Educating Physicians for Rural America

PURPOSE: To evaluate the Rural Medical Scholars (RMS) Program’s effectiveness to produce rural physicians for Alabama.

METHODS: A nonrandomized intervention study compared RMS (1997-2002) with control groups in usual medical education (1991-2002) at the University of Alabama School of Medicine’s main and regional campuses. Participants were RMS and others admitted to regular medical education, and the intervention was the RMS Program. Measures assessed the percentage of graduates practicing in rural areas. Odds ratios compared effectiveness of producing rural Alabama physicians.

FINDINGS: The RMS Program (N = 54), regional campuses (N = 182), and main campus (N = 649) produced 48.1% (odds ratio 6.4, P < .001), 23.8% (odds ratio 2.5, P < .001), and 11.2% (odds ratio 1.0) rural physicians, respectively.

CONCLUSIONS: The RMS Program, contrasted to other local programs of medical education, was effective in producing rural physicians. These results were comparable to benchmark programs in the Northeast and Midwest USA on which the RMS Program was modeled, justifying the assumption that model programs can be replicated in different regions. However, this positive effect was not shared by a disparate rural minority population, suggesting that models for rural medical education must be adjusted to meet the challenge of such communities for physicians.

Citation: Wheat JR, Leeper JD, Murphy S, Brandon JE, Jackson JR. Educating Physicians for Rural America: Validating Successes and Identifying Remaining Challenges With the Rural Medical Scholars Program. J Rural Health. 2017. doi: 10.1111/jrh.12236. 

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Defining and Measuring the Social Accountability of Medical Schools

Countries worldwide increasingly demand more value for money in health care. Medical schools, which both shape the health care system and are shaped by it, must continue to be socially responsible on their own initiative. In addition, they must accept and acknowledge being held to account by society: they must demonstrate social accountability. This paper proposes a framework by which medical schools can gauge their progress in helping promote health care systems characterized by a balance between relevance, quality, cost-effectiveness and equity through their activities in education, research and service delivery. Further studies are suggested to test the validity of the framework and nay tools resulting from it, define more specifically the benchmarks of progress in addressing social accountability, and expand the framework to apply to other health professions schools and health sector insitutions.

Citation: Boelen C, Heck J. Defining and Measuring the Social Accountability of Medical Schools. Geneva, Switzerland: The Word Health Organization. 

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Measuring the Social Responsiveness of Medical Schools: Setting the Standards

This article calls for medical schools to use a new set of standards to gauge how well they contribute to social welfare. Because medical schools receive public funding and are given the authority to certify that providers are sufficiently trained, they incur an obligation to be socially responsible. In addition to setting and using higher standards, medical schools should call on their credibility and use their scientific expertise to find new policies that promote social welfare. In particular, they should do research on socially oriented policies and participate more actively in debates about health sector reform. Although societies vary and have different values, most countries and peoples probably share the following social objectives: They want to use limited public and private resources rationally to produce the best possible health, they do not want individuals or groups to suffer, and they want to protect people against catastrophic illness and associated financial losses. Although new standards are needed, medical schools should be encouraged to continue producing technically sophisticated providers and conducting high-level basic and clinical research. Available evidence suggests that medical schools can further contribute to the three social objectives noted above by increasing the intensity and relevancy of primary care training, expanding the curriculum beyond its biomedical focus, encouraging research in health services, and assessing the effectiveness of social policy in improving the health of the population.

CitationPeabody JW. Measuring the social responsiveness of medical schools: setting the standards. Acad Med. 1999;74(8 Suppl):S59-68.

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Caring for a Common Future: Medical Schools’ Social Accountability

Origins and Context: The concept of ‘the social accountability of medical schools’ is moving from the peripheral preoccupation of a few to a more central concern of medical schools themselves. Born of concerns about the professionalism and relevance of both the institutions and their graduates, it is seen increasingly as an urgent call to focus the considerable social resources vested in academic health science institutions on addressing the priority health concerns of the societies they serve. For a profession embedded in an ethos of service, this would seem an obvious transition. However, as with any movement towards transformative change, it runs the risk of being more mantra and rhetoric than mandate and responsibility.

Needed Response: Proceeding from the assumption that good intentions alone are not enough, this paper seeks to outline the historical development and some current expression of the concept throughout the world. The sadly divergent wealth and health status of modern societies calls for very different actions by medical schools across the spectrum from the least endowed to the wealthiest of schools. In a profession claiming centuries of cohesive commitment to the welfare of others, it is increasingly urgent that the current generation of medical educators converge on a relevant set of principles and coherent activities.

Tools for the Task: While recognising that they are closely intertwined, the paper outlines the difference between the social accountability of the institutions themselves and the social accountability of the graduates they produce. It outlines both individual examples and the international initiatives that are fostering and facilitating institutional collaborations to bring both progress and optimism to this daunting task. It provides connections to practical resources for those who are committed to that task. Other papers in this series add further practical insights into the central role that medical educators must play if we are to fulfil the responsibilities we carry with the privilege of our profession.

