From personal to global: Understandings of social accountability from stakeholders at four medical schools

Aim: This paper addresses the question of how social accountability is conceptualised by staff, students and community members associated with four medical schools aspiring to be socially accountable in two countries.

Methods: Using a multiple case study approach this research explored how contextual issues have influenced social accountability at four medical schools: two in Australia and two in the Philippines. This paper reports on how research participants understood social accountability. Seventy-five participants were interviewed including staff, students, health sector representatives and community members. Field notes were taken and a documentary analysis was completed.

Results: Overall there were three common understandings. Socially accountable medical education was about meeting workforce, community and health needs. Social accountability was also determined by the nature and content of programs the school implemented or how it operated. Finally, social accountability was deemed a personal responsibility. The broad consensus masked the divergent perspectives people held within each school.

Conclusion: The assumption that social accountability is universally understood could not be confirmed from these data. To strengthen social accountability it is useful to learn from these institutions’ experiences to contribute to the development of the theory and practice of activities within socially accountable medical schools.     

What are the features of targeted or system-wide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50

Abstract

Background/purpose: There is interest to increase diversity among health professions trainees. This study aims to determine the features/effects of interventions to promote recruitment/admission of under-represented minority (URM) students to health professions programs.

Methodology: This registered BEME review applied systematic methods to: title/full-text inclusion review, data extraction, and quality assessment (QA). Included studies reported outcomes for interventions designed to increase diversity of health professions education (HPE) programs’ recruitment and admissions.

Results: Of 7225 studies identified 86 met inclusion criteria. Interventions addressed: admissions (34%), enrichment (19%), outreach (15%), curriculum (3%), and mixed (29%). They were mostly single center (76%), from the United States (81%), in medicine (45%) or dentistry (22%). URM definition was stated in only 24%. The dimension most commonly considered was ethnicity/race (88%). The majority of studies (81%) found positive effects. Heterogeneity precluded meta-analysis. Qualitative analysis identified key features: admissions studies points systems and altered weightings; enrichment studies highlighted academic, application and exam preparation, and workplace exposure.

Discussion/conclusions: Several intervention types may increase diversity. Limited applicant pools were a rate-limiting feature, suggesting efforts earlier in the continuum are needed to broaden applicant pools. There is a need to examine underlying cultural and external pressures that limit programs’ acceptance of initiatives to increase diversity.     

Academic excellence in Latin America: Social accountability of medical schools

Abstract

Context: Social accountability of medical schools has emerged as a standard of excellence in medical education during the last decade. However, the lack of valid and reliable instruments to estimate social accountability has limited the possibility of measuring the impact that medical schools have in society. Our aim was to develop an instrument and validate its use for assessing social accountability in Latin American countries.

Methods: We used a three–phase mixed methods research design to develop, validate and estimate social accountability in a diverse convenient sample of 49 medical schools from 16 Latin American countries. We used a qualitative framework approach and a Delphi consensus method to design an instrument with high content validity. Finally, we assessed the psychometric properties of the instrument.

Results: The Social Accountability Instrument for Latin America (SAIL) contained 21 items in four domains: mission and quality improvement, public policy, community engagement, and professional integrity. Its reliability index, estimated using Cronbach’s alpha, was very high (0.96). Most of the medical schools that had ranked over the 80th percentile on traditional national academic estimates did not reach the 80th percentile using SAIL.

Conclusions: There are validity arguments (content and reliability) to support the measurement of social accountability using the SAIL instrument. Its application showed that it provides a complementary dimension to that traditionally obtained when estimating quality in medical schools.     

