|Year : 2021 | Volume
| Issue : 2 | Page : 50-57
Beyond Flexner: A novel framework to implement the social mission of medical education
Fitzhugh Mullan1, Malika Fair2, Amir Meiri3, Amy Zeidan4, Sarah Diamond O’Donnell5, Ashley Darcy-Mahoney6, Asefeh Faraz Covelli6
1 Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, USA; Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, USA
2 Department of Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, USA
3 Department of Medicine, Washington D.C. Veterans Affairs Medical Center, Washington, USA; Department of Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, USA
4 Department of Emergency Medicine, Emory University, Washington, USA
5 Independent Researcher, Washington, USA
6 School of Nursing, The George Washington University, Washington, USA
|Date of Submission||05-Feb-2021|
|Date of Acceptance||02-Jun-2021|
|Date of Web Publication||15-Sep-2021|
Dr. Asefeh Faraz Covelli
1919 Pennsylvania Avenue, Suite 500, Washington, DC.
Source of Support: None, Conflict of Interest: None
Purpose: Medical schools are uniquely positioned to contribute to the changing healthcare climate by increasing diversity in the healthcare workforce and addressing social determinants of health. The purpose of this study was to develop a framework for promoting social mission in medical education and develop case studies of medical schools that exemplify social mission. Materials and Methods: The research team and Advisory Committee first used an iterative process to identify eight core modalities as essential elements in the social mission of medical education. Each modality was supported by a literature review. Six schools were selected for their commitment to enhancing health equity. Interviews and focus groups were then conducted with school leadership, key faculty, students, and residents to learn about the social mission activities of the school and to evaluate the school’s commitment to the eight core modalities. Results: All schools selected for case studies integrated and actively engaged with all eight modalities: school mission, cultivation of the pipeline, student admissions, curricular structure and content, location of clinical experience, tuition management, mentorship, and postgraduate engagement. Each modality was utilized to advance the school’s social mission, demonstrating these modalities as a useful framework for promoting the social mission of medical education. Conclusion: The social mission modalities were developed to provide a tool for institutions to discuss, promote, or measure their social mission. This is ever-more important in the current healthcare climate and should be incorporated not only in medical education but also in all health professions education to build a culture of health.
Keywords: Health equity, health professions education, medical education, social mission
|How to cite this article:|
Mullan F, Fair M, Meiri A, Zeidan A, O’Donnell SD, Darcy-Mahoney A, Covelli AF. Beyond Flexner: A novel framework to implement the social mission of medical education. Educ Health Prof 2021;4:50-7
|How to cite this URL:|
Mullan F, Fair M, Meiri A, Zeidan A, O’Donnell SD, Darcy-Mahoney A, Covelli AF. Beyond Flexner: A novel framework to implement the social mission of medical education. Educ Health Prof [serial online] 2021 [cited 2021 Nov 29];4:50-7. Available from: https://www.ehpjournal.com/text.asp?2021/4/2/50/325999
| Introduction|| |
Medical schools have historically responded to pressing societal needs by providing cutting-edge medical care, facilitating medical research breakthroughs, and developing innovations in physician education. As the nation’s needs are changing to transition to value-based care, population health, and health equity through novel initiatives, medical schools are reevaluating their social mission in response to these shifting paradigms. In fact, all health professions should be engaged in systematically addressing health disparities, health equity, and the social determinants of health.
| Background|| |
Broadly defined, the social mission of a medical school is the contribution of a school in its mission, programs, and the performance of its graduates, faculty, and leadership in addressing the health inequities of the society in which it exists. A few American medical schools have been founded on principles that feature this social mission prominently in areas such as enrollment of underrepresented students, primary care, and rural health., Some schools are also incorporating interprofessional education, public and population health curriculum, and urban and rural training programs, which can assist in addressing the social needs of the nations’ communities.
