 Through a number of later reports, including “The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education” and “A Collective Vision for Postgraduate Medical Education in Canada,” Canadian medical schools have reconfirmed that social accountability forms the foundation for medical education in Canada.5–8 And now demonstration of social accountability is included in the Canadian accreditation requirements.9

The concept of social accountability has developed more over the past decade through the work of the 2008 Global Consensus for Social Accountability of Medical Schools,10 the 2017 World Summit on Social Accountability,11 THEnet (Training for Health Equity Network) schools,12 and the increasing numbers of academic meetings and publications on this topic.13 Social accountability is now understood to involve medical schools engaging, partnering with, and responding to the needs of their community, region, and nation, especially their underserved and vulnerable populations.1,13

To encourage and promote outstanding performance and excellence in medical education, AMEE (the world’s largest medical education organization) established the ASPIRE initiative, which was launched at AMEE 2012. Spearheaded by Dr. Ron Harden, a group of leading international authorities in medical education and educational bodies have developed ASPIRE as a means whereby world-class excellence in education by medical schools can be recognized using an agreed-upon set of standards or benchmarks.14–17

The first three areas of excellence the ASPIRE initiative chose to recognize were assessment of students, student engagement, and social accountability. ASPIRE established expert panels to develop the criteria to be used for assessing medical schools that submitted applications for awards in these areas. The first two (assessment of students and student engagement) were more readily defined than social accountability because this is much broader and involves the whole medical school.

Ultimately, ASPIRE developed the criteria for the ASPIRE-to-Excellence Award for Social Accountability based on the foundational work of the Global Consensus for Social Accountability of Medical Schools,10 published literature, and evolving world experience. To be successful, schools are expected to document social accountability plans in their organization and functions; document social accountability actions in their education and research program activities; and demonstrate positive impacts of their education, research, service, graduates, and partnerships on the health care and health of their community, region, and nation.1,16,17 Thus, these criteria (and their measures) provide quite a contrast to the U.S. News & World Report ratings of medical schools, which consider survey ratings, research funding, and other measures, including number of faculty per student, admission grade point average and MCAT scores, and, for primary care medical schools, the percentage of graduates entering primary care residency training programs.

The ASPIRE criteria for excellence in social accountability provide a useful framework for medical schools to consider when examining their own social accountability (sometimes referred to as social mission). I encourage you to review them16,17 and see how your school might measure up.

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Common Themes

As of December 2017, there have been 29 applications for ASPIRE social accountability awards. Each of the 29 schools or networks established their social accountability mandate to fit their own socio-cultural-geographic context. While all demonstrated commitment to social accountability, many did not have or did not yet have a demonstrable impact (e.g., new schools whose graduates were not yet in practice). As a result, so far only the following 10 schools or networks have received the ASPIRE-to-Excellence Award for Social Accountability: Southern Illinois University School of Medicine (SIUSOM), Northern Ontario School of Medicine, Hull York Medical School, University of New Mexico School of Medicine (UNMSOM), Memorial University of Newfoundland Faculty of Medicine, Brody School of Medicine at East Carolina University, University of Leeds School of Medicine, Florida International University Herbert Wertheim College of Medicine, Leaders in Indigenous Medical Education (LIME) Network, and Université Laval Faculté de Médecine.

The major common themes among the 10 award-winning medical schools include:

  1. Social accountability being evident in the school’s purpose and mandate and integrated into its planning and day-to-day management;
  2. School admissions being focused on reflecting the demographic mix of the school’s community, region, and nation;
  3. The curriculum being relevant to the unique geographic, social, and cultural context and the priority health needs of the school’s community, region, and nation;
  4. The inclusion of clinical learning and service-learning experiences reflecting the diversity of the geographic, social, and cultural mix of the school’s community, region, and nation;
  5. The inclusion of extensive exposure to community-based learning experiences to understand and act on social determinants of health for vulnerable and underserved patients, communities, and populations;
  6. Research being inspired by and responding to the priority health needs of the school’s community, region, and nation and actively engaging the community in research, including developing the research agenda, partnering and participating in research, and taking part in knowledge translation/mobilization; and
  7. The school’s graduates and its health service partnerships having a positive impact on the health and the health care of its community, region, and nation with an emphasis on vulnerable and underserved populations.
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Exemplars

In this section, I describe three winners of the ASPIRE-to-Excellence Award for Social Accountability as exemplars of social accountability. Some of the information in this section comes from the school’s or network’s ASPIRE application and personal communications (see Acknowledgments).

