The concept of “social mission” in medical or health professions education in the United States was not much used before 2010. Academicians, students, and policy leaders did reference ideas such as community oriented primary care, community outreach, minority health, and diversity but these issues rarely enjoyed a common label or a sense of defined mission. The term “social accountability” of medical schools was endorsed by the World Health Organization starting in the 1990’s and has gained some traction in mission statements and policy discussion in Europe and Canada. The term social mission first drew broad attention in 2010 when an article entitled “The Social Mission of Medical Education: Ranking the Schools” (Mullan, Chen, et al, Annals of Internal Medicine, 2010;152:804-811) lit up a national debate about social mission in medical education. The study, conducted by researchers at the George Washington University (GW) and the Robert Graham Center and funded by the Josiah Macy Jr. Foundation, measured the “outcome” of the nation’s allopathic and osteopathic medical schools. It ranked the schools on three core indicators of social mission – 1) what percent of graduates were practicing primary care, 2) what percent were practicing in shortage areas, and 3) what percent were underrepresented minorities. The results indicated that the nation’s three African American schools as well as many rural and public schools far outperformed more research oriented schools – schools which are often ranked highly by the US News and World Report – in social mission. That debate catalyzed the concerns of many educators, students, and policymakers about the lack of attention given to social mission in the programs of medical schools and residency programs.
In the same timeframe as the “Rankings” paper, case studies funded by the W. K. Kellogg Foundation on six schools concentrating on social mission in medical education were carried out by the GW team. That work focused on eight aspects of school activity that were judged to be social mission enhancing — mission statements, pipeline programs, admissions, curriculum, location of clinical experience, tuition management, mentorship, and preparation for residency. The studies at the six schools and the unrest created by the “Rankings” paper led to the convening of the first “Beyond Flexner: Social Mission in Medical Education” Conference in May of 2012 at the University of Oklahoma School of Community Medicine in Tulsa, Oklahoma.
The title, Beyond Flexner, was chosen because of its succinct statement of the social mission challenge. Abraham Flexner, author of a 1910 report
highly critical of medical schools of the time, called for adherence to science and quality standards in medical education. Flexner’s work is often celebrated as the blueprint for 20th century medical education and, indeed, health professions education in general. Flexner’s contributions, foundational as they were for medical school curricula, were silent on the medical school as an agent of community health or social change. While Flexner’s values supported the development of scientifically sound medical education, they did nothing to address the increasingly evident disparities in health and health care that were then, and are now, omnipresent in US and global populations. The concept of Beyond Flexner, then, is not to dismiss science or rigorous instruction as values in health professions education, but rather, to go beyond those precepts to create a philosophy and curriculum that promote health equity and the challenges that health professionals face in working toward it.
The First Beyond Flexner Conference – Tulsa
The first Beyond Flexner Conference was co-hosted by Gerry Clancy, then president of the University of Oklahoma School of Community Medicine in Tulsa, and Fitzhugh Mullan of GW. The meeting was keynoted by former Surgeon General, David Satcher and Jack Geiger, who is recognized as the father of the community health center movement and a leader in the field of social medicine. Many of the 200 participants at the meeting held important university positions in areas such as diversity and inclusion, rural health, and primary care but often felt marginalized in their home settings. At the Beyond Flexner conference, the social mission common ground was everywhere and electrifying. The sense of purpose was strong and participants left Tulsa reinforced in their missions with new concepts and new colleagues.
The timing of the first Beyond Flexner conference coincided with the implementation of the Affordable Care Act and a national emphasis on health care delivery innovation, payment reform, and social determinants of health. Beyond Flexner succeeded in attracting a new generation of supporters, bringing together activists in primary care and service delivery with more established groups in diversity and community engagement – combining new tactics of social media and internet organizing with more traditional approaches to student organizing and curricular reform.