Over the last 20 years, academic medicine has launched several initiatives to prepare the healthcare workforce to meet societal needs. This study shows how medical schools can harness the social mission to meet societal needs by implementing tools and allocating resources spanning various facets of medical education. The assessment framework developed in this study can serve as a guide for medical schools as they modify the infrastructure, policies, and curriculum to pursue a social mission and make lasting contributions to health equity.
| Materials and Methods|| |
Selection of modalities
This study consisted of three phases: formation of an Advisory Committee, literature review, and site visits. The Advisory Committee was formed by the study team and included 16 individuals representing leaders in medical education with a broad range of perspectives on trends in teaching social accountability in medical schools [Table 1]. The Advisory Committee and study team developed eight core modalities that reflect and promote social accountability in medical education through an iterative process: school mission, pipeline, admissions, curriculum, location of clinical experience, tuition/debt management, mentorship, and postgraduate engagement [Table 2]. A literature review was then conducted to support each modality and explore how they contribute to medical schools addressing societal needs. These eight modalities were used to guide the interviews and site visits for the participating medical schools.
The study team conducted a literature review for each modality using keywords specific to the respective modality using PubMed, MEDLINE, CINAHL, and Google Scholar databases. Bibliographies from selected articles were searched as well as references from relevant websites. Articles were considered relevant for each modality if they included keywords (approximately 10–20 unique keywords per modality) or fit into the specific scope of the respective modality [Table 2]. Examples of keywords included “medical education,” “social responsibility,” and “ethics.” A total of 252 articles were reviewed. Articles specific to each modality were reviewed for relevance to social mission.
The Advisory Committee and study team identified six schools that demonstrated a commitment to developing a physician workforce to meet societal needs in a variety of ways (Appendix A). The aim was to find a balance of schools that represented various aspects of medical education: historically Black colleges and universities (HBCU), osteopathy, rural medicine, and international. The eight modalities were used as an assessment framework to conduct interviews and site visits for the participating medical schools. Prior to site visits, schools were sent a survey with questions related to the eight modalities. Examples of questions included identifying the mission of each school, the admissions process, the presence of social mission-related curricula, clinical learning opportunities, financial aid, and postgraduate practice settings. Site visits were 2–3 days and attended by two study teams and 1–2 Advisory Committee members.
The study team conducted interviews and focus groups with school leadership, key faculty, students, and medical residents to learn about social mission-focussed educational programs, including their origins, obstacles to implementation, evaluative efforts, and future prospects. Each interviewee was selected by their institution to voluntarily participate in site visit discussions based on a sample agenda provided to the institutions. A range of 20–40 school faculty, administrators, and learners from each institution expressed their reaction to the modalities, influence of the mission within the school, and the school’s social mission activities. A thorough report was written, documenting the school’s program in regard to social accountability experience and outcomes, and shared with the host institution. This study was reviewed and approved by the George Washington University (GWU) Institutional Review Board.
| Results|| |
While every medical school has a mission statement, most contain elements of the tripartite mission of academic medicine: patient care, research, and education. The development of a mission statement as a standalone activity or as part of a strategic planning exercise was a critical action for the participating schools because their missions are often seen as unorthodox or novel. Institutions with an embedded social mission tend to expand upon the traditional medical school mission statement to include an explicit “fourth” focus. A statement of social mission sends a clear message from the institution’s leadership about their commitment to addressing the needs of their community. Three common themes emerged when comparing mission statements across sites: a geographical target, community engagement, and diversity.
Each institution included a local geographical target to concentrate their efforts, making their goals tangible and well-demarcated. Although the impact of the tripartite mission is global, the study institutions made a commitment to address local needs. For example, the Morehouse School of Medicine (MSM) has a goal to improve health in Georgia. At Southern Illinois University School of Medicine (SIU SOM), one member of the school leadership put it as “We are here to improve the health of the region…It’s why we exist.”
