Education for Health

ORIGINAL RESEARCH ARTICLE
Year
: 2022  |  Volume : 35  |  Issue : 1  |  Page : 3--8

Social accountability in undergraduate medical education: A narrative review


Ariana Mihan1, Laura Muldoon2, Haley Leider3, Hadi Tehfe3, Michael Fitzgerald1, Karine Fournier4, Claire E Kendall5,  
1 C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
2 Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
3 Office of Social Accountability, Faculty of Medicine, University of Ottawa, Ottawa, Canada
4 Library, University of Ottawa, Ottawa, Canada
5 C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute; Department of Family Medicine, Faculty of Medicine; Office of Social Accountability, Faculty of Medicine, University of Ottawa, Ottawa, Canada

Correspondence Address:
Claire E Kendall
85 Primrose Ave, K1N 5C8, Ontario
Canada

Abstract

Background: Medical schools have been increasingly called upon to augment and prioritize their social accountability (SA). Approaches to increasing SA may include reorienting and focusing curricular activities on the priority health needs of the region that they serve. To inform the undergraduate medical education (UGME) curriculum renewal at our school, we examined how SA has been expressed in medical education across several countries and the impacts of SA activities on medical student experience and community-level outcomes. Methods: We conducted a narrative literature review using two electronic databases and searched for studies that reported on SA UGME activities implemented in Canada, Australia, New Zealand, the United States, and the United Kingdom. Studies were screened for inclusion based on predetermined eligibility criteria. Results: We included 40 studies for descriptive analysis and categorized UGME activities into five categories: (1) distributed medical education and community-specific placements/services (32; 80%), (2) community engagement and advocacy activities (23; 58%), (3) international elective preparation and experiences (8; 20%), (4) classroom-based learning of SA-related concepts (17; 43%), and (5) student engagement in SA UGME activities (6; 15%). We categorized impact into four main outcomes: student experience (21; 53%), student competencies (11; 28%), future career choice/practice setting (15; 38%), and community feedback (7; 18%). Student experience was most frequently examined, followed by future career choice/practice setting. Discussion: SA was primarily expressed in UGME activities through placement/service activities and most frequently assessed through student experiences. Student experiences of SA UGME activities have been reported to be largely positive, with benefits also reported for student competencies and influences on future career choice/practice setting. The expression of SA through community engagement in the development of curricular activities indicates a positive shift from social responsibility to SA, but a highly socially accountable curriculum would increasingly consider measures of community impact.



How to cite this article:
Mihan A, Muldoon L, Leider H, Tehfe H, Fitzgerald M, Fournier K, Kendall CE. Social accountability in undergraduate medical education: A narrative review.Educ Health 2022;35:3-8


How to cite this URL:
Mihan A, Muldoon L, Leider H, Tehfe H, Fitzgerald M, Fournier K, Kendall CE. Social accountability in undergraduate medical education: A narrative review. Educ Health [serial online] 2022 [cited 2022 Dec 6 ];35:3-8
Available from: https://educationforhealth.net//text.asp?2022/35/1/3/357522


Full Text



 Background



Over the past two decades, medical schools have been called upon to increase their social accountability (SA), defined as the “obligation to direct their education, research, and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve.”[1] In recent years, SA has been established as a component of undergraduate medical education (UGME) accreditation in Canada.[2] An important aspect of SA is ensuring that the health workforce meets the needs of the populations that they serve. One approach is to increase diversity in medical student selection. Most Canadian medical schools have developed admissions policies to recruit students reflecting particular populations, such as Indigenous populations, rural and remote communities, and certain socioeconomic or ethnocultural demographics.[3] Another important component of SA is curricular activities, often through service-learning opportunities that provide trainees with hands-on experience in rural and remote settings and with specific marginalized populations.[3],[4]

Previous studies have examined the implementation and impact of different SA-focused components of medical education, such as service-learning and curriculum, highlighting the social determinants of health.[5],[6] As our university faculty is undertaking a comprehensive UGME curriculum renewal, including a broad approach to implementing our SA mandate, we sought to examine how SA has been expressed in UGME and the impacts of SA activities on medical student experience and on outcomes at the community-level. We conducted a narrative review to explore the following questions: (1) How has SA been expressed in UGME? and (2) What is the impact of SA UGME activities?

