Putting communities in the driver's seat: the realities of community-engaged medical education

Moving the Needle: Using Guidelines on Diversity, Equity, and Inclusion to Uplift a Stronger Medical Education Community

The Association of Professors of Gynecology and Obstetrics created the Diversity, Equity, and Inclusion Guidelines Task Force to develop best practices to establish a diverse physician workforce and eliminate racism in medical education. Using the guidelines, educators are impacting their communities and, in some areas, leading their institutions toward greater diversity and inclusion. The guidelines are organized by 4 domains: learning environment, grading and assessment, pathway programs, and metrics. This manuscript uses that framework to highlight the work of individual educators who are moving the needle towards racism-free health care and aims to inspire others contemplating incorporation into their programs.

Front row seat: The role MMI assessors play in widening access to medical school

BACKGROUND

While many medical schools utilize the Multiple Mini-Interview (MMI) to help select a diverse student body, we know little about MMI assessors' roles. Do MMI assessors carry unique insights on widening access (WA) to medical school? Herein we discuss the hidden expertise and insights that assessors contribute to the conversation around WA.

METHODS

Ten MMI assessors (1-10 years' experience) participated in semi-structured interviews exploring factors influencing equitable medical school recruitment. Given their thoughtfulness during initial interviews, we invited them for follow-up interviews to gain further insight into their perceived role in WA. Fourteen interviews were conducted and analyzed using a thematic analysis approach.

RESULTS

Assessors expressed concerns with diversity in medicine; dissatisfaction with the status quo fueled their contributions to the selection process. Assessors advocated for greater diversity among the assessor pool, citing benefits for all students, not only those from underrepresented groups. They noted that good intentions were not enough and that medical schools can do more to include underrepresented groups' perspectives in the admissions process.

CONCLUSION

Our analysis reveals that MMI assessors are committed to WA and make thoughtful contributions to the selection process. A medical school selection process, inclusive of assessors' expertise is an important step in WA.

Inspiring rural youth to consider healthcare careers through an interprofessional healthcare traveling roadshow

There are well-documented shortages of healthcare providers in rural and remote communities worldwide, and these shortages correlate with inequitable health outcomes for rural peoples. Despite a wide array of efforts to remedy the issue, these shortages persist to this day. The Healthcare Traveling Roadshow (HCTRS) is a grassroots initiative that began in 2010 to help address the shortage of healthcare providers in rural communities throughout British Columbia. Since its inception, the HCTRS has been predicated on three evidence-based guiding principles which have been shown to markedly increase the rate at which healthcare students choose to practice rurally. These principles are: (1) to showcase healthcare careers as viable and realistic options for rural youth (high school students) using interactive stations and near-peer teaching; (2) to expose healthcare students to rural communities and showcase them as a potential opportunity for their future practice; and (3) to provide a unique interprofessional experience to healthcare students from diverse healthcare careers and backgrounds. Through the synergy of these three principles the HCTRS aims to increase the longitudinal recruitment and retention of healthcare workers in underserved rural communities. This paper will share our experience from 15  years of running this initiative, for those hoping to implement similar programs in other areas of the world.

The Community Health Advocacy Initiative: A Longitudinal Experiential Curriculum in Community Engagement for Preclerkship Medical Students

Introduction

Community partnership is a key strategy for addressing the social determinants of health and achieving health equity. There are few examples of curricula for undergraduate medical education that teach all, rather than self-selected, medical students to collaborate with community members to improve health. We describe the design and implementation of the Community Health Advocacy Initiative (CHAI) curriculum, a new yearlong educational program for medical students at Northwestern University's Feinberg School of Medicine.

Methods

CHAI aimed to fill the curricular gap in social determinants of health education by providing medical students with the knowledge and skills to improve the health of patients through collaborations with community partners. This longitudinal curriculum included structured faculty mentorship and an applied community experience.

Results

The CHAI curriculum was delivered to 164 second-year medical students in academic year 2021-2022. Faculty mentors rated most students as meeting expectations for application of community partnership principles and demonstration of professionalism. Qualitative analysis of faculty mentor comments demonstrated that medical students exhibited positive outcomes in engaging with community organizations, overcoming barriers, developing feasible and impactful goals, and advancing their own knowledge and skills.

Discussion

Implementing a community health curriculum for all medical students is feasible and represents an important model for teaching about the importance of community partnerships in addressing the social determinants of health.

Community-engaged pedagogy in an emergency medicine clerkship: Teaching trauma-informed addiction care and harm reduction through a peer-assisted learning case

Background

The impact of opioid use disorder (OUD) in the United States continues to rise, yet this topic has limited coverage in most medical school curricula. The study partnered with academic and community harm reductionists to design a peer-assisted learning case of opioid withdrawal to teach fourth-year medical students about trauma-informed OUD care and harm reduction services during their emergency medicine clerkship.

Methods

Academic and community harm reductionists iteratively codesigned this case in partnership with the research team. Community-engaged pedagogy informed this process to promote social action and power sharing through education. This case was integrated into the existing weekly peer-assisted learning curriculum (i.e., medical students teaching medical students through a structured case) for all fourth-year medical students during their required emergency medicine clinical rotation. Participants completed a postcase evaluation survey.

Results

Sixty-four medical students completed the survey between June and November 2022. A total of 98.5% of participants found the educational session quite or extremely relevant to their medical education, and 87.5% believed the case to be quite or extremely effective in achieving the learning objectives. A total of 45.3% initially felt quite or extremely competent in talking with patients about their drug use, whereas 53.2% felt quite or extremely more competent after participating in the case. Finally, 21.9% initially felt quite or extremely competent in proposing a treatment plan for a patient who uses drugs, whereas 62.5% felt quite or extremely more competent after participating in the case.

Conclusions

This study supports the feasibility and importance of incorporating the voices of people with lived and living experience into medical school curricular development. This peer-assisted learning case focused on the treatment of OUD in the emergency department was seamlessly integrated into the existing curriculum and well received by medical students. By engaging local experts, it could easily be adapted and expanded to other sites.

Understanding the perspective of community co-educators on community-based service learning: a qualitative analysis

Background

Community-based service learning (CBSL) is a core component of the Canadian medical education system. However, the unique role of community partner organizations (CPOs) in supporting CBSL remains unclear. This qualitative study evaluates the perspective of CPOs as co-educators in the undergraduate medical curriculum.