Half of the participating schools mentioned community engagement in their mission statements and articulated their desire to actively engage with their local community. The community engagement efforts spanned their clinical, educational, and research efforts and were also a leadership priority. Finally, diversity was a noted theme, which indicates a school’s desire to produce a physician workforce that reflects the patient population and includes racial, ethnic, and sociodemographic composition among other factors. Typically, these mission statements resonate with the organization more than traditional statements because of the intended social impact. At A.T. Still School of Osteopathic Medicine (ATSU-SOMA), students and faculty routinely recited the abbreviated mission “to promote primary care service to underserved populations.” Faculty, staff, and learners are attracted to an institution because of these stated goals, and they live the mission within their roles.
The participating schools had several pipeline programs aimed at recruiting students from lower socioeconomic status, underrepresented minorities (URMs), poorly represented areas of a state or province, or rural areas. Most of these programs attempted to improve high school graduation rates, college matriculation rates, overall science grade point average (GPA), performance on standardized exams, and preparation for admission to medical school. Other pipeline programs attempted to develop an interest in medical research or expose underrepresented students to the medical field. Notable examples include SIU SOM’s long-standing postbaccalaureate program for URMs and socioeconomically disadvantaged students, which has been successful in placing over 1000 URM or disadvantaged students in medical schools around the country. University of New Mexico School of Medicine’s (UNM SOM) Bachelor of Arts/Medical Doctorate program has increased the level of diversity in the student body and has more graduates who match into family medicine residencies, compared with other medical schools.
Some schools begin recruitment to a health career earlier. SIU has a Physicians Pipeline Preparatory Program (or P4) that engages high school students who have a strong interest in the field of medicine. One program administrator commented “We believe that there is a high probability that many of these students are going to go on to become medical doctors. And…when you ask them, ‘what do you want to become’ they will quickly correct you and tell you, ‘I am going to become a neurosurgeon, I am going to become…’ They are speaking in the affirmative.”
In all participant schools, a general theme of selecting students with social mission interests was identified. The Admissions Committee highly valued leadership, interpersonal skills, a desire to practice in underserved areas, remain within identified geographic locations, or return to under-resourced communities. Most of the study schools routinely used a holistic admissions practice, including mission-specific essays in their application, and considered prior community involvement. Northern Ontario School of Medicine (NOSM) utilizes a specific multiple mini interview format to highlight noncognitive attributes of students over their cognitive or limited interview performance. NOSM has a separate admission process for indigenous students using a sub-committee to recruit, review applicants, and make recommendations to the Admissions Committee. ATSU-SOMA has a program in which the local community health center can nominate a student who has been active within their organization, significantly increasing their chance of admission. As one faculty member at ATSU-SOMA said, “we can teach them medicine, but we can’t give them the heart to serve,” which is a primary driver in their admissions process.
Identified schools demonstrated unique departures from traditional curricula by integrating public health and community-based education within the preclinical and clinical curriculum. For instance, UNM SOM formally integrates a 17-credit public health certificate as part of the core curriculum for medical students. The certificate program includes courses in health equity, epidemiology, biostatistics, evidence-based practice, the biological and social determinants of health, and public health ethics. University of Oklahoma-Tulsa School of Community Medicine (OU SCM) students begin with a week-long Summer Institute that engages an interdisciplinary team of students with community members to learn about healthcare barriers. According to one faculty member at OU SCM, after the Summer Institute, “There are pretty dramatic shifts in the attitude of…the medical student…who fundamentally believes poverty is a choice and that if people would just go to work everything would be ok…they have a week experiencing what life is really like and they say I didn’t know…I had no idea what happens to people.”
Location of clinical experience
Unique clinical placement decisions by participant schools include longitudinal experiences in rural areas or community health centers, mandatory rural medicine clerkships, and well-integrated interprofessional clinical exposure. At OU SCM, students learn valuable lessons in continuity of care, interdisciplinary teamwork, and underserved care through the required longitudinal clinic in the third and fourth year where they are paired with nursing and pharmacy students to manage medically underserved populations. One student acknowledged not having “come in with a drive to be a public servant…,” but still felt changed by the experience of the longitudinal clinic.
