A Vision for

Canadian Medical Schools

Social Accountability

Health

Canada

Santé

Canada

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Ce document est aussi offert en français sous le titre : Imputabilité sociale – Une vision pour lesfacultés de médecine du Canada

© Her Majesty the Queen in Right of Canada, represented by theMinister of Public Works and Government Services Canada, 2001Cat. No. H39-602/2002ISBN 0-662-66388-8

Our mission is to help the people of Canadamaintain and improve their health.

Health Canada

Social Accountability

A Vision for Canadian Medical Schools

Steering Committee Members

Paul CapponCo-chair(Council of Ministers of Education Canada)

Robert McMurtryCo-chair February to September, 2000(Health Canada)

Jean ParboosinghCo-chair from September 2000(Health Canada)

Richard Cruess(McGill University)

Sylvia Cruess(McGill University)

David Hawkins(Association of Canadian Medical Colleges)

Brian Hennen(University of Manitoba)

Paul Grand’Maison(University of Sherbrooke)

Jason Kur(Canadian Federation of Medical Students)

Don Ling(PEI Ministry of Health and Social Services)

Noni MacDonald(Dalhousie University)

Nadia Mickael(Royal College of Physicians andSurgeons of Canada)

William Rowe(McGill University)

Robert Shearer(Health Canada)

Joshua Tepper(Canadian Association ofInterns and Residents)

Mo Watanabe(University of Calgary)

Michael Whitcomb(Association of American Medical Colleges)

Carl Whiteside(University of British Columbia)

Robert Woollard(University of British Columbia)

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Executive Summary

The Steering Committee on SocialAccountability of Medical Schools adaptedthe concept of social accountability, whichhas been promulgated by the World HealthOrganization (WHO) over the past decade, toproduce a vision for Canadian medicalschools. The expectation of the public is thatgovernments and the professions workcollaboratively to ensure that the highlyvalued Canadian health care system continuesto provide the necessary access and quality tomeet the needs of the population. Medicalschools have an important role to play in thisendeavour.

WHO has defined the Social Accountability ofMedical Schools as “the obligation to direct theireducation, research and service activities towardsaddressing the priority health concerns of thecommunity, region, and/or nation they have amandate to serve. The priority health concerns areto be identified jointly by governments, health careorganizations, health professionals and the public.”

A set of principles of social accountability bywhich Canadian medical schools shouldfunction include:

� Medical schools emphasize to theirfaculty and students the need to maintaintheir competence, the importance of thepatient-physician relationship, and anunderstanding of professionalism and itsobligations.

� Medical schools respond to the changingneeds of the community by developingformal mechanisms to maintainawareness of these needs and advocate forthem to be met.

� Medical schools conduct curiosity-drivenresearch and provide evidence-based care,testing new models of practice thattranslate the results of research intopractice.

� Medical schools work together and inpartnership with their affiliated healthcare organizations, the community, otherprofessional groups, policy makers andgovernments to develop a shared vision ofan evolving and sustainable health caresystem for the future.

Involvement of the community in identifyingcommunity needs, setting priorities,establishing and evaluating new models ofpractice is seen as critical. The role of themedical schools and their partnerorganizations in education, research andservice is articulated within the socialaccountability framework and the need forthe medical community at large tounderstand and demonstrate the concept ofprofessionalism is underlined.

The development of an effective socialaccountability model for medical schools willprovide the basis for all partners to workcollectively on meeting the needs of theCanadian population in a collegial andcollaborative manner.

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Introduction

At the beginning of the new millennium, theexpectation of the public is that governmentsand the professions work collaboratively toensure that the highly valued Canadian healthcare system continues to provide thenecessary access and quality to meet theneeds of the population. Medical schools havean important role to play in this endeavour.

By identifying and responding to the needs ofthe community, whether defined by risk or bygeography, and by ensuring that individualgraduating physicians understand their rolein society, Canadian medical schools, alongwith their partners, have a major role to playin influencing the changes in the health caresystem that are necessary to ensure aneffective, efficient, accessible, equitable andsustainable system in the 21st century.

