Social Accountability

 

Offline: The case for a medical school revolution

 

www.thelancet.com Vol 384 September 13, 2014

“Students often underestimate the power they have to change the curriculum and change their medical school.” This message, inciting resistance and even rebellion, did not come from a maverick activist undergraduate. It came from Roger Strasser, the very establishment but equally unusual Founding Dean of Canada’s North Ontario School of Medicine. He was speaking in Milan at the annual meeting of the Association for Medical Education in Europe. This was my first AMEE conference and I left deeply admiring a community of researchers and practitioners that is motivated, inspiring, and committed to advancing health with a passion that one too rarely sees among many of today’s discontented doctors and overregulated researchers. The enthusiasm one could feel in Milan is at least partly due to a messianic zeal among these educators to make education matter. And making education matter means making it socially accountable.

What is social accountability? There is no one-line definition. Social accountability is a cluster of attitudes, values, and behaviours that deliver the mission of a medical school. Here are some of the meanings I heard in Milan—anticipating society’s health needs; defining institutional objectives hand-in-hand with society; partnering with the health system; partnering with the public; adapting to the evolving roles of all health professionals; putting in place responsive and responsible governance within the medical school; redefining the scope of medical education, research, and service delivery; supporting continuous quality improvement in education, research, and service delivery; balancing global principles with local needs; ensuring that medical students learn about the communities they serve; teaching epidemiology for a better understanding of the health needs of local populations; being clear about the essential attributes of a  socially accountable doctor in society; creating graduates who are health system change agents, not merely experts or professionals; implementing an evaluation regime for medical schools that depends on outcomes, not outputs; understanding the influence of social and cultural factors on illness; spending time meeting with other health service providers; allowing patients to participate in decision making about their care; ensuring that students learn to serve as leaders in health systems; encouraging students to take part in social justice activities; providing students with the skills to engage in lifelong learning; and giving students the confi dence to seek help with personal or professional difficulties. How do these qualities of social accountability become the foundation for a medical school? One might hope that every school was led by a charismatic Dean, such as Roger Strasser (or AMEE’s President, Trudie Roberts, who directs the Institute of Medical Education at the University of Leeds). But, as one student said in Milan, “we can’t wait for a great charismatic leader”. What can we achieve right now?

A great deal (the clue lies in Roger Strasser’s call to action). For some, though, talk of social accountability was impossible. One American physician pleaded for an alternative name. The term “social accountability” was interpreted as “socialist” by her academic colleagues. The best she could do was to use a politically neutral term, such as “service learning”. Indeed, there still exists a pervasive scepticism about the social mission of medicine (those in Milan were not typical of medical school leaders). Writing in the Annals of Internal Medicine recently, Michael Stillman (from the University of Louisville School of Medicine, Kentucky) argued that instead of a social mission, “I want [our residents] first and foremost to be superb clinicians”. He went on: “I worry that medical educators are being asked to train young physicians not in the best traditions of our profession, but rather to simply melt into a dizzyingly complicated and capricious health system.” The UK’s General Medical Council is more ambitious. It has commissioned educators, clinicians, and students to devise objectives for sustainable (socially accountable) health care. Why is social accountability proving so difficult to achieve? Perhaps because clinicians and educators have very different perspectives. As one paediatric intensivist from Canada explained to me, “Doctors are not trained to think about health. We are trained to think about disease. If you talked about health with someone in intensive care on a ventilator, they would roll their eyes.” Medical education and clinical practice: can these two cultures be bridged? I’d like to think so. But that’s not good enough.

richard.horton@lancet.com