At NOSM, the third-year Comprehensive Community Clerkship is the centerpiece of the curriculum, where students spend 8 months in a rural community setting. During this time, they develop close ties with local family practice physicians and gain an understanding of rural healthcare access and care systems. At ATSU-SOMA, students only spend 1 year on campus and are then distributed around the country for community health center-based education for the remaining 3 years. A recent ATSU-SOMA alumnus stated, “I don’t think without this experience I would have considered underserved medicine…now I have a deep understanding of what practice in a community health center looks like.”
Some medical students face tremendous financial burden after completion of medical training. The participant schools have employed multiple strategies to help minimize debt burden for students. They offer incentive programs that provide financial support for students who will practice in designated shortage areas or seek out state or provincial funding for scholarships or loan repayment. For example, OU SCM and UNM SOM have established financial programs for practicing in underserved areas. In Tulsa, $7.5 million was made available to students in the form of scholarships and loan repayment in exchange for practicing in underserved areas. MSM is committed to providing various loan repayment options to students so that their specialty choice remains broad. “If you are really truly committed to primary care, there are options out there,” says a second-year student who has decided to practice primary care.
While each participant school had a unique mentoring strategy, some common themes emerged: introducing students to career-satisfied primary care role models early on, joint community service projects with faculty and staff, and well-organized one-on-one mentoring for students during each year of training. Some schools had formal assigned mentors, whereas others encouraged students to form informal relationships with community preceptors. SIU SOM provides multiple mentors for each stage of medical school training. Starting in the first 2 years, students have a designated primary care physician mentor, a different mentor for each clerkship, and a student-selected career advisor within their desired specialty in the fourth year. Students remarked that the alumni network is very strong, providing access to socially minded physicians. “Mentoring Students at Morehouse” is the formalized mentoring program at MSM that provides students with a longitudinal community experience through a learning community. They are assigned a clinical and nonclinical faculty mentor, linked with second-year students, and spend one clinical day with third-year medical students. The goal of this project is to formally train faculty mentors, support academically challenged students, and provide mentorship to all MSM students. “You are automatically grafted into a family,” one second-year student commented.
In addition to formal education to meet their social mission, the participant schools were also determined to influence the “hidden curriculum,” which refers to the culture of discouraging students from pursuing specific specialties (i.e., primary care, family medicine, or pediatrics) and practicing in specific areas (i.e., rural or underserved). Successful strategies included exposing students to career-satisfied primary care physicians, recruiting alumni to serve as preceptors and mentors, and aligning the institution’s residency programs with the medical school’s mission. SIU SOM exposes students to primary care physicians who are dedicated to the social mission of the school, hoping that students will want to emulate these physicians regardless of their chosen specialty. About 40% of the clinical faculty are alumni of the school or its residency and fellowship programs, which sends a strong message about SIU SOM graduates’ allegiance to the school and their community. “They see a bunch of SIU SOM trained, positive-minded, community service-oriented, happy physicians in primary care, practicing medicine in central and southern Illinois and those are their role models and they emulate them,” commented an SIU faculty member.
MSM employs a similar strategy by using faculty and residents as role models. Students witness their faculty volunteering at free clinics and churches, teaching, and deriving meaning from their community-based work. In addition, students observe residents participating in similar activities, as several of their graduate medical education programs have a mandatory community service requirement.
| Discussion|| |
The social mission modalities were developed to provide a framework for institutions to discuss, enhance, and evaluate their social mission. From both the experience of site visitors and discussions with medical school faculty and administration, all eight modalities were used by the participating schools to advance their social mission and offer a useful analytic framework for social mission discussion. The breadth of modalities from the mission statement to preparation for graduate medical education represents a span that captures the full arc of medical school. The modalities are not only found in schools that emphasize social mission as an articulated part of their mission but also represent activities present at all medical schools. The goal of the social mission framework for medical education is to provide an analytic framework and road map for all medical schools as they review and revise their programs to ideally include all eight modalities.