Methods

We conducted eight semi-structured, one-on-one interviews with CPOs at a medical school in Toronto, Ontario between 2020-2021. Interviews were conducted following a pre-determined interview guide and then recorded, de-identified, and transcribed. Three reviewers independently performed an inductive thematic analysis of codes followed by a group review of discrepancies.

Results

Five main findings were identified: 1) CPOs share a common interest in serving as co-educators; 2) considerable heterogeneity in the understanding of co-education exists; 3) there is an opportunity for increased partnerships between CPOs and faculty; 4) the role of co-educators is limited by curriculum structure; and 5) co-educators facilitate unique teachings of social determinants of health otherwise not available through traditional didactic teaching.

Conclusions

There is an emerging, unique role for community co-educators in the undergraduate medical curriculum, supported by interest from CPOs. Its emphasis may contribute to future cohorts of medical students capable of understanding and addressing the needs of the populations they serve.

Storylines of family medicine XI: professional identity formation-nurturing one's own story

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XI: professional identity formation-nurturing one's own story', authors address the following themes: 'The social construction of professional identity', 'On becoming a family physician', 'What's on the test?-professionalism for family physicians', 'The ugly doc-ling', 'Teachers-the essence of who we are', 'Family medicine research-it starts in the clinic', 'Socially accountability in medical education', 'Personal philosophy and how to find it' and 'Teaching and learning with Storylines of Family Medicine'. May these essays encourage readers to find their own creative spark in medicine.

Storylines of family medicine XII: family medicine and the healthcare system

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

The climate and health crisis: Heeding our responsibility in medical education research

The authors issue a call to action to the medical education research community, encouraging each of us to lean into the important role we play in addressing the climate and health crisis.

Validity evidence and psychometric evaluation of a socially accountable health index for health professions schools

There is an expectation that health professions schools respond to priority societal health needs. This expectation is largely based on the underlying assumption that schools are aware of the priority needs in their communities. This paper demonstrates how open-access, pan-national health data can be used to create a reliable health index to assist schools in identifying societal needs and advance social accountability in health professions education. Using open-access data, a psychometric evaluation was conducted to examine the reliability and validity of the Canadian Health Indicators Framework (CHIF) conceptual model. A non-linear confirmatory factor analysis (CFA) on 67 health indicators, at the health-region level (n = 97) was used to assess the model fit of the hypothesized 10-factor model. Reliability analysis using McDonald's Omega were conducted, followed by Pearson's correlation coefficients. Findings from the non-linear CFA rejected the original conceptual model structure of the CHIF. Exploratory post hoc analyses were conducted using modification indices and parameter constraints to improve model fit. A final 5-factor multidimensional model demonstrated superior fit, reducing the number of indicators from 67 to 32. The 5-factors included: Health Conditions (8-indicators); Health Functions (6-indicators); Deaths (5-indicators); Non-Medical Health Determinants (7-indicators); and Community & Health System Characteristics (6-indicators). All factor loadings were statistically significant (p < 0.001) and demonstrated excellent internal consistency ( ω >0.95). Many schools struggle to identify and measure socially accountable outcomes. The process highlighted in this paper and the indices developed serve as starting points to allow schools to leverage open-access data as an initial step in identifying societal needs.

Foundations of Community Engagement: A Series for Effective Community-Engaged Research

Introduction

Medical students lack systematic exposure to community engagement. Community-engaged research (CEnR) is an effective approach to improve community health, and community-engaged physicians are better attuned to the community context of their patients' health and well-being. The Medical College of Wisconsin (MCW) Office of Community Engagement began offering the educational series Foundations of Community Engagement in 2021 to meet this need.

Methods

We developed and implemented a four-session series for medical students at MCW and the University of Nebraska Medical Center. A 1-hour session on the foundations of CEnR was held for all learners. Three 1-hour sessions dove deeper into CEnR principles for a self-selected cohort. These small-group sessions involved discussion between faculty and community partners and facilitated small-group discussion. Students completed evaluations after each session.

Results

A total of 160 students participated in the introductory session; 36 took part in the follow-up series. Survey response rates varied from 38% to 67% for each session. Overall, 87% of students in all sessions felt their session was worthwhile, with 85% of large-group and 96% of small-group respondents reporting they learned something they would use in their practice or profession. Qualitative responses included appreciation for addressing a curricular gap and desire for more time and more sessions to continue discussions.

Discussion

The program was effective at stimulating medical student self-reported gains in skills, attitudes, and future intentions regarding CEnR in an efficient manner. Effective programs that transfer positive CEnR skills and attitudes to future physicians can promote CEnR within academic medicine.

Readiness of Medical Students to Care for Diverse Patients: A Validated Assessment of Cross-Cultural Preparedness, Skills, and Curriculum

Introduction

Effective cross-cultural care is foundational for mitigating health inequities and providing high-quality care to diverse populations. However, medical school teaching practices vary widely, and learners have limited opportunities to develop these critical skills. To understand the current state of cross-cultural education and to identify potential opportunities for improvement, we disseminated a validated survey instrument among medical students at a single institution.

Methods

Learners across 4 years of medical school participated in the cross-cultural care assessment, using a tool previously validated with resident physicians and modified for medical students. The survey assessed medical student perspectives on (1) preparedness, (2) skillfulness, and (3) educational curriculum and learning environment. Cross-sectional data were analyzed by class year, comparing trends between school years.

Results

Of 700 possible survey responses, we received 260 (37% response rate). Fourth-year students had significantly higher scores than first-year students (p<0.05) for 7 of 12 preparedness items and 4 of 9 skillfulness items. Less than 50% of students indicated readiness to deliver cross-cultural care by their fourth year in 9 of 12 preparedness items and 6 of 9 skillfulness items. Respondents identified inadequate cross-cultural education as the primary barrier.

Discussion

Medical students reported a lack of readiness to provide cross-cultural care, with self-assessed deficiencies persisting through the fourth year of medical school. Medical educators can use data from the cross-cultural care survey to longitudinally assess students and enhance curricular exposures where deficiencies exist. Optimizing cross-cultural education has the potential to improve the learning environment and overall patient care.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.

Community-engaged medical education is a way to develop health promoters: A comparative study

BACKGROUND

Although the importance of health promotion and empowerment of the community has been recognized for many years, there are still many barriers to adopting health promotion in the world. One of the solutions is socially accountable medical education and community engagement.

OBJECTIVE

This study aimed to compare the medical programs of five medical schools that practiced community-engaged medical education to medical education in Iran.