The DISCuSS model: Creating connections between community and curriculum – A new lens for curricular development in support of social accountability

Abstract

Medicine’s social mandate recognizes the importance of introducing changes to systems and practices to meet the healthcare needs of marginalized populations. Social accountability efforts encompass a wide array of actions, including equity, diversity and inclusion initiatives, and adapting knowledge relevant to practice across education, research, and clinical domains. To influence change in education, ongoing structures and processes are needed to ensure adequacy, relevance, and effectiveness of curricular coverage. In support of this, we created an innovative and creative approach to developing curricular modules to prepare medical students to provide care that is responsive to the cultural, economic, and psychosocial realities of diverse patient populations. The DISCuSS model (Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability) provides a community-engaged, iterative approach to curriculum development relevant to social accountability. Over the past 5 years, we have created nine curricular modules focused on health-related inequities and social concerns, including modules on Indigenous and refugee health, sexual and gender minority health, human trafficking, and addiction. AFMC Graduation Questionnaire results have shown a statistically significant increase in our students ‘preparedness to provide care to diverse populations.’ The DISCuSS model, which continues to evolve, can be adapted and used in other settings.     

German MedicalTeachingNetwork (MDN) implementing national standards for teacher training

Background: An increasing demand for proof of professionalism in higher education strives for quality assurance (QA) and improvement in medical education. A wide range of teacher trainings is available to medical staff in Germany. Cross-institutional approval of individual certificates is usually a difficult and time consuming task for institutions. In case of non-acceptance it may hinder medical teachers in their professional mobility.

Aim: The faculties of medicine aimed to develop a comprehensive national framework, to promote standards for formal faculty development programmes across institutions and to foster professionalization of medical teaching.

Methods and results: Addressing the above challenges in a joint approach, the faculties set up the national MedicalTeacherNetwork (MDN). Great importance is attributed to work out nationally concerted standards for faculty development and an agreed-upon quality control process across Germany. Medical teachers benefit from these advantages due to portability of faculty development credentials from one faculty of medicine to another within the MDN system.

Conclusion: The report outlines the process of setting up the MDN and the national faculty development programme in Germany. Success factors, strengths and limitations are discussed from an institutional, individual and general perspective. Faculties engaged in similar developments might be encouraged to transfer the MDN concept to their countries.     

Crowdsourcing for assessment items to support adaptive learning

Abstract

Purpose: Adaptive learning requires frequent and valid assessments for learners to track progress against their goals. This study determined if multiple-choice questions (MCQs) “crowdsourced” from medical learners could meet the standards of many large-scale testing programs.

Methods: Users of a medical education app (Osmosis.org, Baltimore, MD) volunteered to submit case-based MCQs. Eleven volunteers were selected to submit MCQs targeted to second year medical students. Two hundred MCQs were subjected to duplicate review by a panel of internal medicine faculty who rated each item for relevance, content accuracy, and quality of response option explanations. A sample of 121 items was pretested on clinical subject exams completed by a national sample of U.S. medical students.

Results: Seventy-eight percent of the 200 MCQs met faculty reviewer standards based on relevance, accuracy, and quality of explanations. Of the 121 pretested MCQs, 50% met acceptable statistical criteria. The most common reasons for exclusion were that the item was too easy or had a low discrimination index.

Conclusions: Crowdsourcing can efficiently yield high-quality assessment items that meet rigorous judgmental and statistical criteria. Similar models may be adopted by students and educators to augment item pools that support adaptive learning.     

Benchmarking for research-related competencies – a curricular mapping approach at medical faculties in Germany

Objectives: Internationally, scientific and research-related competencies need to be sufficiently targeted as core outcomes in many undergraduate medical curricula. Since 2015, standards have been recommended for Germany in the National Competency-based Learning Objective Catalogue in Medicine (NKLM). The aim of this study is to develop a multi-center mapping approach for curricular benchmarking against national standards and against other medical faculties.

Method: A total of 277 faculty members from four German medical faculties have mapped the local curriculum against the scientific and research-related NKLM objectives, using consented procedures, metrics, and tools. The amount of mapping citations of each objective is used as indicator for its weighting in the local curriculum. Achieved competency levels after five-year education are compared.