CitationWoollard RF. Caring for a common future: medical schools’ social accountability. Med Educ. 2006;40(4):301-13.

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Building the Evidence Base: Networking Innovative Socially Accountable Medical Education Programs

Introduction: To date, traditional biomedical hospital-centered models of medical education have not produced physicians in quantities or with the competencies and commitment needed to meet health needs in poor communities worldwide. The Global Health Education Consortium conducted an initial assessment of selected medical education programs/schools established specifically to meet these needs. The goals of this assessment are to determine whether there is a need for and interest in collaborating and developing a common framework of core principles and evaluation standards to measure the impact of the programs on access to care and on health status in the communities they serve.

Methods: A literature review of 290 articles was conducted focusing on standards, tools and multi-institutional evaluation efforts of socially accountable medical education programs designed to increase the number of doctors in underserved communities. Site visits, which included semi-structured interviews with deans, faculty and students, were carried out at eight schools on five continents, whose core mission is self-described as training to meet the needs of the underserved. Preliminary findings form the framework around which a rigorous outcome and impact evaluation tool will be developed by participating schools.

Findings: No systematic international evaluation of socially accountable medical schools was found and current tools to measure the social responsiveness of programs need more rigor. All target schools identified a need to develop common evaluation and collaborative frameworks. Preliminary findings suggest that these schools, although operating in different contexts and employing somewhat different strategies, share common principles and a core mission to serve marginalized communities.

Conclusion: There is a clear need for a common rigorous evaluation tool for socially accountable medical education, particularly for schools created to address the shortage of doctors in neglected areas. While it will be difficult to determine the impact of socially accountable medical education on health outcomes, target schools agreed to collaborate and develop a common evaluation framework to strengthen the evidence base on how to train doctors to meet health needs in underserved area.

Citation: Pálsdóttir B, Neusy AJ, Reed G. Building the evidence base: networking innovative socially accountable medical education programs. Educ Health (Abingdon). 2008;21(2):177. Epub 2008 Aug 26.

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The Social Accountability of Medical Schools and its Indicators

Context: There is growing interest worldwide in social accountability for medical and other health professional schools. Attempts have been made to apply the concept primarily to educational reform initiatives with limited concern towards transforming an entire institution to commit and assess its education, research and service delivery missions to better meet priority health needs in society for an efficient, equitable an sustainable health system.

Methods: In this paper, we clarify the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and we expand on a previously described conceptual model of social accountability (the CPU model), by further delineating the parameters composing the model and providing examples on how to translate them into meaningful indicators.

Discussion: The clarification of concepts of social responsibility, responsiveness and accountability and the examples provided in designing indicators may help medical schools and other health professional schools in crafting their own benchmarks to assess progress towards social accountability within the context of their particular environment.

Citation: Boelen C, Dharamsi S, Gibbs T. The social accountability of medical schools and its indicators. Educ Health (Abingdon). 2012;25(3):180-94. doi: 10.4103/1357-6283.109785.

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Primary Care Specialty Choices of United States Medical Graduates, 1997–2006

Purpose: To describe trends in specialty choice and to identify predictors of primary care specialty choices among graduates of U.S. MD-granting medical schools.

Method: A longitudinal study evaluated 1997– 2006 medical school graduates who completed the Association of American Medical Colleges’ Matriculating Student Questionnaire and Graduation Questionnaire. Multivariate logistic regression identified significant predictors of graduates’ choice of primary care specialty (general internal medicine, general pediatrics, internal medicine subspecialties, pediatrics subspecialties, family medicine, and obstetrics–gynecology) or “no-board- certification specialty,” compared with all other specialties (reference).

Results: The sample included 102,673 graduates (64.9% of all 1997–2006 graduates). General internal medicine, family medicine, general pediatrics, and obstetrics–gynecology choice decreased, whereas internal medicine subspecialties, pediatrics subspecialties, and no-board- certification specialty choice increased over time (each: P .001). Female graduates and those who planned to practice in underserved communities, espoused more-altruistic beliefs about health care, and ascribed greater importance to social responsibility in their choice of medicine at matriculation were more likely to choose general internal medicine, general pediatrics, family medicine, or obstetrics–gynecology, whereas graduates who had a physician parent and who planned full-time academic medicine careers were less likely to do so (each: P .01). Graduates with higher debt were less likely to choose internal medicine and pediatrics specialties (each: P .001) and more likely to choose obstetrics–gynecology (P = 0.001).

Conclusions: Generalist–primary care specialty choices declined since 1997, whereas primary care subspecialty and no-board- certification specialty choices increased. Associations between primary care specialty choices and demographic, attitudinal, and career intention variables can inform the design of interventions to address expected primary care workforce shortages.

