Measuring the social responsiveness of medical schools and health professional institutions

Society is demanding more social responsiveness and accountability from all its institutions including medical schools. This requires medical schools to accept social responsiveness as a fourth obligation, alongside the traditional three tasks of teaching, research and clinical service. We maintain that medical schools should accept some responsibility for shortcomings in the quality of their graduates, their distribution and their impact on the burden of ill-health in the community.

This paper builds on previous work by WHO on defining and measuring the social responsiveness of medical schools with regard to relevance, quality, cost effectiveness and equity. We suggest a number of relatively simple measures by which a school could evaluate itself or measure change in its own level of social responsiveness to the priority health care needs of its constituent community.

Measuring the social responsiveness of medical schools

Society is increasingly demanding more responsiveness and accountability from all of its institutions and is asking medical schools to be part of that process. Society wants accessible, competent doctors who are more knowledgeable about common problems than esoteric ones. It also wants enough doctors to serve the needs of special groups such as the elderly, the mentally ill, the deprived and the geographically isolated and to do so in the most cost effective manner (Ewan, 1985; EFPO, 1992).

There have been notable attempts at fulfilling these needs such as the creation of a global network of community based institutions (Network of Community Oriented Educational Institutions for Health Sciences, 1986) as well as blueprints for future educational action (General Medical Council, 1993; Association of American Medical Colleges and American Medical Association, 1993; Pew Report 1993; Australian Medical Council, 1998). Many other medical schools are also beginning to devote some of their energies in education, research and service not only towards improving quality of care but also to the issues of relevance, cost effectiveness and equity in health care for the community, region and nation they have a mandate to serve (Boelen and Heck, 1995). Indeed the World Health Assembly - the governing body of the World Health Organisation - unanimously affirmed this direction in its 1995 resolution, WHA48.8, "Reorientation of medical education and medical practice for all" (WHO, 1995).

It is not the intention of this paper to impose on the diversity or academic autonomy of a medical school by giving a detailed view of what or how something should be taught. The aim is to inform the existing positive mission of a medical school and enable it to assess to what degree it is exposing students to important topics and issues which affect patients, taxpayers, health departments and which are necessary in providing good, equitable, affordable health care for most of the people most of the time.

This paper builds on work already done by WHO on defining and measuring the social responsiveness of medical schools (Boelen and Heck, 1995). It produces a number of relatively simple measures by which a school could evaluate itself and measure change in its own level of social responsiveness or through which an accrediting body could compare one institution with another or against some desired norms.

Method

Values	Domains and phases
	Education			Research			Service
	Planning	Doing	Impacting	Planning	Doing	Impacting	Planning	Doing	Impacting
Relevance
Quality
Cost effectiveness
Equity

The grid is a strategy by which a medical or health professional school could examine its level of social accountability

Relevance

Table 1 describes measures of relevance which should either be readily available or which, with no more than moderate effort, can usually be obtained.

The relevant curriculum	How can it be measured?
	Planning	Doing	Impacting
Places a priority on: the 10 most important national and local health priorities the most modifiable significant ailments in the community those with the highest burden of ill-health	intent for relevance in mission statement and curricular objectives demonstrates that national or local data on priority health needs are used to update curriculum at least every 10 years	proportion of pass/fail examinations devoted to priority issues amount, adequacy and funding for clinical teaching in ambulatory and community settings	proportion of randomly selected students who can identify priority problems and % reporting competence and confidence in dealing with them provincial data on changes in health indicators about the 10 priority areas

The most controversial measure is likely to be about the impact of education, research and service on outcome measures and changes in local and provincial health statistics. Of course there are many variables and confounding factors beside education which influence outcomes. But if, for example, immunisation rates in a country are poor, medical education should accept some responsibility. It should be a priority topic in undergraduate and postgraduate education and research and, where a university runs a service practice, it should demonstrate how it may be done better.

Quality of care

Education for quality care	How can it be measured?
	Planning	Doing	Impacting
Places a priority on: preparing graduates to assess and provide quality of care	mission statement which includes desired curricular outcomes in terms of quality of care competencies eg, ability to think critically, communicate efficiently, behave ethically and continue self directed learning	evidence of consistency in teaching across disciplines based on: evidence based medicine and/or inter-departmental consenses for 10 most common conditions found in primary medical care	interview randomly selected students on their awareness, knowledge, attitudes and skills about evidence based medicine feedback on performance of graduates from hospital administrators who employ them and from professional bodies which provide vocational training and education medical audit of a random sample of graduates in primary medical care on management of 10 most common conditions and provincial data on the application of effective preventative medicine, eg. immunisation, cervical smear rates

In the domain of education a common finding, especially in traditionally organised medical schools, is for students to have to learn different answers to the same question in order to satisfy teachers from different medical disciplines. One common example is the diagnosis and management of the sore throat. Students can receive different teaching from departments of ear, nose and throat, paediatrics, microbiology and family medicine. Therefore one measure of education for quality care would be evidence of teaching across disciplines preferably based on research evidence or if that is lacking on interdisciplinary consensus (Table 2).