There are several limitations of this study. The nature of the interviews was informal, and although each site visitor used the same interview guide, specific questions could be modified so that conversations flowed naturally. Although there is literature to support each of the proposed modalities, comparable data from the study schools relevant to each of the modalities are not available as it is in narrative form. Responses were not quantified or coded but instead summarized in site visit reports. Although each of the schools exhibited all eight modalities, they were not discussed at length, but rather several key modalities were highlighted for each school. In addition, differentiating the social mission of a medical school from traditionally respected institutional practices can be difficult. Separately, many medical schools operationalize the modalities, whereas few have explicitly tied these practices to a stated mission of impacting the workforce and subsequently the health for a designated area.
The modalities capture areas in which schools can promote social mission and offer a framework for institutions to augment social mission teaching and outcomes. Although each of the modalities may not appear to have the same weight or relevance at a given institution, the modalities as a whole provide a concept menu available for omnibus or selective revisions at a given school. They certainly provide an opportunity for any institution interested in reviewing its performance in the area of social mission. Future studies could build on this work and propose a robust evaluation plan, metrics, and supporting data from internal evaluations of institutional programs and practices.
Finally, the discussion about the importance of social mission should extend beyond medical education to all health professions education. Although the study was focussed on medical schools, the modalities can be applied to other health professions. This work has begun in nursing with calls to action to increase diversity in nursing education and to address social determinants of health to promote health equity and diversity., With an increasing focus on the importance of health inequities, embedding social mission in all health professions programs represents an opportunity to enhance excellence within the professions through a stronger sense of equity, inclusion, and justice.
The authors would like to thank the additional study team members for their involvement in the Beyond Flexner Study including Jennifer Lee, MD and Gretchen D. Kolsky, MPH. In memoriam, the authors dedicate this article to Fitzhugh Mullan, MD. They honor his significant contributions to advancing health equity through education, activism, and mentorship.
Financial support and sponsorship
This study was supported through a grant from the WK Kellogg Foundation.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rohan-Minjares F, Alfero C, Kaufman A. How medical schools can encourage students’ interest in family medicine. Acad Med 2015;90:553-5.
Mullan F. Social mission in health professions education: Beyond Flexner. J Am Med Assoc 2017;318:122-3.
Dalton ML. The History of the Mercer University School of Medicine: 1965–2007. Macon, GA:Mercer University Press; 2009.
Gasman M. The Morehouse Mystique: Becoming a Doctor at the Nation’s Newest African American Medical School. Baltimore, MD: Johns Hopkins University Press; 2012.
Skochelak SE. A decade of reports calling for change in medical education: What do they say? Acad Med 2010;85(9 Suppl.):S26-33.
Valsangkar B, Chen C, Wohltjen H, Mullan F. Do medical school mission statements align with the nation’s health care needs? Acad Med 2014;89:892-5.
Morley CP, Mader EM, Smilnak T, Bazemore A, Petterson S, Rodriguez JE, et al
. The social mission in medical school mission statements: Associations with graduate outcomes. Fam Med 2015;47:427-34.
Rourke J. Social accountability: A framework for medical schools to improve the health of the populations they serve. Acad Med 2018;93:1120-4.
Thomson WA, Ferry P, King J, Wedig CM, Villarreal GB. A baccalaureate-MD program for students from medically underserved communities: 15-year outcomes. Acad Med 2010;85:668-74.
McDougle L, Way DP, Lee WK, Morfin JA, Mavis BE, Matthews D, et al
. A national long-term outcomes evaluation of U.S. Premedical postbaccalaureate programs designed to promote health care access and workforce diversity. J Health Care Poor Underserved 2015;26:631-47.
Metz AM. Medical school outcomes, primary care specialty choice, and practice in medically underserved areas by physician alumni of MEDPREP, a postbaccalaureate premedical program for underrepresented and disadvantaged students. Teach Learn Med 2017;29:351-9.