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Southern Illinois University School of Medicine

The mission of SIUSOM is to provide for the people of central and southern Illinois through education, patient care, research, and community service. SIUSOM has a wide variety of partnerships with communities, professional organizations, health managers, and policy makers to help meet this mission. For example, the Rural Health Initiative is a major component of SIUSOM’s outreach efforts to assist rural and underserved areas in central and southern Illinois by increasing access to health care services, improving local health care infrastructure, and providing rural-focused educational opportunities for medical students.

SIUSOM’s admissions committee uses a holistic process to select its future students. One of the selection criterion used is evidence of extensive volunteer work and/or community service. In addition, there are pipeline programs in place at SIUSOM that serve the community by encouraging local high school students interested in becoming physicians and by preparing underrepresented minority and educationally/economically disadvantaged students for careers in medicine. SIUSOM’s medical student admissions represent the demographic mix of the region.

In a study of graduates in practice in 2008, SIUSOM was ranked 15th in the country on the social mission score, with 45% of the school’s graduates practicing in primary care fields and 46.5% practicing in health professional shortage areas.18 Furthermore, half of all SIUSOM medical school graduates continue to practice in Illinois after residency.

The SIUSOM Office of Continuing Medical Education provides educational activities to improve physician practice throughout downstate Illinois. For example, the school has developed a network of video conferencing sites that allow physicians at 50 critical access hospitals throughout downstate Illinois to participate in campus-based formal educational experiences.

The vast majority of research conducted at SIUSOM is grounded in the needs of the community. The school is also actively engaged in collaborative grants with community groups, and serves as advisors and provides technical assistance to community groups as they prepare health-related grants.

In 2017, SIUSOM published about the value of going through the ASPIRE awards process.19

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University of New Mexico School of Medicine

UNMSOM is a pioneering institution in social accountability in medical education. Since its inception, UNMSOM has included service to the state of New Mexico as a clear priority and has focused on improving the population’s health and health equity as a measure of the institution’s success.20

Like virtually all other aspects of UNMSOM’s programs, the admissions policies are heavily influenced by the school’s explicit commitment to meet the specific health care needs and improve the population health status of their predominantly rural, substantially diverse, and relatively lower-income state. UNMSOM also has well-designed and well-managed pipeline efforts that start as early as middle school. Over 30% of UNMSOM’s student body comes from backgrounds that are underrepresented in medicine, and the number of Hispanic/Latino and American Indian students puts UNMSOM in the 95th percentile for diversity in comparison with the nation’s other MD-granting medical schools.

UNMSOM strongly promotes service-learning as a core component of health professions education. Accordingly, to balance their experiences in more traditional urban, tertiary academic health center venues, all medical students also have practical experiences in underserved, community-based settings (urban and reservation Native American sites and rural farming and ranching communities) during each year of the curriculum.

In 2017, a higher percentage of UNMSOM senior medical students matched in family medicine residencies (30.2%) than any of the other 141 MD-granting medical schools in the United States.21

The University of New Mexico (UNM) Health Sciences Center research programs “are focused around critical health problems affecting New Mexico residents and bridge the clinical and basic sciences to more rapidly deliver discoveries in molecular medicine to the clinical setting.”22 In addition, the UNM Clinical & Translational Science Center’s academic–community partnerships work to improve the health and well-being of New Mexico’s diverse population through collaborative and sustainable research that supports the dissemination of evidence-based practices to inform local health decisions.

Both SIUSOM and UNMSOM were selected by the Beyond Flexner Alliance in 2011 as two of six model schools that most fulfilled their obligation to society through their admissions processes, undergraduate and graduate programs, and student support initiatives.23

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LIME Network

The LIME Network application presented a challenge to ASPIRE as it is not a medical school but, rather, a collective of representatives from all the medical schools in Australia and Aotearoa/New Zealand. ASPIRE accepted the application as a pilot for considering networks, and the submission was so strong it earned an award.