 Methods



An information specialist (KF) performed searches in MEDLINE(R) ALL (OvidSP) and Education Source (EBSCOHost). The search was performed using a combination of subject headings terms and keywords focused on SA and UGME. We uploaded search results into Covidence (Veritas Health Information, Melbourne, Australia) and screened study titles/abstracts using predetermined eligibility criteria. Specifically, the study must have been published in the last 10 years and focused on Canada, the United States of America, New Zealand, Australia, or the United Kingdom as the context. These countries were selected due to their similarities in medical education and health system context. Studies were eligible for inclusion if they focused on implemented SA UGME curricular activities (e.g., service learning). We excluded studies that solely focused on postgraduate medical education, or other health professions education, and excluded studies that were guidelines or frameworks for future implementation, as we aimed to capture existing curricular activities. We excluded commentaries, editorials, opinion pieces, and letters to the editor. For titles/abstracts determined to be potentially eligible, we retrieved the full text to screen against the inclusion criteria. If a study's eligibility was unclear, the reviewer (AM) consulted with other team members (LM and CK) to determine the final decision. The team was composed of two subject matter experts (the Director of Social Medicine (LM) and Associate Dean of SA (CK) of our UGME faculty), two medical students (HT and HL), and a research coordinator (AM) who were engaged in our SA Curriculum Renewal Leadership Working Group. We (AM, HT, and HL) extracted key components of the included studies, narratively summarized SA curricular activities and, when reported, their outcomes. We grouped studies into meaningful UGME curricular categories and outcome categories based on the common concepts that emerged during data extraction. The narrative summary process was iterative and collaborative, and categories were revised based on team member input and discussion.

 Results



The search yielded 270 studies. After removing duplicates, 250 studies remained to be screened. Following eligibility screening, 40 studies were included in the descriptive analysis.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46] The types of studies varied, including cross-sectional, mixed-methods, qualitative, reports, reviews, program descriptions, cohort, and case studies.

Question 1: How has SA been expressed in UGME curricula?

We grouped UGME curricular activities into five categories: (1) distributed medical education and community-specific placements/services (32; 80%), (2) community engagement and advocacy activities (23; 58%), (3) international elective preparation and experiences (8; 20%), (4) classroom-based learning of SA-related concepts (17, 43%), and (5) student engagement in SA UGME activities (6; 15%). Categories were not mutually exclusive. We developed category definitions, which are presented in [Table 1].{Table 1}

Thirty-two (80%) studies reported on distributed medical education and community-specific placements/services. Services involved medically related activities, including taking patient histories and conducting health screening, as well as nonmedical activities, including mentoring and tutoring students in socioeconomically disadvantaged communities. We identified subcategories for studies that indicated the specific communities served. Twenty-one (53%) studies reported on rural/remote placements/services.[9],[12],[13],[14],[15],[16],[17],[18],[20],[21],[24],[28],[29],[33],[34],[35],[36],[38],[42],[44],[46]Placements/services were reported by seven studies (18%) in Indigenous communities,[13],[15],[18],[20],[21],[45],[46] three studies (8%) in northern Canadian and Australian communities,[11],[12],[15] three studies (8%) in community health centers/units,[14],[24],[32] three studies (8%) in underserved urban communities,[11],[12],[27] and one (3%) in underserved communities.[25] Several studies reported on learning opportunities with certain patient populations or types of care, including patients experiencing homelessness (3; 8%),[23],[24],[27] socially disadvantaged youth (2; 5%),[24],[31] aged care (1; 3%),[32] disability care (1; 3%),[32] refugees (1; 3%), and prison care (1; 3%).[24]

Twenty-three (58%) studies reported on community engagement and advocacy activities. This included student–community interactions, such as engaging with the community for research[10],[12],[20],[27] and understanding the experiences of and advocating for the community.[19],[27],[30],[39] Studies also reported on community engagement during the development of curricular activities,[15],[21],[23],[25],[31],[32],[37],[40],[43],[45],[46] as well as through collaborative delivery and implementation of activities,[23],[25],[27],[32],[40],[41] including hosting and facilitating placement and service-learning activities,[13],[20],[35] and through forming partnership agreements.[18],[20],[29]

Eight (20%) studies reported on the international experience context, including predeparture training and students' opportunities to participate in international electives.[7],[11],[12],[15],[22],[26],[38],[42]

Seventeen (43%) studies reported on classroom-based learning of SA-related concepts.[7],[9],[11],[17],[18],[19],[23],[25],[26],[27],[32],[37],[40],[42],[43],[45],[46] Studies reported on a variety of instruction methods, including tutorials, workshops, presentations, case-based discussions, online learning sessions/modules, and reflective activities. Learning concepts included the unique health-care needs of different populations, health inequities, health advocacy, harm reduction, and global health ethics.

Six (15%) studies reported on student engagement in SA UGME activities,[16],[19],[26],[27],[32],[37] including students' input and feedback in developing and improving activities. Studies reported on methods of engagement, including student advisory councils, student representatives, and student-led interest groups.

Question 2: What is the impact of these activities?

Thirty-six (90%) studies examined the impact of SA UGME activities.[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[21],[23],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] We categorized impact into four main outcomes: student experience, student competencies, future career choice/practice setting, and community feedback [Table 2].{Table 2}

Twenty-one (53%) studies reported on student experience, measured through student perspectives and reflections on SA UGME activities. Among the majority of studies, experiences were reported to be largely positive.[9],[10],[11],[12],[14],[15],[18],[23],[25],[27],[30],[31],[32],[37],[39],[40],[42],[43],[45] For example, one study reported that student course evaluations showed that the SA UGME activity cultivated an appreciation for “cultural competence, patient-centered communication skills, and SA.”[25] Students also appreciated the opportunity to develop therapeutic relationships and continuity of care with patients and their communities.[9] In addition, one study found that SA community-oriented topics learned earlier in the curriculum were reported by students to be “activated” later when completing placements.[42]