MATERIALS AND METHODS

This comparative study has been performed in 2022 by the four-stage Bereday method, including description (the educational programs of the selected medical schools were examined), interpretation (a validated checklist was prepared according to community-based strategies), proximity (similar and different information was identified), and comparison (solutions were recommended to improve health promotion and community engagement in Iran's medical education program. The purposive sampling method was used to select five universities.

RESULTS

Although successful initiatives have been attempted to integrate public health promotion and community orientation into the Iranian curriculum, they do not appear to be sufficient in comparison to leading countries. The main distinction is that the community is actively engaged in all stages of curriculum design, implementation, and evaluation.

CONCLUSIONS

Although Iran's medical education program has a long way to go in terms of social accountability, by including more community-oriented initiatives into the curriculum, health needs of the community can be met and physician shortages in poor areas can be alleviated. It is recommended to implement modern teaching methods, to recruit diverse faculty and community members, and to increase the community placement in medical education.

The Integration of Primary Care and Public Health in Medical Students' Training Based on Social Accountability and Community-Engaged Medical Education

Objectives: Primary care and public health comprise the bedrock of health systems, but their divergence has produced two groups of practitioners either focused on individual health or population health. We explored how primary care and public health were integrated in medical students' training in Zamboanga Peninsula, Philippines. Methods: Our qualitative study reviewed community health plans in two municipalities and thematically analyzed the perspectives of medical students, faculty, alumni, and community stakeholders through focus group discussions and in-depth interviews. Results: Integration began by operationalizing a curriculum requiring medical students to serve rural communities during most of their training-a departure from the conventional, hospital-based medical education in the Philippines. The medical students' community immersion provided opportunities for integrating primary care and public health activities that influenced their personal orientations and the health situation in communities. Integration continued after training as alumni found themselves serving as primary care and public health practitioners in the region. Conclusion: Social accountability and community-engaged medical education provided the foundation for medical students to integrate primary care and public health in practice to respond to local needs.

Twelve tips for engaging students and community partners in medical education

There is increasing evidence on the positive outcomes of engaging students and community partners in medical education, especially in achieving social accountability. However, less is known about the steps through which these engagements are established. This paper outlines twelve tips on establishing a robust and enduring partnership with students and community partners in medical education, using examples from the Western Sydney University School of Medicine. While context is paramount in any engagement program, these tips are formulated to be transferable to medical education settings in different countries, education systems, and the broader context of health professional education.

Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review

PURPOSE

To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD).

METHOD

The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020.

RESULTS

Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation.

CONCLUSIONS

Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.

Community-Academic Partnerships: A Report on the COVID Support Our Schools (SOS) Initiative

The SARS-CoV-2 pandemic disrupted the delivery of education in our school systems and exacerbated pre-existing health and educational disparities. School administrators and staff from underserved communities struggled with continuously changing medical guidance, ensuring equitable education by virtual platforms, and re-opening schools safely. The Hackensack Meridian School of Medicine (HMSOM) partnered with statewide resource-limited school districts to create the COVID Support Our Schools (SOS) initiative. This consisted of a physician advisory board, medical student task forces, and community leaders. Numerous sessions were hosted by the COVID SOS team to answer questions, address community needs, and carry out initiatives to meet identified needs. Surveys, including Likert scale questions and open-ended feedback, were administered to all participating school districts. In total, 100% of respondents strongly agreed or agreed that the COVID SOS program was dedicated to community needs and provided timely support with necessary resources. Open-ended feedback described that the K-12 school districts valued our partnership as well as found the opportunity to engage with other districts informative and rewarding. The partnership between our academic medical institution and community school districts is mutually beneficial, providing an opportunity for medical student service learning as well as imparting medical expertise in times of need.

Ten years of graduates: A cross-sectional study of the practice location of doctors trained at a socially accountable medical school

Introduction

The study predicted practice location of doctors trained at a socially accountable medical school with education programs in over 90 communities.

Methods

A cross-sectional study examined practice location 10 years after the first class graduated from the Northern Ontario School of Medicine (NOSM), Canada. Exact tests and logistic regression models were used to assess practice location in northern Ontario; northern Canada; or other region; and rural (population <10,000) or urban community.

Results

There were 435 doctors with 334 (77%) practising as family doctors (FPs), 62 (14%) as generalist specialists and 39 (9%) as other medical or surgical specialists. Approximately 92% (128/139) of FPs who completed both UG and PG at NOSM practised in northern Ontario in 2019, compared with 63% (43/68) who completed only their PG at NOSM, and 24% (30/127) who completed only their UG at NOSM. Overall, 37% (23/62) of generalist specialists and 23% (9/39) of other specialists practised in northern Ontario. Approximately 28% (93/334) of FPs practised in rural Canada compared with 4% (4/101) of all other specialists. FP northern Ontario practice was predicted by completing UG and PG at NOSM (adjusted odds ratio = 46, 95% confidence interval = 20–103) or completing only PG at NOSM (15, 6.0–38) relative to completing only UG at NOSM, and having a northern Ontario hometown (5.3, 2.3–12). Rural Canada practice was predicted by rural hometown (2.3, 1.3–3.8), completing only a NOSM PG (2.0, 1.0–3.9), and age (1.4, 1.1–1.8).

Conclusion

This study uniquely demonstrated the interaction of two mechanisms by which medical schools can increase the proportion of doctors’ practices located in economically deprived regions: first, admit medical students who grow up in the region; and second, provide immersive UG and PG medical education in the region. Both mechanisms have enabled the majority of NOSM-trained doctors to practise in the underserved region of northern Ontario.

Developing Standards for Cultural Competency Training for Health Care Providers to Care for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual Persons: Consensus Recommendations from a National Panel

Purpose:

Lesbian, gay, bisexual, transgender, queer, intersex, and/or asexual and other sexual and gender diverse persons (LGBTQIA+ or SGD persons) experience barriers to equitable health care. The purpose of this article is to describe a collaborative process that resulted in core cultural competency recommendations addressing training for those who provide health care and/or social services to LGBTQIA+ patients.

Methods:

In 2018 and 2019, Whitman-Walker Health, a Federally Qualified Community Health Center in Washington, DC, and the National LGBT Cancer Network purposively selected leaders of community clinics and community-based organizations, cultural competency trainers, and clinicians and researchers with expertise in SGD health with diverse lived experiences to develop consensus-based cultural competency recommendations. Recommendations were developed through a synthesis of peer-reviewed studies, publicly accessible curricula, and evaluations of SGD cultural competency trainings; two in-person convenings; and iterative feedback from diverse stakeholders.