The Second Beyond Flexner Conference – Albuquerque
The second Beyond Flexner Conference took place in Albuquerque, NM in April 2015 and was co-hosted by the University of New Mexico (UNM. The UNM Health Science Center has a rich history of community engagement dating back to the opening of the medical school in 1965. Conference participants not only deliberated issues of social mission but had the opportunity to take part in one of 16 site visits in and around Albuquerque. These visits were to programs where
health professions students and faculty engaged in community based health delivery, agriculture, environmental improvement, and information exchange projects, modeling the impact a medical school could have on social determinants of health. There were 400 attendees at the New Mexico Conference, of whom about 15% were students or residents. The conference was co-hosted by Arthur Kaufman, Vice Chancellor for Family and Community Medicine at UNM and Fitzhugh Mullan of GW, and keynoted by Don Berwick, founder of the Institute of Health Care Improvement and former CMS administrator.
Two important decisions were made at that conference. The first was in response to the group consensus that inter-professional education for health professions students is essential to quality clinical practice and promotion of health equity in the future. Based on this view, the conference endorsed a change in the name and identity of the movement to “Beyond Flexner: Social Mission in Health Professions Education” with a commitment to broaden the agenda and the participation of nurses, PAs, community health workers, dentists, and others in future Beyond Flexner Conferences. The second decision was to create a formal organization, the Beyond Flexner Alliance (BFA), devoted to promoting social mission in health professions education. The BFA would have core goals of reducing health disparities, enhancing diversity, advancing community engagement, and using health care resources responsibly. The number of organizations with increasing interest in pursuing social mission (by whatever definition) within health professions education was large and growing. The BFA was envisioned as a common ground that would provide a human and electronic platform for these people, organizations, and institutions as well as an accelerator for their common missions.
In March 2016, with the assistance of a supportive grant from the Atlantic Philanthropies, 19 leaders from the Beyond Flexner movement met for a weekend in Millwood, VA with special attention given to including representatives from the inter-professional education movement. The meeting resulted in agreement on the BFA vision, mission, and core concepts as well as the establishment of a 12-member Board of Directors. Fitzhugh Mullan was elected Board Chair, Divina Grossman, Professor of Nursing and Former Chancellor at the University of Massachusetts – Dartmouth was elected Board Vice-Chair, and Leigh Anne Butler from the GW Health Workforce Institute as Secretary/Treasurer. The agreed upon work of the Board was to build a communications presence (website, newsletter, blogs, webinars, etc.), a membership strategy, and a business plan. Additionally, they were tasked with overseeing Beyond Flexner national meetings, creating awareness of and recognizing best practices, and exploring additional sources of support and collaboration for the BFA.
The Third Beyond Flexner Conference – Miami
The third Beyond Flexner Conference took place in September 2016 and was co-hosted by Florida International University in Miami. Pedro J. Greer, Jr., Associate Dean for Community Engagement and Professor and Chair, Department of Medicine, Family Medicine, and Community Health, served as convener along with Fitzhugh Mullan and the BFA Board. Television commentator and social activist, Soledad O’Brien, and Massachusetts General Hospital CEO Peter Slavin provided the keynote presentations. Divina Grossman presented on the social mission of nursing education and Mona Hanna-Attisha, pediatrician from Flint, MI invoked the social mission of the health professions in talking about her critical role in the Flint water crisis. One of the highlights of the conference was the Student/Resident Poster Presentations recognizing research being done in social mission. First, second, and third place winners also received special recognition for their work. As a way to continue to reach out to students and residents, the “Young Flexnerians” group, which was loosely formed in Albuquerque, found more traction in the third conference and has received support by the BFA Board.
The Fourth Beyond Flexner Conference – Atlanta
The fourth Beyond Flexner Conference was held in Atlanta, Georgia and was hosted by Morehouse and Emory School of Nursing.
The Macy Awards
George Thibault, President of the Josiah Macy Jr. Foundation and an early supporter of the Beyond Flexner movement, responded to an idea for recognizing social mission accomplishments by funding the Josiah Macy Jr. Foundation Awards for Excellence in Social Mission in Health Professions Education. The BFA Board oversaw the first cycle of Macy Awards that were presented to the Morehouse School of Medicine for institutional excellence, University of Florida Putting Families First: An Inter-Professional Family Health Experience for program excellence, and Tom Curtin former Chief Medical Officer of the National Association of Community Health Centers for individual excellence. The awards ceremony climaxed with the presentation of a lifetime achievement award for accomplishment in social mission to Jack Geiger.