LIME was established in 2005 and is committed to ensuring the quality and effectiveness of teaching and learning of Indigenous health in medical education, as well as best practices in the recruitment and graduation of Aboriginal and Torres Strait Islander (from Australia) and Māori (from Aotearoa/New Zealand)—henceforth, collectively referred to as Indigenous—medical students.24 The LIME Network operates as a community of practice, which furthers knowledge and innovation and sustains collaborative efforts while promoting excellence in Indigenous health in medical education, research, and service delivery.25

LIME recognizes and promotes the primacy of Indigenous leadership and knowledge and uses multiple collaborative components to achieve these goals. As part of this, the LIME quality review processes encourage individual medical schools to devise and implement their own internal review processes by which they can evaluate the quality of the Indigenous health curriculum and the effectiveness of initiatives to support the participation of Indigenous people in medical education programs. It is also essential to address the hidden curriculum in relation to Indigenous health education to support formal curricular initiatives and for lasting and systemic change.26 The LIME Network, therefore, has developed a range of review tools to highlight the processes required to support initiatives in Indigenous health and development and to draw attention to how the dominant values of the institution have an impact on the value and learning of Indigenous health.

LIME representatives and their colleagues engage with and deliver initiatives in Indigenous medical and health education and develop scholarly work on best teaching practices, resource development, and assessment and program evaluation to support Indigenous medical education, as well as the recruitment and retention of Indigenous students.25 Further, the leadership of LIME successfully engaged with the accrediting body for Australia and Aotearoa/New Zealand to introduce accreditation standards that specifically highlight Indigenous health or health workforce development across all relevant domains.

In 2011, the number of Indigenous students studying medicine in Australia reached population parity for the first time, with the intake of first-year Indigenous medical students at a high of 2.5%, and Aotearoa/New Zealand is close to graduating Indigenous students at demographic equity. And in 2013, the “Review of Australian Government Health Workforce Programs” (the Mason Review) recommended that “the Commonwealth should build on the success of the Leaders in Indigenous Medical Education (LIME) Network.”27

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Challenges

The ASPIRE-to-Excellence Award for Social Accountability framework does not include GME—often referred to as resident training or vocational training—because GME is not included in the mandate of most medical schools in most countries. In Canada and the United States, however, GME is a core component of medical school, and it may be even more important than undergraduate medical education (UME) in developing the doctors needed for tomorrow. As GME undergoes the major transformation to competency-based training, many are asking: Why, how, who, and what difference will it make? These questions are closely related to social accountability and providing vocational training directed toward meeting society’s needs. Because of the wide variety of GME programs, it is even more difficult to apply social accountability principles to this phase of the medical education continuum than it is to apply them to UME, so much work remains to be done. This should be a priority for GME programs and the organizations that fund and accredit them.

Another issue of concern for this social accountability conversation is the role of medical schools with regard to the ecosystem/environment. Both the ecosystem/environment as a major contributor to the social determinants of health of the populations served by the medical school and the impact of the medical school and its partners on the ecosystem/environment are emerging as important components of social accountability. Medical schools can have a powerful positive ecosystem/environmental impact by developing, role modeling, and teaching ecosystem health and environmental best practices.28 ASPIRE is now working on integrating this into the 2019 version of the social accountability award criteria.

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Conclusion

Socially accountable medical schools engage with, partner with, and respond to the needs of their communities, regions, and nations. Improvement in the health of the populations they serve (especially those who are marginalized, vulnerable, and underserved) should be considered vital outcome measures of medical school education, research, and patient care. Shouldn’t all medical schools strive for excellence in social accountability?

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Acknowledgments:

The author would like to thank the ASPIRE Social Accountability Panel members for sharing their expertise; Debra Klamen for information on Southern Illinois University School of Medicine; Arthur Kaufman for information on University of New Mexico School of Medicine; and Papaarangi Reid, Odette Mazel, and Shaun Ewen for information on the Leaders in Indigenous Medical Education Network.