Results:

Five anchoring recommendations emerged: (1) know your audience; (2) develop and fine-tune the curriculum; (3) employ both adult and transformational learning theories; (4) choose multiple effective trainers; and (5) evaluate impact of training. These recommendations promote an ongoing process of individual and organizational improvement and a stance of humility rather than competence to be mastered.

Conclusion:

By setting core cultural competency standards for all persons involved in health care and social services, these recommendations complement existing clinical competency recommendations to advance SGD health equity.

How rural immersion training influences rural work orientation of medical students: Theory building through realist evaluation

AIM

To develop theory about how contexts and mechanisms interact to contribute to openness to future rural practice by medical students undertaking immersive rural training.

METHODS

A realist evaluation based on RAMESES II protocol. We interviewed 23 students exploring Contexts (C) which were external (place-based) and internal (the student's characteristics), Mechanisms (M) (that drive a response) and Outcomes (O) (openness to rural work).

RESULTS

'Openness to rural work' related to: a desire to live rurally, work in rural medicine, or consider this as a possibility. This was triggered by responses to experience in rural places of an aspirational, intellectual and emotional nature (mechanisms). Students most affected were those with a strong motivation to help others and who value teamwork. Students with clearly envisaged career paths suited to metropolitan areas, or those retaining/prioritising strong social and community ties in metropolitan areas were less likely to commit to future rural work.

CONCLUSION

Our theory indicates multi-level stimuli activates openness. Implications are that rural immersion programs could select students with an orientation towards teamwork, without pre-set professional ideation, and with a strong commitment to helping others. Experiencing rural immersion will trigger aspirational, intellectual and emotional responses leading to rural work openness for such students.

The Clarion Call of the COVID-19 Pandemic: How Medical Education Can Mitigate Racial and Ethnic Disparities

Public health crises palpably demonstrate how social determinants of health have led to disparate health outcomes. The staggering mortality rates among African Americans, Native Americans, and Latinx Americans during the COVID-19 pandemic have revealed how recalcitrant structural inequities can exacerbate disparities and render not just individuals but whole communities acutely vulnerable. While medical curricula that educate students about disparities are vital in rousing awareness, it is experience that is most likely to instill passion for change. The authors first consider the roots of health care disparities in relation to the current pandemic. Then, they examine the importance of salient learning experiences that may inspire a commitment to championing social justice. Experiences in diverse communities can imbue medical students with a desire for lifelong learning and advocacy. The authors introduce a 3-pillar framework that consists of trust building, structural competency, and cultural humility. They discuss how these pillars should underpin educational efforts to improve social determinants of health. Effecting systemic change requires passion and resolve; therefore, perseverance in such efforts is predicated on learners caring about the structural inequities in housing, education, economic stability, and neighborhoods-all of which influence the health of individuals and communities.

Using Kern's 6-Step Approach to Integrate Health Systems Science Curricula Into Medical Education

The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted 6-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the 6-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.

Understanding community family medicine preceptors' involvement in educational scholarship: perceptions, influencing factors and promising areas for action

BACKGROUND

Residency training is increasingly occurring in community settings. The opportunity for community-based scholarship is untapped and substantial. We explored Community Family Medicine Preceptors' understanding of Educational Scholarship (ES), looked at barriers and enablers to ES, and identified opportunities to promote the growth of ES in this setting.

METHODS

We conducted semi-structured interviews with fifteen purposively chosen community-based Family Medicine preceptors in a distributed Canadian family medicine program.

RESULTS

Community Family Medicine Preceptors strongly self-identify as clinical teachers. They are not well acquainted with the definition of ES, but recognize themselves as scholars. Community Family Medicine Preceptors recognize ES has significant value to themselves, their patients, communities, and learners. Most Community Family Medicine Preceptors were interested and willing to invest in ES, but lack of time and scarcity of primary care research experience were seen as barriers. Research process support and a connection to the academic center were considered enablers. Opportunities to promote the growth of ES include recognition that there are fundamental differences between community and academic sites, the development of a mentorship program, and a process to encourage engagement.

CONCLUSIONS

Community Family Medicine Preceptors identify foremost as clinician teachers. They are engaged in and recognize the value of ES to their professional community at large and to their patients and learners. There is a growing commitment to the development of ES in the community.

A Curriculum for Achieving Universal Health Care: A Case Study of Ateneo de Zamboanga University School of Medicine

Introduction: Universal Health Care requires equal distribution of a health workforce equipped with competencies appropriate for local population needs. While health inequities persist in the Philippines, the Ateneo de Zamboanga University School of Medicine (ADZU-SOM) in Zamboanga Peninsula – an impoverished and underserved region – has demonstrated significant success retaining graduates and improving local health statistics. This study describes the qualitative evidence of ADZU-SOM students and graduates having positive impacts on local health services and communities, and the contextual factors associated with the school's socially-accountable mission and curriculum that contribute to these impacts.

Methods: This qualitative study involved 41 one-on-one or group interviews conducted across seven participant groups (faculty, graduates, final-year students, health professionals, health workers, community members, community leaders). Gale et al's method for analyzing qualitative data in multi-disciplinary health research, WHO's “6 Building Blocks for quality health systems” framework and THEnet's social-accountability framework were used to organize and interpret data.

Results: Local community members, community leaders, and health staff consistently reported examples of ADZU-SOM students and graduate doctors developing health infrastructure and providing health education, health promotion, and disease prevention activities accessible to all population groups. Students and graduates suggested these impacts were due to a number of factors, including how ADZU-SOM's sandwich model of longitudinal community-engagement culminating in 10-months continuous community placement in the final year helped them develop a strong motivation for community service, the teachings and curriculum activities that focused on public health and the social determinants of health, and faculty's commitment and ability to operationalize ADZU-SOM's mission and values. Staff also reported impacts were driven by integration of regional and national health priorities as core curriculum, and involving local stakeholders in curriculum development.

Conclusions: This study provides qualitative evidence that ADZU-SOM's curriculum content and immersive community placements are training a medical workforce that is strengthening local health systems and health infrastructure across all 6 WHO “Building Blocks for quality health systems.” These findings suggest ADZU-SOM has managed to evolve a consciousness toward community service among final year students and graduates, adding evidence to the assertion it is a fully socially-accountable health professions institution.