Concepts of Social Accountability and

Social Responsiveness

WHO has defined the Social Accountability ofMedical Schools as “the obligation to direct theireducation, research and service activities towardsaddressing the priority health concerns of thecommunity, region, and/or nation they have amandate to serve. The priority health concerns areto be identified jointly by governments, health careorganizations, health professionals and the public.”Social responsiveness is a complementarycapability by which a medical school respondsto societal needs and acts proactively to meetthose needs.

WHO has developed a framework designed tohelp medical schools evaluate their progresstowards achieving the goal of socialaccountability. This framework addresses thefour values of social accountability, relevance,quality, cost effectiveness and equity, as theypertain to the activities of medical schools,

namely education, research and service.Academic freedom and clinical autonomy areother values entrenched within the Canadianacademic and clinical communities, whichmust be weighed in any assessment of therole and functions of medical schools.

The relevance of the activities of medicalschools implies that they, together withgovernments, the profession and other majorstakeholders in the health care system, have asystematic approach to addressing priorityhealth needs, including issues of access toservices, determining and educating theappropriate number and mix of physicians,and facilitating the geographic distributionnecessary to meet the needs of thecommunity. High quality health care isevidence-based, comprehensive and culturallysensitive; the definition of quality, however,may vary over time and be dependent on theavailability of resources. Thus, settingpriorities and ensuring the cost effectivenessof care are important mechanisms by whichmedical schools, in partnership with otherkey stakeholders, can demonstrate theirresponsiveness to societal needs at a locallevel. Equity means striving to make qualityhealth care available to all people; medical

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The definition of social accountabilityof medical schools is the obligation todirect their education, research and serviceactivities towards addressing the priorityhealth concerns of the community, region,and/or nation they have a mandate toserve. The priority health concerns are to beidentified jointly by governments, healthcare organizations, health professionalsand the public. WHO, 1995

schools can assist by defining populations atrisk through well-designed research,identifying methods of removing barriers toaccess and educating students inenvironments in which they are exposed tothose in need.

These values are implicit in the Canadianhealth care system and are recognized by theCanadian population at large, which is, today,better informed and more demanding ofbetter access and quality for the health caresystem. At this time of reinvestment inhealth by governments, an explicitacknowledgement by Canadian medicalschools that these are important issues forthem, will show how they are in a uniqueposition and are prepared to play a major rolein seeking to contribute to the sustainabilityof the health care system into the future.

A Vision: The Leadership Role of

Canadian Medical Schools

While recognizing the role of governmentsand others in providing funding for healthcare services and for research and education,medical schools can play a leadership role inhelping to contribute, in partnership with awide variety of other parties and agencies, inthe following areas:

� the development of a clear and sharedvision of the health care system and ofthe health care providers of the 21st

century. This vision will have to be clearlyarticulated and constantly revised torespond to changing needs;

� the optimal preparation of futurepractitioners to respond to populationneeds;

� the establishment and promotion ofinnovative practice patterns to bettermeet individual and community needs;

� the reinforcement of partnerships withother stakeholders, including academichealth centres, governments,communities and other relevantprofessional and non-professionalorganizations;

� advocacy for the services and resourcesneeded for optimal patient care;

� the definition and clarification of theconcept of social accountability and thedissemination of methods for measuringresponsiveness to societal needs;

� the inclusion of the concept of socialaccountability in the accreditation processof medical schools and other healthinstitutions.

Medical schools exist within a larger healthand social system, which involves alldeterminants of health including wealth,education, the environment, housing and aspectrum of services from health promotionto palliative care. There are many health careproviders, in addition to physicians, who haveobligations to meet societal needs.

Principles of Social Accountability

The following set of principles by whichCanadian medical schools should function issuggested. These will allow medical schoolsto identify where they stand with respect toresponding to the needs of society and tocontinuously strive to ensure that they aredoing so. Formal measurement of the socialaccountability of medical schools requires

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Canadian medical schools are in aunique position and are prepared toplay a major role in seeking tocontribute to the sustainability of thehealth care system into the future.

considerable resources. In a substantiallypublicly funded medical education and healthcare system such as exists in Canada, medicalschools work in partnership and in a climateof collegiality and collaboration to contributeto the health and well-being of the people andthe communities they serve by incorporatingthe following principles:

� Medical schools emphasize to theirfaculty and students the need to maintaintheir competence, the importance of thepatient-physician relationship, and anunderstanding of professionalism and itsobligations.