Results: All four programs fulfill the NKLM standards, with each emphasizing different sub-competencies explicitly in writing (Scholar: 17–41% of all courses; Medical Scientific Skills: 14–37% of all courses). Faculties show major or full agreement in objective weighting: Scholar 44%, scientific skills 79%. The given NKLM competency level is met or even outperformed in 78–100% of the courses.

Conclusions: The multi-center mapping approach provides an informative dataset allowing curricular diagnosis by external benchmarking and guidance for optimization of local curricula.     

How we incorporated service learning into a medical student rural clinical training experience

Background: Many medical schools have developed admission policies and clinical training programs designed to address the rural physician workforce shortages in their state.

Aim: To enhance medical student rural clinical training experiences, and assist in preparing students for living and working in rural communities.

Methods: As part of their Rural Track Clerkship (RTC) Program, the University of Missouri School of Medicine developed the Community Integration Program (CIP). Students, individually or in groups, voluntarily identify a health need and implement a community-based project to meet that need.

Results: From 2007 to 2013, 80 (53%) students participated in the CIP and 86% completed the 11-item post-experience questionnaire. After the experience, participants reported a deeper understanding of the broad impact of a rural physician and the impact of rural culture on physician interactions. Participants reported they felt more integrated into the community, had a greater understanding of community health needs and resources, and were more likely to participate in future community service activities.

Conclusions: The CIP exposes students to rural culture and helps them understand community health needs. Replication of this program can increase student interest in rural medicine and better prepare students for rural practice.     

Measuring the attitudes of dental students towards social accountability following dental education – Qualitative findings

Background: The term social accountability has gained increased interest in medical education, but is relatively unexplored in dentistry.

Aims: The aim of this study is to explore dental students’ attitudes towards social accountability.

Methods: A qualitative study utilizing focus groups with University of Otago final year (5th year) Bachelor of Dental Surgery (BDS) students was carried out. A questionnaire designed to measure medical students’ attitudes towards social responsibility was used as a guide. Following data collection, framework analysis was used to analyze each of the three focus groups, and repeating themes were noted.

Results: Analysis of the focus groups discovered recurring themes, such that participants believed that dentists should be accountable to society in a professional context and that they are responsible for patients who present at their clinic but that there is no professional obligation to help reduce oral health inequalities by working with populations facing inequalities. There was strong agreement that there needs to be change to the dental health care system from a structural and political level to address oral health inequalities, rather than individual dentists assuming greater responsibility.

Conclusion: Our findings show that dental education may not be accountable to society in the sense that it is not producing graduates who believe that they have an obligation to address the priority oral health concerns of society.     

Growth of the James Cook University Medical Program: Maintaining quality,continuing the vision,developing postgraduate pathways

Abstract

Background: James Cook University (JCU) enrolled its first cohort of 64 in 2000 into a 6-year undergraduate medical program aimed at producing graduates capable of meeting the needs of North Queensland, Australia, with a focus on rural, remote, Indigenous and tropical health. The school’s 1465 graduates over 13 cohorts who have a pattern of practice likely to meet the region’s health needs. The JCU course was the first new Australian medical program for 25?years. The number of Australian medical schools has since doubled, while enrollments have almost tripled.

Methods: JCU’s course features innovations such as dispersed, community-based education, rurally-focused selection, extended rural placements, and an emphasis on community needs – which are all now mainstream. This paper traces developments at JCU over the past decade, illustrating parallels with the broader Australian scene.

Results: Maintaining quality and educational integrity while numbers grow is challenging. The course has undergone modest curriculum redesign, but the fundamental elements are intact. The focus on meeting the region’s needs remains, with some evolution of its mission to include social accountability and the needs of underserved populations.

Conclusions: Postgraduate pathways are an important priority. Regional training hubs are being developed to support local pipelines into specialty practice. Queensland’s Rural Generalist Pathway provides an incentivised pathway to rural practice while Generalist Medical Training provides a local training pipeline into general practice and rural medicine. As these initiatives mature, communities should benefit as JCU and other Australian programs continue to address local workforce needs.     