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References

1. Rourke J. AM Last Page: Social accountability of medical schools. Acad Med. 2013;88:430.
2. Boelen C. Towards unity for health: Challenges and opportunities for partnership in health development. 2000. Geneva, Switzerland: World Health Organization; http://www.who.int/hrh/documents/en/TUFH_challenges.pdf. Accessed March 22, 2018.
3. Boelen C, Heck JE. Defining and measuring the social accountability of medical schools. 2015. Geneva, Switzerland: World Health Organization; WHO/HRH/95.7. http://apps.who.int/iris/bitstream/10665/59441/1/WHO_HRH_95.7.pdf. Accessed March 14, 2018.
4. Health Canada Steering Committee on Social Accountability of Medical Schools. Social Accountability: A Vision for Canadian Medical Schools. 2001.Ottawa, Ontario, Canada: Health Canada.
5. Association of Faculties of Medicine of Canada. The Future of Medical Education in Canada (FMEC): A collective vision for MD education. https://afmc.ca/pdf/fmec/FMEC-MD-2010.pdf. Accessed March 14, 2018.
6. Association of Faculties of Medicine of Canada. FMEC MD 2015: Five years of innovations at Canadian medical schools. https://afmc.ca/pdf/fmec/FMEC-MD-2015.pdf. Accessed March 14, 2018.
7. Association of Faculties of Medicine of Canada. A collective vision for postgraduate medical education in Canada. https://www.afmc.ca/future-of-medical-education-in-canada/postgraduate-project/pdf/FMEC_PG_Final-Report_EN.pdf. Published 2012. Accessed March 27, 2018.
8. Busing N, Harris K, MacLellan AM, et al. The future of postgraduate medical education in Canada. Acad Med. 2015;90:1258–1263.
9. Committee on Accreditation of Canadian Medical Schools. Committee on Accreditation of Canadian Medical Schools website. https://cacms-cafmc.ca/. Accessed March 14, 2018.
10. Global Consensus for Social Accountability of Medical Schools. Global Consensus for Social Accountability of Medical Schools website. http://healthsocialaccountability.org/. Accessed March 14, 2018.
11. The Network: Towards Unity for Health. World Summit on Social Accountability: Tunis Declaration. http://thenetworktufh.org/2017conference/. Published 2017. Accessed March 14, 2018.
12. THEnet. THEnet website. https://thenetcommunity.org/. Accessed March 14, 2018.
13. Boelen C, Pearson D, Kaufman A, et al. Producing a socially accountable medical school: AMEE guide no. 109. Med Teach. 2016;38:1078–1091.
14. Harden R. Excellence in medical education—Can it be assessed? Asia Pacific Scholar TAPS. 2018;3:1–5.
15. Hunt D, Klamen D, Harden RM, Ali F. The ASPIRE-to-Excellence Program: A global effort to improve the quality of medical education. Acad Med. 2018;93:1117–1119.
16. Association for Medical Education in Europe. ASPIRE-to-Excellence Award. https://amee.org/awards-prizes/aspire-award. Accessed March 14, 2018.
17. ASPIRE. ASPIRE website. http://www.aspire-to-excellence.org/. Accessed March 14, 2018.
18. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: Ranking the schools. Ann Intern Med. 2010;152:804–811.
19. Cianciolo AT, Klamen DL, Beason AM, Neumeister EL. ASPIRE-ing to excellence at SIUSOM. MedEdPublish. 2017. doi: https://doi.org/10.15694/mep.2017.000082.
20. Kaufman A, Roth PB, Larson RS, et al. Vision 2020 measures University of New Mexico’s success by health of its state. Am J Prev Med. 2015;48:108–115.
21. Kozakowski SM, Travis A, Marcinek JP, Bentley A, Fetter GT Jr.. Entry of medical school graduates into family medicine residencies: 2016–2017. Fam Med. 2017;49:686–692.
22. UNM Health Sciences Center Office of Research. Signature research programs. https://hsc.unm.edu/research/research-centers/signature-research-programs/index.html. Accessed March 14, 2018.
23. Mullan F, Fair M, Diamond S, Lee J. Teaching social accountability in medical education. Beyond Flexner Alliance website. http://beyondflexner.org/resources/first-generation-schools/. Accessed April 2, 2018.
24. Haynes TM, Collins ME, Mazel O, Lawler LM, Ryan C, Ewen SC. History of the LIME network and the development of Indigenous health in medical education. Med J Aust. 2013;199:65–68.
25. Mazel O, Ewen S. Innovation in indigenous health and medical education: The Leaders in Indigenous Medical Education (LIME) network as a community of practice. Teach Learn Med. 2015;27:314–328.
26. Ewen S, Mazel O, Knoche D. Exposing the hidden curriculum influencing medical education on the health of Indigenous people in Australia and New Zealand: The role of the critical reflection tool. Acad Med. 2012;87:200–205.
28. Pearson D, Walpole S, Barna S. Challenges to professionalism: Social accountability and global environmental change. Med Teach. 2015;37:825–830.
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