� Medical schools respond to the changingneeds of the community by developingformal mechanisms to maintainawareness of these needs and advocate forthem to be met.

� Medical schools conduct curiosity-drivenresearch and provide evidence-based care,testing new models of practice thattranslate the results of research intopractice.

� Medical schools work together and inpartnership with their affiliated healthcare organizations, the community, otherprofessional groups, policy makers andgovernments to develop a shared vision ofan evolving and sustainable health caresystem for the future.

The balance between community relevanceand the unfettered search for andtransmission of knowledge is never a quietone but an unambiguous dedication to thewelfare of our collective future is part of thesocial responsibility of medical schools andacademic health care organizations (theacademic health sciences centres).

Canadian society provides medical schoolsand the medical profession with certainprivileges and resources; these are justifiedonly insofar as they are unambiguously placedin the service of those in need and thecommunity of which they are a part. Theprimary goal of medical education is toprepare graduates to practice effectively inreducing the burden of illness and improvingthe health of their communities. This goalincludes the concept of professionalism, i.e.the social contract between a professional andsociety, with its core values of scientificexpertise and altruism. In order to meet thissocial contract, professionals in trainingshould be equipped with the knowledge,skills and resources to meet societal needs.

Social Commitment and

Community Engagement

Medical schools should explicitly expoundtheir commitment to social accountability andsocial responsiveness in their generalorientation, including in their publicly-statedmandate or mission statement. They shouldproactively define these concepts and identifythe actions to be implemented in order todemonstrate their commitment to be sociallyaccountable and responsive. Included in theseactions is fostering the engagement of thecommunity in their activities.

The public, as consumers, are demandingmore of all providers of consumer productsand services; this is reflected in the increasingdemands on the health care system to meetthe needs of each and every person who usesthe system. Identifying community needs,

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The core values of professionalism(the social contract betweenprofessional and society) are scientificexpertise and altruism.

setting priorities, establishing and evaluatingnew models of practice are areas in whichcommunity participation is critical.

The Role of Medical Schools

Medical schools function in three majorarenas: education, research and, usually withother partners, in health care provision. Inaddition, they are expected to manage theirresources, relate to policymakers and otherstakeholders and be proactive and innovativein all aspects of their work, thereby helpingto shape the external world in which theyexist.

1. Education

Canadian medical schools are responsible forundergraduate, postgraduate and continuingmedical education as well as the training offuture health scientists. The need to inculcatethe concepts of lifelong learning into teachingand learning across all levels is increasinglybeing recognized. The content of educationalprograms should be directed towards thepriority health problems in all sectors of thecommunity, both hospital-based andcommunity-based, and to the range of healthissues from health promotion to palliativecare.

The role of the medical schools inpostgraduate training is key to the productionof a well-trained and appropriate generalist :specialist mix of practitioners to meet theneed of the Canadian health care system. Toachieve this, a national approach to physicianresource planning is necessary in Canada.This requires that medical schools collaboratewith the federal, provincial and territorialgovernments and the other national medicaleducational and licensing bodies to ensurethat the right number and mix of physiciansenter practice. To this end, it is recognizedthat individual volition and enhancement of

opportunity are more effective strategies forencouraging physicians to meet the needs ofsociety than are coercive measures.

Medical schools have the obligation to ensurethat their learning environments respond tothe ever-increasing knowledge base, butequally to ensure that they producewell-rounded professionals. This includesensuring that students and residentsunderstand the contributions of other healthcare disciplines and have the ability topractice within an interdisciplinary team. Aphilosophy that values health promotion anddisease prevention as components of medicalcare and an assumption that physicians havea responsibility in health promotion anddisease prevention are important to futurepractitioners.

In addition to their role in educating medicalprofessionals, as knowledge expands andhealth care becomes increasingly complex,medical schools have an obligation to impartthat knowledge to the public as do individualphysicians to their patients.

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A well-rounded professional demon-strates: knowledge, clinical com-petence, lifelong learning, evidence-based practice, interdisciplinaryteamwork, balance between diseasemanagement and disease prevention/health promotion, professional andethical behaviour in practice, optimaluse of resources and consciousness ofwell-being of self and colleagues.