Fostering student motivation towards community healthcare: a qualitative study

OBJECTIVES

This study investigated what kinds of experiences influence regional quota (chiikiwaku) medical students' motivation to practice community healthcare (CH), and the mechanism of this influence, by focusing on their experiences in a community-based medical education (CBME) programme.

DESIGN

A qualitative thematic analysis based on interviews.

SETTING

Participants were recruited from the chiikiwaku students of Kobe University, Japan, using purposive sampling.

PARTICIPANTS

Fourteen students participated. The median (IQR) age of participants was 23 (23-24); half were sixth-year and half fifth-year students.

ANALYSIS

From September to December 2018, the interviews were audiorecorded and transcribed verbatim. Data were analysed according to the 'Steps for Coding and Theorisation' method. Our theoretical framework comprised three internal motives (ie, needs, cognitions and emotions) and their subordinate motivation theories self-determination theory, expectancy-value theories, and positive and negative emotions, respectively.

RESULTS

Three mechanisms and corresponding experiences emerged. The first mechanism, envisioning and preparing for practising CH, included corresponding experiences-empathy for the community, grasping the demands for CH, understanding the practices of CH, finding a role model and diminishing the conflicts between personal life and career. The second mechanism, belonging to a supportive community, included the robust construction of students' CH community and harmonisation with community residents. The third mechanism, psychological effects included the affect heuristic and framing effect. Student experiences brought about the changes and influences described in the presented mechanisms, and had both positive and negative impacts on their motivation towards CH. These results can be interpreted through the multifaceted lenses of motivation theories.

CONCLUSIONS

The authors revealed that motivation mechanisms of medical students towards CH derived from positive interaction with community residents, healthcare professionals and other students, and from exposure to attractive community environments and cultures. These experiences should be incorporated into CBME programmes to further encourage positive attitudes towards CH.

Personalizing the BioPsychoSocial Approach: "Add-Ons" and "Add-Ins" in Generalist Practice

Generalist practitioners often find interacting with patients deeply satisfying and joyful; they also experience encounters that are challenging and complex. In both cases, they must be aware of the many issues that affect the processes and outcomes of patient care. Although using the BioPsychoSocial approach is an important, time-tested framework for cultivating one's awareness of patients' presenting concerns, recent developments suggest that additional frames of reference may enhance communication and relationships with patients. In this article, we describe several additions to the BioPsychoSocial approach, considerations we call "add-ons" and "add-ins". We invite generalist practitioners and, indeed, all health care practitioners, to consider how they can improve their ongoing care of patients by personalizing these and other additions in their day-to-day work with patients.

Using Design Thinking to Explore Rural Experiential Education Barriers and Opportunities

INTRODUCTION

Design thinking is a creative problem-solving framework that can be used to better understand challenges and generate solutions in health professions education, such as the barriers to rural education. Rural education experiences can benefit students, providers, and patients; however, placement in and maintenance of rural education experiences offer unique challenges. Design thinking offers strategies to explore and address these challenges.

METHODS

This study used a design thinking framework to identify barriers of student placement in rural locations; this was accomplished using strategies to empathize with users (eg, students, practitioners, and administrators) and define the problem. Data were collected from focus groups, interviews, and a design thinking workshop. Design activities promoted participant discussion by drawing pictures, discussing findings, and creating empathy maps of student experiences. Qualitative data were analyzed to identify salient barriers to rural experience selection and opportunities for support.

RESULT

Focus group (n = 6), interview (n = 13), and workshop participants (n = 18) identified substantial advantages (eg, exposure to a wider variety of patients, less bureaucracy and constraints, more time with faculty) and disadvantages (eg, isolation, lack of housing, and commuting distances) of rural experiences. Participants identified physical, emotional, and social isolation as a significant barrier to student interest in and engagement in rural experiences. Workshop participants were able to generate over 100 ideas to address the most prominent theme of isolation.

DISCUSSION

Design thinking strategies can be used to explore health professions education challenges, such as placement in rural settings. Through engagement with students, practitioners, and administrators it was identified that physical, social, and emotional isolation presents a significant barrier to student placement in rural experiences. This perspective can inform support systems for students, preceptors, and communities that participate in rural educational experiences.

Organização da Atenção Primária à Saúde em um município rural remoto do norte do Brasil

RESUMO O objetivo do artigo foi caracterizar a organização da Atenção Primária à Saúde (APS) e suas interfaces com os demais serviços da rede assistencial em um Município Rural Remoto (MRR). Foi realizado estudo de caso único em Assis Brasil (AC), por meio de entrevistas com usuários, gestores e profissionais de saúde. Os resultados indicaram distribuição desigual de estabelecimentos de saúde com áreas descobertas; dificuldades de acesso por condições climáticas; barreiras econômicas para custeio de transporte; promoção de ações itinerantes na zona rural; descontinuidade e insuficiência de medicamentos; dificuldades para a fixação de profissionais; escassez de recursos tecnológicos; falta de acesso à internet; necessidade de adaptação cultural; concentração de serviços especializados do SUS na capital. Foram identificados esforços da gestão local para manutenção da Estratégia Saúde da Família (ESF) e adequação dos processos de trabalho para atendimento ao grande fluxo de demanda espontânea, estrangeiros e população indígena. Argumenta-se que o MRR e suas populações somam vulnerabilidades econômicas, sociais e de acesso aos serviços de saúde, parcialmente atendidas pelas políticas nacionais, e que o ente municipal, sem o suficiente apoio e aporte de recursos estadual e federal, mantém arranjos possíveis para a provisão de APS, nem sempre afeitos aos princípios abrangentes da ESF.

Accountability in medical education from theory to practice Tabriz 2018 statement: A step towards the implementation of this social necessity

Background: To implement the education reform package on accountability in medical education, the Education Development Center (EDC) of Tabriz University of Medical Sciences has held the first national conference on accountability in medical education, and the present statement is the result of scientific interactions and exchanges in the conference.

Methods: For implementation of the accountability in medical education, there was a need to inform faculty members and other stakeholders about their responsibility in education and health care needs. The provision of such platform was provided by holding a specialized conference on accountability in medical education by Tabriz University of Medical Sciences. Steps of preparing the draft version of the Tabriz 2018 Statement were as follow: Formation the scientific committee; Division of the responsibility for drafting the statement between various workgroups; and Preparation and primary approval of the draft of Tabriz 2018 Statement.