CitationJeffe DB, Whelan AJ, Andriole DA. Primary care specialty choices of United States medical graduates, 1997-2006. Acad Med. 2010;85(6):947-58. doi: 10.1097/ACM.0b013e3181dbe77d.

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Social Accountability of Medical Schools: Do Accreditation Standards Help Promote the Concept?

The social accountability of medical schools is an emerging concept in medical education. This issue calls for the consideration of societal needs in all aspects of medical programmes, including the values of relevance, quality, cost-effectiveness and equity. Most importantly, these needs must be defined collaboratively with people themselves. Social accountability should be considered in the accreditation of medical education, a process implemented with the aim of ensuring quality in medical education. This process may be voluntary or mandatory and varies from one country to another. The objective of this study is to analyse current accreditation standards in relation to the concept of social accountability. The standards of the World Federation for Medical Education (WFME), the Liaison Committee on Medical Education (LCME) and the Australian Medical Council standards (AMC) were classified into process standards, content standards or outcome standards. The three sets of standards were plotted against the social accountability grid suggested by Boelen and Heck. Most of the standards are process standards. Content standards are addressed less frequently than process standards, and very few standards address the outcomes of the medical school. When considering standards that address social accountability, the focus is on education more than the service and research functions of the medical school. Standards should consider all aspects of the medical school’s functions to promote the concept of social accountability.

CitationAbdalla, ME. Social Accountability of Medical Schools: Do Accreditation Standards Help Promote the Concept? Journal of Case Studies in Accreditation and Assessment. 2014;3.

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Developing a Professional Pathway in Health Equity to Facilitate Curricular Transformation at the University of Michigan Medical School

Problem: Medical schools are challenged to realign curricula to address society’s needs in a rapidly changing environment, and to support new instruction and assessment methods that require substantial faculty time.

Approach: In 2010, the University of Michigan Medical school began planning the Global Health and Disparities Path of Excellence (GHD Path), an optional co-curriculum for students interested in health disparities, with explicit goals to (1) draw attention to the school’s social mission; (2) test new, faculty-intensive methods of learning and assessment for all students; and (3) serve as a template for additional co-curricular paths.

Outcomes: Intended outcomes of the program include enhancing students’ competency in leadership related to ameliorating health disparities and the study institution’s ability to plan feasible and effective school wide reforms in self-directed learning, faculty advising systems, narrative-based feedback for goal setting, Web-based student portfolios, and additional Paths of Excellence.

Next Steps: During academic year 2013–2014, the GHD Path is adding more community-based experiences. The faculty development and support model will be streamlined to decrease resources required for program development while retaining key features of the advising system. Lessons from the GHD Path are central to planning school wide reform of instructional methods, faculty advising, and student portfolios. The use of a small-scale program to pilot new ideas to inform longer-term, larger-scale changes at our institution might prove useful to other schools striving to meet societal needs while implementing innovative methods of instruction and assessment.

CitationWilliams BC, Mullan PB, Haig AJ, et al. Developing a professional pathway in health equity to facilitate curricular transformation at the University of Michigan Medical School. Acad Med. 2014;89(8):1153-6. doi: 10.1097/ACM.0000000000000286.

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The Social Mission in Medical School Mission Statements: Associations with Graduate Outcomes

Background and Objectives: Mission statements of medical schools vary considerably. These statements reflect institutional values and may also be reflected in the outputs of their institutions. The authors explored the relationship between US medical school mission statement content and outcomes in terms of graduate location and specialty choices.

Methods: A panel of stakeholders (medical school deans, faculty, medical students, and administrators) completed a Web-based instrument to create a linear scale of social mission content (SMC scale), scoring the degree to which medical school mission statements reflect the social mission of medical education to address inequities. The SMC scale and targeted medical school outputs were analyzed via OLS regression, controlling for allopathic/osteopathic and public/private school designation. The medical school outputs of interest included percent physician output in primary care specialties (family medicine, pediatrics, and general internal medicine), as well as percent physician output in designated Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/Populations (MUA/P).

Results: SMC scale was a statistically significant, positive predictor of the percent of physician graduates entering primary care (?=2.526, P=.001). When examining the specialties within primary care, the SMC scale only significantly predicted percent of graduating physicians entering family medicine (?=1.936, P=.003). SMC scale was also a statistically significant predictor of several measures of physician output to work in underserved areas and populations, the strongest of which was the percent of graduating physicians working in MUA/Ps (?=4.256, P?.01).

Conclusions: Mission statements that are diligently utilized by leaders in medical education may produce a higher degree of alignment between institutional structure, ideology, and workforce outcomes.

Citation: Morley CP, Mader EM, Smilnak T, et al. The social mission in medical school mission statements: associations with graduate outcomes. Fam Med. 2015;47(6):427-34.

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