Social accountability: at the heart of family medicine

In 1995, the World Health Organization¹ formally defined social accountability in the context of medical education as the obligation of medical schools to meet the priority health needs of the communities they serve. This definition highlights the fact that the role physicians play in addressing gaps in health care delivery and health outcomes is central to the profession. This makes sense to the point of being nearly self-evident: a profession that has as its central role the treatment of the sick is by definition responsive to health needs. Why then have the World Health Organization,¹ the Association of Faculties of Medicine of Canada,² numerous faculties of medicine, and now the College of Family Physicians of Canada (CFPC)³ felt the need to focus attention on this concept in recent years?

Looking outward

In recent decades, medical training has emphasized technical competency and specialization. This inward focus, while successful in producing skilled practitioners, could be described as a physician-centred rather than a community- and patient-centred approach to training and practice. The call for social accountability urges the profession to look outward and examine how medical practice can lead to the most meaningful health outcomes for communities.

Two important recent documents give us a clearer vision of where medical education is heading. The first is the Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education,⁴ which outlines 10 key recommendations for undergraduate medical education (Box 1).⁴ The concept of social accountability is woven throughout, underpinning the focus of the entire document.

Box 1. The FMEC undergraduate medical education project recommendations.

The following are the recommendations of the FMEC’s undergraduate medical education project: Address individual and community needs Enhance admissions processes Build on the scientific basis of medicine Promote prevention and public health Address the hidden curriculum Diversify learning contexts Value generalism Advance interprofessional and intraprofessional practice Adopt a competency-based and flexible approach Foster medical leadership

FMEC—Future of Medical Education in Canada.

Data from the Association of Faculties of Medicine of Canada.⁴

The second is the recently released Future of Medical Education in Canada (FMEC) Postgraduate Project: A Collective Vision for Postgraduate Medical Education in Canada (Box 2),⁵ a collaborative effort of the Association of Faculties of Medicine of Canada, the Royal College of Physicians and Surgeons of Canada, the Collège des médecins du Québec, and the CFPC. Social accountability is also at the heart of this document. The first 2 recommendations—ensure the right mix, distribution, and number of physicians to meet societal needs and cultivate social accountability through experience in diverse learning and work environments⁵—explicitly bring the concept to the fore. Recognizing family medicine and primary care as critical to the health and well-being of the population, the document stresses that, in order to appropriately meet the health care needs of Canadians, Canada must find the right ratio of broad-scope generalist family physicians to other specialists, including clinician scientists, educators, and leaders. This recommendation is fundamental and sets the tone for the rest of the document. Cultivating social accountability requires commitment from all of Canada’s medical schools. Postgraduate programs must develop educational experiences in environments that, through meeting the needs of Canada’s diverse populations, demonstrate the social responsibility required of physicians individually and collectively. Residency training has to move beyond the academic health science centre environment into ambulatory-based community practices, where by far most health care delivery in Canada actually takes place. These experiences will no doubt inform future physicians’ career choices and serve to ultimately create the right mix and distribution of family physicians and other specialists across the country.

Box 2. The FMEC postgraduate medical education project recommendations.

The following are the recommendations of the FMEC’s postgraduate medical education project: Ensure the right mix, distribution, and number of physicians to meet societal needs Cultivate social accountability through experience in diverse learning and work environments Create positive and supportive learning and work environments Integrate competency-based curricula in postgraduate programs Ensure effective integration and transitions along the educational continuum Implement effective assessment systems Develop, support, and recognize clinical teachers Foster leadership development Establish effective collaborative governance in postgraduate medical education Align accreditation standards

FMEC—Future of Medical Education in Canada.

Data from the Association of Faculties of Medicine of Canada.⁵

Creating change

The creation of the FMEC reports has been the easy part. The challenge will be in the implementation, as the structure, the curriculum, and—above all—the culture of medical training are slow to respond to change.

One example of an effort to create a culture of social accountability within a medical faculty comes from the College of Medicine at the University of Saskatchewan in Saskatoon. This school has chosen to form a dedicated Social Accountability Committee that works to integrate the concepts of social accountability into every aspect of the work of the medical school.⁶ This committee uses the acronym CARE to describe the work of a medical school as having 4 main areas: clinical activity, advocacy, research, and education. The elements of the CARE acronym are used to work on specific areas of interest, such as indigenous health, global health, and immigrant and refugee health, and with departments within the faculty to evaluate the degree to which priority health needs are being addressed and to explore potential new areas of involvement.

This has resulted in the development of numerous programs and led to greater connections with community-based organizations. One interesting element has been the development of numerous student-led initiatives, ranging from a student-run interdisciplinary clinic (ie, Student Wellness Initiative Toward Community Health), to a Political Advocacy Committee, to interest groups in reproductive health and care of the elderly. This activity has been attributed to various factors, including the emphasis on social accountability at all levels within the College of Medicine.

While there has been some success at the undergraduate level, faculties of medicine across Canada have struggled with integrating opportunities for exposure to socially accountable practice into residency and beyond into practice and continuing education. The FMEC postgraduate framework offers some hope for this gap to be addressed, but it will require sustained efforts on the part of the faculties and their national organizations.

To that end, the CFPC has established a Social Accountability Working Group. This group reports to the Executive Committee and explores how the College should be involved in social accountability and the needs, opportunities, and barriers related to its integration into family medicine training and practice. This group is working on strategies to better incorporate these concepts into the programs and activities of the CFPC. An invitational forum is being planned for 2014 to involve CFPC members in setting the direction for the future of this initiative. If this is an area of interest to you, please contact the Chair of the Social Accountability Working Group, CFPC Past President Dr Sandy Buchman, at sbuchman@cfpc.ca for more information on how you can become involved in making family medicine more socially responsive and accountable to Canadians.