Results: Steps of preparing the draft version of the Tabriz 2018 Statement were: Formation of the scientific committee, Division of the responsibility for drafting the statement between the various workgroups and Preparation and primary approval of the draft of Tabriz 2018 Statement.

Conclusion: Establishing an educational accreditation model and reviewing accreditation standards based on social accountability can be an effective step to strengthen accountability towards community needs.

Social Accountability Frameworks and Their Implications for Medical Education and Program Evaluation: A Narrative Review

PURPOSE

Medical schools face growing pressures to produce stronger evidence of their social accountability, but measuring social accountability remains a global challenge. This narrative review aimed to identify and document common themes and indicators across large-scale social accountability frameworks to facilitate development of initial operational constructs to evaluate social accountability in medical education.

METHOD

The authors searched 5 electronic databases and platforms and the World Wide Web to identify social accountability frameworks applicable to medical education, with a focus on medical schools. English-language, peer-reviewed documents published between 1990 and March 2019 were eligible for inclusion. Primary source social accountability frameworks that represented foundational values, principles, and parameters and were cited in subsequent papers to conceptualize social accountability were included in the analysis. Thematic synthesis was used to describe common elements across included frameworks. Descriptive themes were characterized using the context-input-process-product (CIPP) evaluation model as an organizational framework.

RESULTS

From the initial sample of 33 documents, 4 key social accountability frameworks were selected and analyzed. Six themes (with subthemes) emerged across frameworks, including shared values (core social values of relevance, quality, effectiveness, and equity; professionalism; academic freedom and clinical autonomy) and 5 indicators related to the CIPP model: context (mission statements, community partnerships, active contributions to health care policy); inputs (diversity/equity in recruitment/selection, community population health profiles); processes (curricular activities, community-based clinical training opportunities/learning exposures); products (physician resource planning, quality assurance, program evaluation and accreditation); and impacts (overall improvement in community health outcomes, reduction/prevention of health risks, morbidity/mortality of community diseases).

CONCLUSIONS

As more emphasis is placed on social accountability of medical schools, it is imperative to shift focus from educational inputs and processes to educational products and impacts. A way to begin to establish links between inputs, products, and impacts is by using the CIPP evaluation model.

Healthcare systems and the sciences of health professional education

Health professions education is that part of the education system which applies educational philosophy, theory, principles and practice in a complex relationship with busy clinical services, where education is not the primary role. While the goals are clear-to produce the health workforce that society needs to improve health outcomes-both education and healthcare systems continue to evolve concurrently amidst changes in knowledge, skills, population demographics and social contracts. In observing a significant anniversary of this journal, which sits at the junction of education and healthcare systems, it is appropriate to reflect on how the relationship is evolving. Health professions educators must listen to the voices of regulators, employers, students and patients when adapting to new service delivery models that emerge in response to pressures for change. The recent COVID-19 pandemic is one example of disruptive change, but other factors, such as population pressures and climate change, can also drive innovations that result in lasting change. Emerging technology may act as either a servant of change or a disruptor. There is a pressing need for interdisciplinary research that develops a theory and evidence base to strengthen sustainability of change.

[Mapping the implementation characteristics of new Medicine programs in Brazilian federal universitiesMapeo de las características de implementación de los nuevos programas de medicina en universidades federales brasileñas]

Objetivo.

Mapear as características de implantação de novos cursos de Medicina nas universidades federais brasileiras, a partir de 2013.

Métodos.

Estudo exploratório com metodologia quantitativa e qualitativa. Foi realizado um levantamento das novas escolas de Medicina em universidades federais, com análise dos projetos pedagógicos dos cursos e entrevistas a estudantes, professores e profissionais de serviços de saúde vinculados às escolas de Medicina. Os dados coletados foram analisados quantitativa e qualitativamente.

Resultados.

Foram identificados 30 novos cursos de Medicina, dos quais 24 foram visitados. Todos os novos cursos se localizam fora dos grandes centros urbanos e capitais, nas cinco macrorregiões brasileiras; são organizados em arranjos formativos diversos, que buscam superar a fragmentação disciplinar com metodologias ativas e avaliação formativa. A rede de saúde é utilizada na formação para enfrentamento dos desafios da integração ensino-serviço-comunidade, com vistas a uma formação crítica e voltada à saúde pública. A criação dos cursos promoveu a interiorização de docentes, embora de forma limitada, e contribuiu para o ingresso de estudantes locais e a criação de residências médicas, expedientes potentes na fixação médica.

Conclusões.

Observou-se diversidade nas formas da materialidade e aderência ao disposto pelas Diretrizes Curriculares Nacionais de Medicina publicadas em 2014. A construção de modelos de formação médica condizentes com as particularidades locais e com as exigências do Sistema Único de Saúde (SUS) em seu papel de ordenador da formação dos profissionais da saúde pode contribuir para reduzir as desigualdades em saúde.

Plan, recruit, retain: a framework for local healthcare organizations to achieve a stable remote rural workforce

BACKGROUND

Recruiting and retaining a skilled health workforce is a common challenge for remote and rural communities worldwide, negatively impacting access to services, and in turn peoples' health. The research literature highlights different factors facilitating or hindering recruitment and retention of healthcare workers to remote and rural areas; however, there are few practical tools to guide local healthcare organizations in their recruitment and retention struggles. The purpose of this paper is to describe the development process, the contents, and the suggested use of The Framework for Remote Rural Workforce Stability. The Framework is a strategy designed for rural and remote healthcare organizations to ensure the recruitment and retention of vital healthcare personnel.

METHOD

The Framework is the result of a 7-year, five-country (Sweden, Norway, Canada, Iceland, and Scotland) international collaboration combining literature reviews, practical experience, and national case studies in two different projects.

RESULT

The Framework consists of nine key strategic elements, grouped into three main tasks (plan, recruit, retain). Plan: activities to ensure that the population's needs are periodically assessed, that the right service model is in place, and that the right recruits are targeted. Recruit: activities to ensure that the right recruits and their families have the information and support needed to relocate and integrate in the local community. Retain: activities to support team cohesion, train current and future professionals for rural and remote health careers, and assure the attractiveness of these careers. Five conditions for success are recognition of unique issues; targeted investment; a regular cycle of activities involving key agencies; monitoring, evaluating, and adjusting; and active community participation.

CONCLUSION

The Framework can be implemented in any local context as a holistic, integrated set of interventions. It is also possible to implement selected components among the nine strategic elements in order to gain recruitment and/or retention improvements.