Patel SI, Rodríguez P, Gonzales RJ. The implementation of an innovative high school mentoring program designed to enhance diversity and provide a pathway for future careers in healthcare related fields. J Racial Ethn Health Disparities 2015;2:395-402.
Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The road to rural primary care: A narrative review of factors that help develop, recruit, and retain rural primary care physicians. Acad Med 2018;93:130-40.
Xierali IM, Maeshiro R, Johnson S, Arceneaux T, Fair MA. Public health and community medicine instruction and physician practice location. Am J Prev Med 2014;47:S297-300.
Verma P, Ford JA, Stuart A, Howe A, Everington S, Steel N. A systematic review of strategies to recruit and retain primary care doctors. BMC Health Serv Res 2016;16:126.
Farmer J, Kenny A, McKinstry C, Huysmans RD. A scoping review of the association between rural medical education and rural practice location. Hum Resour Health 2015;13:27.
Phillips JP, Petterson SM, Bazemore AW, Phillips RL. A retrospective analysis of the relationship between medical student debt and primary care practice in the united states. Ann Fam Med 2014;12:542-9.
Rohlfing J, Navarro R, Maniya OZ, Hughes BD, Rogalsky DK. Medical student debt and major life choices other than specialty. Med Educ Online 2014;19:25603.
Stagg P, Prideaux D, Greenhill J, Sweet L. Are medical students influenced by preceptors in making career choices, and if so how? A systematic review. Rural Remote Health 2012;12:1832.
Kost A, Bentley A, Phillips J, Kelly C, Prunuske J, Morley CP. Graduating medical student perspectives on factors influencing specialty choice: An AAFP national survey. Fam Med 2019;51:129-36.
Rabow MW. Becoming a doctor: Learning from the hidden curriculum in medical education. In: Hafferty FW, O’Donnell JF, Baldwin DC Jr, editors. The Hidden Curriculum in Health Professional Education. Hanover: Dartmouth College Press; 2015. p. 130-9.
Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study. Med Teach 2016;38: 410-8.
Martimianakis MA, Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the hidden curriculum, and educational reform: A scoping review and thematic analysis. Acad Med 2015;90:S5-S13.
Fair M. Beyond Flexner Southern Illinois University Site Visit Report: September 21–23, 2011. Available from: https://www.beyondflexner.org/uploads/1/3/0/8/130847098/beyond_flexner_report-siu-final1.pdf. [Last accessed on 2021 May 11].
Fair M. Beyond Flexner A.T. Still University School of Osteopathic Medicine in Arizona Site Visit Report: November 7–11, 2011. Available from: https://www.beyondflexner.org/uploads/1/3/0/8/130847098/beyond-flexner-atsu-soma-final.pdf. [Last accessed on 2021 May 11].
Mullan F. Beyond Flexner University of Oklahoma School of Community Medicine Site Visit Report: April 12–15, 2011. Available from: https://www.beyondflexner.org/uploads/1/3/0/8/130847098/beyond-flexner-ouscm-report_final1.pdf. [Last accessed on 2021 May 12].
Mullan F. Beyond Flexner Morehouse School of Medicine Site Visit Report: September 6–7, 2011. Available from: https://www.beyondflexner.org/uploads/1/3/0/8/130847098/beyond-flexner-msm-final-report1.pdf.
National League for Nursing releases: A vision for integration of the social determinants of health into nursing education curricula. Nurs Educ Perspect 2019;40:390.
Darcy-Mahoney A, Carter B, Green K, Mullan F, Beard KV. Looking backwards to move forward: Using a social mission lens in nursing education. J Prof Nurs 2020;36:412-6.
Mahoney AD, Westphaln KK, Covelli AF, Mullan F. Advancing social mission in nursing education: Recommendations from an expert advisory board. J Nurs Educ 2020;59:433.
[Table 1], [Table 2]