While most studies reported that students' experiences were mainly positive, some noted potential shortcomings. For example, one study found that students perceived their training to be responsive/responsible and not yet “accountable” and experienced some barriers in their learning.[38] Two studies noted that amid mostly positive responses, there was resistance from students when the clinical relevance of activities was not apparent[32] and challenges regarding increased workload and unclear expectations in newly developed SA UGME activities.[27] One study reported that students found their global health preparatory sessions too broad, which resulted in topic modifications,[26] and another found that although students valued the experience highly, they struggled with the short nature of placements.[11]

Eleven (28%) studies reported on student competencies, nine of which reported on self-reported competencies.[9],[18],[23],[25],[27],[30],[35],[40],[43] One study found that students anticipated that their research-based theater advocacy activity with individuals experiencing homelessness would positively influence their future interactions with marginalized populations.[30] Another study reported that participation in an Indigenous health orientation program increased self-reported Indigenous health competencies.[40] Two studies reported on the outcomes of national medical college questionnaires: one that found increases in preparedness to provide care to diverse populations following the introduction of the UGME activities[43] and the other that graduates reported more experiences regarding health disparities and cultural awareness compared to their other-school counterparts.[25] Externally assessed competencies were also reported in three studies.[25],[28],[29] One study reported that graduates of a program involving underserved communities and SA-related classroom learning were ranked highly by residency directors for communication, cultural sensitivity, teamwork, and accountability.[25] Another study reported that graduates of SA medical schools were rated higher than graduates of other medical schools in SA-related competencies, including teamwork, professionalism, and commitment to practice in underserved communities.[28]

Fifteen (35%) studies reported on the impact of SA UGME activities on future career choice and practice setting. Several studies reported the positive influence of rural/remote or northern placements and distributed medical education on: choosing family medicine or practicing in primary care settings;[8],[11],[12],[21],[34],[36] intention of future rural practice;[11],[35] and choosing to practice in rural/remote settings or northern Canadian or Australian settings.[11],[12],[13],[14],[15],[16],[17],[33],[34],[37],[44]

Finally, seven (18%) studies reported on community feedback,[10],[18],[21],[31],[35],[41],[45] including positive feedback from community members, host organizations and stakeholders on the implementation of SA UGME activities;[18],[31],[35],[41],[45] appreciation for these activities;[10] and empowerment as a result.[21]

 Discussion



The aim of this review was to examine the expression of SA in UGME curricula and to understand the impact of curricular activities on medical students and communities. SA was most often expressed through placements or service activities within specific regions or communities. We found that student experience was the most frequently examined outcome, followed by future career choice/practice setting.

Of the SA UGME curricula that focused on placements/service activities, the majority were concerned with rural and remote contexts. This may be because the majority of our included studies focused on Canada and Australia, both of which have geographically dispersed populations and shortages of healthcare providers in rural and remote regions.[48] Fewer studies focused on placements concerning marginalized populations, such as patients with substance use disorders and refugees. Just over one-half of the included studies examined UGME activities related to community engagement, such as for curricular development, research, and understanding and advocating for the needs of the community. Given that engaging with local communities to understand their needs is one of the core components of SA,[49] this may indicate a shift of curricular activities on the social obligation scale, from social responsibility to SA.[50]

Our review found that studies examining the impact of SA UGME activities on future practice setting frequently reported positive associations between rural/remote placements and future rural/remote practice settings. Studies also reported that, overall, students indicated that exposure to SA activities was a meaningful experience with the potential to positively influence their future patient care. Student competencies also benefited from SA UGME activities. These impacts were reported not only for individual students' self-reflection, but also when externally evaluated and compared to counterparts who had not engaged in these activities.

This review has some limitations. An information specialist performed the search, but as this was a narrative review, it was limited in terms of database and search term comprehensiveness. Thus, our search may not have exhaustively captured all studies relating to SA UGME in our countries of focus. In addition, our search terms were specific to “SA” and did not employ related terms such as “service learning” that might have captured more studies. This may have also limited our findings to countries where “SA” has gained greater traction in medical education. However, the concept of SA in medical education is becoming increasingly adopted, and it was important for our curriculum renewal context to ensure we captured its expression in the way intended by its definition.[51] As this was not a formal systematic review, we did not conduct dual screening or dual extraction/analysis of studies. However, any uncertainties were discussed with team members, who also collaboratively developed categories for synthesis of studies. Finally, as this study only examined specific countries, the findings may not be generalizable to all medical education settings, possibly an important direction for future research.

 Conclusion



Our review found that SA was primarily expressed in UGME activities through placement/service activities and most frequently assessed through student experiences. Several studies reported community engagement in curricular activities' development, which indicates a promising shift from social responsibility to SA. Reports of largely positive student experiences and benefits on competencies, combined with community feedback and future medical student career directions, demonstrate encouraging impacts of SA UGME activities and emphasize the importance of assessing their impact from multiple perspectives. To be fully socially accountable, we anticipate that more medical schools will track their graduates' practice patterns and will increasingly expand their success measures to include impact on community health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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