Twelve tips for establishing a new medical school

Many new medical programs have been established during the last 20 years, and this trend seems set to continue as the health care needs of the world's populations become more complex and demand increases for more physicians to provide the necessary health care. In this paper, we address how best to establish a new medical school, based on our experiences in new ventures in several countries. Success requires a combination of boldness of vision, support from many stakeholder groups, adequate financial and human resources, educational expertise, confidence, patience, and persistence.

The do's, don'ts and don't knows of establishing a sustainable longitudinal integrated clerkship

INTRODUCTION

The longitudinal integrated clerkship is a model of clinical medical education that is increasingly employed by medical schools around the world. These guidelines are a result of a narrative review of the literature which considered the question of how to maximize the sustainability of a new longitudinal integrated clerkship program.

METHOD

All four authors have practical experience of establishing longitudinal integrated clerkship programs. Each author individually constructed their Do's, Don'ts and Don't Knows and the literature that underpinned them. The lists were compiled and revised in discussion and a final set of guidelines was agreed. A statement of the strength of the evidence is included for each guideline.

RESULTS

The final set of 18 Do's, Don'ts and Don't Knows is presented with an appraisal of the evidence for each one.

CONCLUSION

Implementing a longitudinal integrated clerkship is a complex process requiring the involvement of a wide group of stakeholders in both hospitals and communities. The complexity of the change management processes requires careful and sustained attention, with a particular focus on the outcomes of the programs for students and the communities in which they learn. Effective and consistent leadership and adequate resourcing are important. There is a need to select teaching sites carefully, involve students and faculty in allocation of students to sites and support students and faculty though the implementation phase and beyond. Work is needed to address the Don't Knows, in particular the question of how cost-effectiveness is best measured.

Addressing the health advocate role in medical education

The health advocate role is an essential and underappreciated component of the CanMEDs competency framework. It is tied to the concept of social accountability and its application to medical schools for preparing future physicians who will work to ensure an equitable healthcare system. Student involvement in health advocacy throughout medical school can inspire a long-term commitment to address health disparities. The Social Medicine Network (SMN) provides an online platform for medical trainees to seek opportunities to address health disparities, with the goal of bridging the gap between the social determinants of health and clinical medicine. This online platform provides a list of health advocacy related opportunities for addressing issues that impede health equity, whether through research, community engagement, or clinical care.First implemented at the University of British Columbia, the SMN has since expanded to other medical schools across Canada. At the University of Ottawa, the SMN is being used to augment didactic teachings of health advocacy and social accountability. This article reports on the development and application of the SMN as a resource for medical trainees seeking meaningful and actionable opportunities to enact their role as health advocates.

Rethinking Goals: Transforming Short-Term Global Health Experiences Into Engagements

The authors challenge the conventional wisdom guiding what participants in short-term experiences in global health (STEGHs) should be learning. Medical students and residents from the United States have been told to focus on standardized competencies and ethical principles, in addition to the biomedical knowledge, skills, and attitudes highlighted by working internationally. The authors suggest that although these training goals are important, they may divert learners from developing their professional identities in ways that contribute to the health of all persons, especially those who are economically poor and socially marginalized. The authors postulate that such a professional transformation will occur only if STEGH participants attend to 5 key learning goals: develop contextual inquisitiveness, grow in insightful understanding, nurture global humility, cultivate structural awareness, and critically engage in the pursuit of creating equitable and just societies. Further, the authors argue that only by attending to these goals will any genuine change in the root causes of inequities in health outcomes occur. The authors review these goals and encourage their use for professional and pedagogical purposes over the duration of any STEGH-before departure, while in host communities, and upon return home.

Using a virtue ethics lens to develop a socially accountable community placement programme for medical students

BACKGROUND

Community-based education (CBE) involves educating the head (cognitive), heart (affective), and the hand (practical) by utilizing tools that enable us to broaden and interrogate our value systems. This article reports on the use of virtue ethics (VE) theory for understanding the principles that create, maintain and sustain a socially accountable community placement programme for undergraduate medical students. Our research questions driving this secondary analysis were; what are the goods which are internal to the successful practice of CBE in medicine, and what are the virtues that are likely to promote and sustain them?

METHODS

We conducted a secondary theoretically informed thematic analysis of the primary data based on MacIntyre's virtue ethics theory as the conceptual framework.

RESULTS

Virtue ethics is an ethical approach that emphasizes the role of character and virtue in shaping moral behavior; when individuals engage in practices (such as CBE), goods internal to those practices (such as a collaborative attitude) strengthen the practices themselves, but also augment those individuals' virtues, and that of their community (such as empathy). We identified several goods that are internal to the practice of CBE and accompanying virtues as important for the development, implementation and sustainability of a socially accountable community placement programme. A service-oriented mind-set, a deep understanding of community needs, a transformed mind, and a collaborative approach emerged as goods internal to the practice of a socially accountable CBE. The virtues needed to sustain the identified internal goods included empathy and compassion, connectedness, accountability, engagement [sustained relationship], cooperation, perseverance, and willingness to be an agent of change.

CONCLUSION

This study found that MacIntyre's virtue ethics theory provided a useful theoretical lens for understanding the principles that create, maintain and sustain CBE practice.

The Contextual Curriculum: Learning in the Matrix, Learning From the Matrix

Changes in the health care landscape over the last 25 years have led to an expansion of training sites beyond the traditional academic health sciences center. The resulting contextual diversity in contemporary medical education affords new opportunities to consider the influence of contextual variation on learning. The authors describe how different contextual patterns in clinical learning environments-patients, clinical and educational practices, physical geography, health care systems, and culture-form a contextual learning matrix. Learners' participation in this contextual matrix shapes what and how they learn, and who they might become as physicians.Although competent performance is critically dependent on context, this dependence may not be actively considered or shaped by medical educators. Moreover, learners' inability to recognize the educational affordances of different contexts may mean that they miss critical learning opportunities, which in turn may affect patient care, particularly in the unavoidable times of transition that characterize a professional career. Learners therefore need support in recognizing the variability of learning opportunities afforded by different training contexts. The authors set out the concept of the contextual curriculum in medical education as that which is learned both intentionally and unintentionally from the settings in which learning takes place. Further, the authors consider strategies for medical educators through which the contextual curriculum can be made apparent and tangible to learners as they navigate a professional trajectory where their environments are not fixed but fluid and where change is a constant.