2. Research

A balance between the freedom to carry outcuriosity-driven research and researchdirected to meeting the needs of thecommunity is essential, as is the need for along term vision of research thatencompasses multiple settings and acollaborative approach. As the scope ofmedical research is expanding, funding forresearch has increased significantly. Medicalschools must meet the challenge of achanging research paradigm that includesareas that have not been of paramountinterest to academic researchers, whilemaintaining a leadership role in thetraditional research arena. The goal is to beresponsive to the current and emerging needsof their individual communities, within thelarger context of national and internationaltrends, by continually profiling the healthstatus and health care needs of thecommunity.

While basic science and clinical and healthservices research have been priorities formedical schools, research in populationhealth becomes ever more important toidentify the needs of the communities servedby medical schools. Where needs areidentified, mechanisms to meet those needsmust be put into place; this may mean thatmedical schools take the initiative to developand implement interventions in collaborationwith community health groups and othersectors to improve the health care and healthstatus of the communities they serve.Evaluation research is key to ensuring thatsuch interventions meet identified needs andto providing a strong evidence base forsustainability. Evaluation research intoeducational techniques and processes alsoneeds to be promoted so that the mosteffective means of educating students, facultyand the community are developed.

Basic biomedical research creates newknowledge and understanding of molecularand cellular mechanisms of health anddisease and the biological pathways to thedeterminants of health. Discoveries anddevelopment in this arena have the potential,through technology transfer, to contribute tocommercialization and the creation of jobs.Applied clinical research is involved in theevaluation of the safety and efficacy of newand existing drugs, treatments andprocedures and thus contributes to theprotection of the health of all Canadians andto the quality of care provided.

Health services research evaluates the care ofindividual patients and of new deliverymodels of community-based andsystem-based care. As new models of deliveryof primary care are implemented, healthservices research will play an important partin evaluating the impact of its individualcomponents, such as interdisciplinary care,alternate funding mechanisms andregistration of patients. At a systems level,health services research can contribute byevaluating the care provided in integratedsystems of care, such as cancer care networks.As the use of information technology andtelehealth expands, research will be needed todemonstrate their impact on the health caresystem in terms of quality, access andcost-effectiveness.

Medical schools and the social mechanismsthat fund research have an obligation torecognize the potential influence thatpecuniary considerations can have on thepriorities of the research endeavour. Medicalschools have a particular responsibility to bebeyond reproach in conducting themselves insuch a way that the unfettered search forknowledge is not unduly influenced by factorsother than the needs of society.

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3. Provision of Health Care

In addition to the role that they play ineducation and research, the part time and fulltime faculty of all medical schools areinvolved in the provision of clinical services,usually under the aegis of an affiliated healthcare institution. This arises in part because ofthe very nature of medical education andclinical research but also reflects the activepartnerships with other institutions andcommunities that are the legitimateresponsibility of medical schools engaged inassessing and responding to communityneeds. Provision of tertiary and quaternarycare to the community are almost exclusivelywithin the purview of the health careorganizations linked to a medical schoolforming the academic health sciences centre.Participation by medical schools in secondaryand primary care reflects the learningenvironment required to appropriatelyeducate physicians for community service.The whole of the learning environment for amedical school constitutes the academichealth sciences network. A balancedintegration of service and education,regardless of which sector of the health caresystem it takes place in, is essential to ensurethe well-being of trainees and that theappropriate educational outcomes areachieved.

Support for the establishment of innovativepractice patterns and participation in definingand shaping the health care system of thefuture are other valued contributions that canand should be attributed to medical schools.This future orientation needs theestablishment of partnerships with externalhealth care institutions and policy makers.

Active, thoughtful engagement with othermedical organizations responsible forcertification, regulation and advocacy is partof the expression of a medical school’spartnership obligation. Similarly a broad

engagement with the health care system andthe communities in which it is embedded is anecessary basis for the expression of its socialresponsibility.

Professionalism

Professionalism is the moral understandingamong professionals that underpins theconcept of a social contract between theprofession and the public; under thiscontract, professional occupations have beengranted authority to self-regulate andindependence to control key aspects of theirworking conditions through accreditation,licensing, credentialing and professionalconduct review. The call to professionalresponsibility must be an articulate one thatapplies equally well to practising members ofthe profession as it does to those in training.