What makes a medical school socially accountable in Latin America? A report from a Latin American panel based on a qualitative approach

Background: Latin America is a region with huge health inequalities and a tremendous growth in the number of medical schools during the last decades. The role of the medical schools in reducing health inequality has not been systematically explored.

Methods: A qualitative framework method was used to explore the meaning, barriers, and facilitators of the concept of the social accountability of medical schools in Latin America. Twenty nine Latin American academic leaders from seven countries participated in an expert panel discussion. The Atlas ti.7 software was used to analyze the information.

Results: Social accountability was identified as a core dimension of the mission of medical schools. The panel identified a gradient of three dimensions associated with social accountability. First, a formative dimension related to student selection, curricular structure and community based learning initiatives. Second, a societal dimension associated with institutional mission, community partnerships, and social research projects. Third, a political dimension related with involvement in health policies and primary care engagement. Lack of accreditation standards was identified as a main barrier to improve social accountability.

Conclusions: Latin American leaders consider that medical schools should develop specific formative, societal, and political initiatives in order to be socially accountable.     

Training medical students for the twenty-first century: Rationale and development of the Utrecht curriculum “CRU+”

Abstract

Aim: The aim of this report, written for the 40th anniversary issue of Medical Teacher, is to document 20 years of development of the Utrecht undergraduate medical curriculum, as both to exhibit accountability and to inform the community of the process and choices that can be made in long-term curriculum development.

Methods: We used the SPICES model, created by Medical Teacher’s Editor Ronald Harden and colleagues in 1984.

Results: The Utrecht six-year program, now called “CRU+”, has many distinct features that were introduced, most of which are well documented. A limited selection includes

• ???A new 3+3 years Bachelor-Master structure following the EU Bologna rules leading to MD registration for cohorts of about 300.

• ???Horizontally integrated classroom teaching of basic sciences with clinical disciplines predominantly in groups of 12 and limited lectures.

• ???Mandatory knowledge retention tests, retesting the clinically relevant core knowledge from block tests of semesters one through four.

• ???Vertical integration not only linking clinical experience with background knowledge, but also exemplified by a stepwise increase in health care responsibilities throughout the curriculum.

• ???A final year focussing on growth towards the level of a primary responsible physician in a 12-week sub-internship for a limited number of patients and beds, in a chosen specialty. The student is called a semi-physician in the clerkship of this transitional year to residency.

• ???Teaching skills training for all medical graduates, an elective teaching rotation and various peer-teaching arrangements throughout the curriculum.

• ???Integrated semi-longitudinal clerkships with an assessment focus on entrustment decisions for Entrustable Professional Activities.

Conclusion: UMC Utrecht has made a continuous attempt to both develop its medical curriculum and to study and report on its development in the literature, regarding new methods found and insights derived. UMC Utrecht will remain committed to developing training to meet twenty-first century demands of medical graduates.     

Establishing a new medical school: A contemporary approach to personalizing medical education

Abstract

Objective: To borrow a public health concept, there has been a global outbreak, perhaps a pandemic, of new medical schools during the last 20 years, resulting in a diverse range of programs in many different contexts. The question posed was: how should the task of establishing a new medical program be approached in 2018?

Methods: Based on involvement with several new medical programs, this paper presents a highly idealistic commentary on what a new medical program might look like. The paper adopts the organizational structure of the World Federation of Medical Education Basic Medical Education standards as a scaffold, because accreditation both locally and globally is intended.

Results: The program design reflects both progress in learning technology and the challenges faced in a changing world, where disruption appears inevitable, and innovation may be necessary to produce the medical graduates needed to improve the health status of an expanding, ageing and ailing global population.

Conclusion: The program model described represents a combination of educational design, emerging technology and a focus on future health care needs.     