Toward interprofessional service-learning and social accountability in health: One South African University's process-oriented-participatory journey

The Nelson Mandela University in Port Elizabeth, South Africa, seeks to transform its health professions curricula in order to achieve equity in health outcomes. Integral to this are interprofessional education service-learning initiatives attendant to socially accountable objectives. We describe one such initiative, the Zanempilo Mobile Health Education Platform (MHEP), which engages interprofessional healthcare students and faculty members in delivering health services to underserved communities. The Zanempilo MHEP consists of a converted 13-ton truck as a mobile clinic from where student-run services are provided. We illustrate the intentional process by which we, an interprofessional health science working group, created socially accountable learning goals appropriate to the above platform. We developed, employed, and refined a process-oriented-participatory approach rooted in theories of social constructivism and social network development that included the following phases: orientation, analysis, synthesis, production, and dissemination. Out of this approach emerged several socially accountable learning goals for students and faculty members working on the Zanempilo MHEP. These goals incorporated five educational domains, namely knowledge, attitudes, skills, intentions, and relationships. We anticipate using these goals to identify future curricular objectives and competencies.

Time for action: key considerations for implementing social accountability in the education of health professionals

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Work settings of the first seven cohorts of James Cook University Bachelor of Medicine, Bachelor of Surgery graduates: Meeting a social accountability mandate through contribution to the public sector and Indigenous health services

OBJECTIVE

The James Cook University medical school's mission is to produce a workforce appropriate for the health needs of northern Australia.

DESIGN, SETTING AND PARTICIPANTS

James Cook University medical graduate data were obtained via cross-sectional survey of 180 early-career James Cook University medical graduates from 2005-2011 (response rate of 180/298 contactable graduates = 60%). Australian medical practitioner data for 2005-2009 graduates were obtained via the 2015 'Medicine in Australia: Balancing Employment and Life' wave 8 dataset.

MAIN OUTCOME MEASURE

Comparison of the range of work settings and hours worked by James Cook University medical graduates to Australian medical graduates.

RESULTS

Compared to a similar group of Australian medical graduates, James Cook University Bachelor of Medicine, Bachelor of Surgery graduates are significantly more likely to work in government-funded 'public' organisations (hospitals, community health centres, Aboriginal Community Controlled Health Services, government departments, agencies or defence forces). In particular, James Cook University medical graduates were more likely to work in Aboriginal Community Controlled Health Services and community health centres and other state-run primary health care organisations than other Australian medical graduates.

CONCLUSION

James Cook University medical graduates appear to work in a higher proportion of public settings; in particular, primary care settings, than Australian medical graduates. This is an appropriate mix for the predominantly rural and remote geography of Queensland and its associated medical workforce priorities. Reporting medical graduate outcomes by their nature of practice could be an important adjunct to other measures, such as geographic location and choice of specialty.

Can non-clinical community placements enhance medical students' understanding of the social determinants of ill health?

OBJECTIVES

Teaching the social determinants of health using classroom methods and medical settings is not effectual, yet few institutions require students to undertake placements in non-clinical settings. We sought to understand through qualitative investigation how non-clinical community placements contributed to students' understanding of health disparities.

STUDY DESIGN

Qualitative methods.

METHODS

Semistructured interviews with eight purposively selected students and a focus group were conducted by an independent, non-medical and non-religiously affiliated researcher. A thematic analysis elicited key themes and findings.

RESULTS

On analysis, students valued the placements, reporting a greater understanding of and empathy for the needs of people from marginalised socio-economic, cultural and ethnic groups. Some believed this was better gained in non-clinical settings where doctor-patient barriers were absent.

CONCLUSIONS

Non-clinical community placements may provide a special opportunity to teach health determinants and cultural competence to medical students.

The Effect of a Community-Based Medical School on the State and Local Physician Workforce

PURPOSE

To assess the effect of community-based medical education as implemented by Michigan State University College of Human Medicine (MSU-CHM), which has immersed students in diverse communities across Michigan since its founding, on the physician workforce in the six communities in which clinical campuses were initially established.

METHOD

The authors used American Medical Association Masterfile data from 2011 to obtain practice locations and specialty data for all MSU-CHM graduates from 1972 through 2006. They classified physicians as either practicing primary care or practicing in a high-need specialty. Using Geographic Information Systems software, the authors geocoded practice locations to the ZIP Code level, evaluated whether the practice was within a Health Professional Shortage Area, and determined rurality, using 2006 Rural-Urban Commuting Area Code data. They visually compared maps of the footprints of each campus to glean insights.

RESULTS

The authors analyzed 3,107 of 3,309 graduates (94%). Of these, 635 (20%) practiced within 50 miles of their medical school campus. Saginaw and Flint graduates were more likely to practice in Detroit and its surrounding suburbs, reflecting these communities' urban character. Grand Rapids, the community with the strongest tertiary medical care focus, had the lowest proportions of rural and high-need specialty graduates.

CONCLUSIONS

This case study suggests that distributed medical education campuses can have a significant effect on the long-term regional physician workforce. Students' long-term practice choices may also reflect the patient populations and specialty patterns of the communities where they learn.

Translating medical school social missions to student experiences

CONTEXT

There is a growing focus on the social missions of medical schools as a way of expressing an institutional commitment to service, responsibility and accountability. However, there has been little exploration of how a social mission translates to student experiences.

METHODS

This multicentre study explored how the social missions of eight medical schools (from Australia, Belgium, Canada, the Philippines, South Africa, Sudan and the USA) translated to their medical education programmes, and how their students perceived the mission. The study used a nested case study design involving interviews with final-year medical students. Constructivist grounded theory techniques were used to analyse the data. Cultural-historical activity theory concepts of externalisation and internalisation were used to structure the analyses.

RESULTS

The study identified substantial variation in the form, focus and depth of expression of each school's social mission, significant variation in how and to what extent the mission was externalised in the design of each school's undergraduate medical education programme, and significant variation in how students perceived the social mission and its translation to their training experiences. The translation of a social mission to educational outcomes depended on a cascade of externalisation and internalisation processes, each of which could alter or reinterpret the mission. Translation depended to a great extent on sensitising learners to the mission's values and issues and subsequently activating this knowledge in the context of direct clinical encounters that embodied the issues the mission was seeking to address.

CONCLUSION

Whether a medical school's social mission is focused on equity of access to the medical profession or on its graduates serving particular community needs, the mission principles need to be translated into practice. This translation process involves a series of externalisation and internalisation steps, each of which determines how much and what aspects of the mission are translated.