Professionalism of Individuals

Medical schools should ensure that individualphysicians graduate aware that the professionof medicine is one of constant change and,thus, they need to be lifelong learners.Methods need to be in place to demonstratethat graduates have achieved anunderstanding of the concept ofprofessionalism. Graduates need to beprepared to demonstrate their competence inan ever-changing environment, to ensure thattheir practice is based on evidence and torespond to the changing environment inwhich they practice. This includes recognitionof the role of the patient in thepatient-physician interaction, advocacy onbehalf of the patient, the willingness to work

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The call to professional responsibilityapplies equally well to practisingmembers of the profession as it does tothose in training.

in a variety of settings where need exists formedical services and recognition of the rolesof other health care professionals.

Professionalism of Medical Schools

Faculty and medical schools must be able todemonstrate that the outcomes of theiractivities in these arenas make a difference.They have the obligation to demonstrate tosociety that they produce physicians whorecognize their role in society and that theapplication of their education, research andservice activities have a positive impact onthe health care and health status of thepopulation they serve.

Potential Outcomes

Faculty and graduates of Canadian medicalschools will embrace their socialresponsibility through the provision andpromotion of health for all individuals andgroups. This requires a knowledge of andengagement with marginalized and vulnerableindividuals and communities who will needunique strategies in order to facilitateaccessibility to health care.

Faculty and graduates will recognize thecritical importance of the following concepts:community consultation and communityinclusion in the entire health care enterprise,disease prevention and health promotion,integrated and interdisciplinary care, lifelonglearning and continuing professionaldevelopment, performance measurement andresearch.

Faculty and graduates will foster collegialattitudes that promote interdisciplinary andmultidisciplinary approaches to health careand ensure meaningful exchange with otherprofessions.

An explicitly articulated recognition by themedical schools that they are listening andresponding to their various publics isimportant to increasing the confidence of thegovernments and the public that theresources spent on them are justified. Oneapproach is for individual medical schools tocarry out specific projects consistent with arenewed emphasis on social accountability.Governments will be more likely to recognizethe importance of this work, the medicalcommunity will be more satisfied with theirworking conditions and more motivated toput forth additional efforts on behalf of theirpatients.

The explicit incorporation of socialaccountability within the fabric of medicalfaculties will provide a basis for developmentof respectful partnerships for health withgovernment, health authorities, communitiesand business. These partnerships willfacilitate and encourage shared work onhealth planning, problem solving, healthservice delivery, health service evaluation andhealth policy development. The developmentof an effective social accountability model formedical schools provides a pattern for otherprofessions and partners in health to developsimilar social accountability frameworks. Italso provides the basis for all to workcollectively on meeting the needs of theCanadian population in a collegial andcollaborative manner.

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The development of an effective socialaccountability model for medicalschools will provide the basis for allpartners to work collectively onmeeting the needs of the Canadianpopulation in a collegial andcollaborative manner.

Bibliography

Defining and measuring the social accountability of medical schools; Division of Development ofHuman Resources for Health, World Health Organization, Geneva, Switzerland; 1995.

Code of Ethics of the Canadian Medical Association,http://www.cma.ca/inside/policybase/1996/10-15.htm; 1996.

Doctors for Health: A WHO global strategy for changing medical education and medical practicefor health for all. World Health Organization, Geneva, Switzerland; 1996.

Cappon P & Watson D. Improving the Social Responsiveness of Medical Schools: Lessons fromthe Canadian Experience. Academic Medicine. 1999; 74(8): S81-S90.

Gastel B. Improving the Social Responsiveness of Medical Schools: Summary of the Conference.Academic Medicine. 1999; 74(8): S3-S7.

Boelen C. Adapting Health Care Institutions and Medical Schools to Societies’ Needs. AcademicMedicine. 1999; 74(8): S11-S20.

Universities and the health of the disadvantaged. World Health Organization, Geneva,Switzerland; 2000.

Towards Unity for Health: Challenges and opportunities for partnership in health development.World Health Organization, Geneva, Switzerland; 2000.

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