School of Medicine of Federal University of Rio Grande Do Norte: A traditional curriculum with innovative trends in medical education

Abstract

Introduction: The Medical School of the Federal University of Rio Grande do Norte (UFRN) is one of the biggest public medical schools in Northeast Brazil. In the last decade, significant investment in faculty development, innovative learning methodologies and student engagement has been key milestones in educational improvement at this medical school, harnessed to recent political changes that strengthened community-based and emergency education. This study describes how curriculum changes in UFRN Medical School have been responsible for major improvements in medical education locally and which impacts such transformations may have on the educational community.

Methods: A group of students and teachers revised the new curriculum and established the key changes over the past years that have been responsible for the local enhancement of medical education. This information was compared and contrasted to further educational evidences in order to define patterns that can be reproduced in other institutions.

Results: Improvements in faculty development have been fairly observed in the institution, exemplified by the participation of a growing number of faculty members in programs for professional development and also by the creation of a local masters degree in health education. Alongside, strong student engagement in curriculum matters enhanced the teaching-learning process.

Conclusions: Due to a deeper involvement of students and teachers in medical education, it has been possible to implement innovative teaching-learning and assessment strategies over the last ten years and place UFRN Medical School at a privileged position in relation to undergraduate training, educational research and professional development of faculty staff.     

COVID 19: Designing and conducting an online mini-multiple interview (MMI) in a dynamic landscape

Abstract

Introduction: The COVID-19 pandemic presented numerous, significant challenges for medical schools, including how to select the best candidates from a pool of applicants when social distancing and other measures prevented “business as usual” admissions processes. However, selection into medical school is the gateway to medicine in many countries, and it is critical to use processes which are evidence-based, valid and reliable even under challenging circumstances. Our challenge was to plan and conduct a multiple-mini interview (MMI) in a dynamic and stringent safe distancing context.

Methods: This paper reports a case study of how to plan, re-plan and conduct MMIs in an environment where substantially tighter safe distancing measures were introduced just before the MMI was due to be delivered.

Results: We report on how to design and implement a fully remote, online MMI which ensured the safety of candidates and assessors.

Discussion: We discuss the challenges of this approach and also reflect on broader issues associated with selection into medical school during a pandemic. The aim of the paper is to provide broadly generalizable guidance to other medical schools faced with the challenge of selecting future students under difficult conditions.     

Moving a mountain: Practical insights into mastering a major curriculum reform at a large European medical university

Abstract

Aim: Undergraduate medical education is currently in a fundamental transition towards competency-based programs around the globe. A major curriculum reform implies a dual challenge: the change of the curriculum and the delivering organization. Both are closely interwoven. In this article, we provide practical insights into our approach of managing such a fundamental reform of the large undergraduate medical program at the Charité – Universitätsmedizin Berlin.

Methods: Members of the project management team summarized the key features of the process with reference to the literature.

Results: Starting point was a traditional, discipline-based curriculum that was reformed into a fully integrated, competency-based program. This change process went through three phases: initiation, curriculum development and implementation, and sustainability. We describe from a change management perspective, their main characteristics, and the approaches that were employed to manage them successfully.

Conclusions: Our report is intended to provide practical insights and guidance for those institutions which are yet considering or have already started to undergo a major reform of their undergraduate programs towards competency medical education.     

Versatility in multiple mini-interview implementation: Rater background does not significantly influence assessment scoring

Abstract

The medical school admissions process seeks to assess a core set of cognitive and non-cognitive competencies that reflect professional readiness and institutional mission alignment. The standardized format of multiple mini-interviews (MMIs) can enhance assessments, and thus many medical schools have switched to this for candidate interviews. However, because MMIs are resource-intensive, admissions deans use a variety of interviewers from different backgrounds/professions. Here, we analyze the MMI process for the 2018 admissions cycle at the VCU School of Medicine, where 578 applicants were interviewed by 126 raters from five distinct backgrounds: clinical faculty, basic science faculty, medical students, medical school administrative staff, and community members. We found that interviewer background did not significantly influence MMI evaluative performance scoring, which eliminates a potential concern about the consistency and reliability of assessment.