Cost effectiveness

Education for cost effectiveness	How can it be measured?
	Planning	Doing	Impacting
the teaching of all pertinent departments in the medical school places emphasis on cost effective care	is cost effectiveness a topic on curriculum? is evidence based medicine used to inform this teaching?	which departments teach it? ongoing topic in clinical training? a topic in final year written and clinical examinations?	5-10% random selection of medical students: are they aware of it having been taught? Does it influence the way in which they practise medicine? where available, comparative cost data on medical school's graduates for: investigations prescribing

In some countries, such as Australia, comparative data on the investigation, costs and prescribing habits of the graduates from the 10 medical schools are available. One school produces graduates who generate greater costs for drugs. The reasons for this are still under investigation. Such data have a major potential to influence the teaching of medicine.

Equity

Equity in education	How can it be measured?
	Planning	Doing	Impacting
The medical school is concerned with equity of access to a medical education for all population groups	affirmative entry policies for members of under-represented population groups marketing of career in health services to potential entrants from under-represented communities availability of financial assistance to help prevent exclusion of meritorious students from deprived backgrounds	% of students admitted: female rural minority groups compared to % in provincial population	% of all minority groups in graduating classes
challenges students to provide care to deprived and medically underserved populations	programs to encourage students to learn about continuity of care through care of deprived patients over time	are students exposed to deprived and/or underserved groups? % students who are regular members of student societies eg, rural, overseas medical school provides information on physician supply and societal need to help career choice	what proportion of doctors providing designated care to underserved populations in the province, eg,. indigenous, rural, elderly, mental health, are graduates of the medical school fulfilment of need for various types of doctors in province eg, 1 surgeon/25,000 people; 1 primary care doctor/2,500 people; 1 psychiatrist/20,000 people

A socially responsive medical school should also have a place at the leading edge of health care delivery, both as a model for demonstrating care for the future rather than the past, and as a means of challenging future graduates to provide appropriate medical services to deprived populations.

Use of social responsiveness indicators

Thus a school could have a maximum equity score of 24. We maintain that a responsible and responsive medical school with an equity in education score of less than 50% would, at the very least, review and debate its performance and would hopefully make some necessary changes.

The domains of research and service

Research
Since there is already a lot known about the most common conditions and health priorities, research in these areas is more likely to be applied rather than basic. The level and amount can be measured by asking a faculty whether it has a research plan to encourage some members to do research in the four values of relevance, quality of care, cost effectiveness and equity and whether national health priorities and the views of the broad community are taken into account in identifying applied research priorities. Similarly process measures would include the number of refereed research papers produced in the last five years which address priority areas. Outcome measures would include any evidence that such research impacts on satisfaction with access to and quality of care, local priorities, priority health programmes and priority health status.

Service
Social responsiveness in service can be measured in a similar manner to that of research. For example, what plans and processes does the faculty have to assist in providing services to people and areas of greatest need and to educational and locum support for isolated doctors? How many ambulatory clinics does it support in providing care to the deprived and to special groups with a high burden of poor health such as those with AIDS, the elderly and the mentally ill? What proportion of staff contribute their expertise to national and provincial health authorities? Outcome measures would include the degree to which these clinics meet cost effective targets such as a 90% rate for cervical cancer smears, skin cancer examinations, blood pressure control and full immunisation. Measures of impact would also include any evidence of the effect of role modelling on other health care providers and documentation of change in access to health care by underserved populations.

Discussion

It is recognised that some of the measures may not be readily available, or if they are available may not be accurate, for example, the proportion of graduates of a school providing care in underserved geographical or disciplinary areas. In such cases a desirable implication of using these measures will be the necessity to improve the amount and quality of information that is available.

Social responsiveness must also be measured within the socio-cultural context of a country and of a medical school. Some measures may not be appropriate or applicable to all countries or all medical schools. For example, the needs of poor countries may be better served by epidemiological studies to define health care priorities or to monitor health programs rather than focussing on issues of quality of care or cost effectiveness.

The aim of this paper is to produce measurement tools which can help medical schools to measure their levels of social responsiveness in meeting the particular health care priorities of their constituent communities. Clearly the tools used here to measure social responsiveness need refinement and since the main mission of the medical school is education, the items ultimately need to be weighted in terms of their importance, validity and reliability. Attention must also be paid to the sustainability of the measures to reflect a commitment from most departments and not just those with an orientation to community based primary health care. The intention of this paper is to start discussion and action in such a process.

References

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