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Abstract
Introduction Current medical education prepares doctors to diagnose, assess and treat individual patients yet lacks the expectation to be responsible for the care of the wider community. Learning the skills to recognise and redress the social determinants of health are increasingly being recognised as an essential part of medical education.
Objectives The goal of this research was (1) to investigate how medical education can be leveraged to reduce health inequalities through the role and practice of doctors and (2) to elucidate how key innovations in medical education are a necessity that can support doctors as ‘change agents.’
Methods Two international multidisciplinary roundtable focus groups with 23 healthcare leaders from various backgrounds were facilitated. The discussions were audiorecorded, transcribed and then thematically analysed with the qualitative analysis software QDA Miner.
Results Eight themes emerged: (1) Social innovation training in medical education; (2) Linking community working with social innovation; (3) Future curricula development; (4) Settings, context, environment and leaving the classroom; (5) Developing links with third sector organisations and community, including low-income and middle-income countries; (6) Including learners’ perspectives and lived experience; (7) Medical roles are political and need political support and (8) The need to address power imbalances and impact of discrimination.
Conclusions Medical education needs to fundamentally widen its focus from the individual doctor–patient relationship to the doctor–community relationship. Doctors’ training needs to help them become social innovators who can balance interventions with prevention, promote good health on a community and societal scale and tailor their treatments to the individuals’ contexts.
- Social innovation
- medical education
- medical students
- medicine
- public good
- society
- community
- social determinants of health
- health inequalities
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Social innovation
- medical education
- medical students
- medicine
- public good
- society
- community
- social determinants of health
- health inequalities
WHAT IS ALREADY KNOWN ON THIS TOPIC
Contemporary healthcare work has been described as complex and often inadequately captured by medical training and students have reported a lack of skills, resources and tools to address the social determinants of health.
WHAT THIS STUDY ADDS
Consensus findings in this research suggest extending the location of medical education to community settings, and community-based third sector organisations or from high-income countries to low-income and middle-income countries. These changes would allow the students to engage in clinically transformative social innovations.
The transformation needed for curricula reform requires the integration of the lived experience of individuals and communities, which also includes the individual social situations, alongside broader population-level data.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE AND/OR POLICY
Practice, policy and future research requires a fundamental cultural shift expanding the role of doctors from individual care providers to social innovators engineering healthy changes in their communities of practice.
Introduction
Healthcare professionals, including medical practitioners, are members of the communities they work and reside in. This familiarity, combined with their training, makes them acutely aware of the challenges and discrimination that deprived sections of their communities’ face. This discrimination can be based on characteristics such as race, gender, sexuality, disability and class. These communities experience high levels of chronic health problems, disability and reside in geographically isolated areas which lack access to necessary healthcare provision. While social determinants are recognised as having a significant impact on health outcomes, the means to address these through social innovation is largely absent from medical training and practice. The WHO defines the social determinants of health as the conditions in which people are born, grow, live, work and age, including the health system.1 Research also suggests that patients from deprived areas want medical practitioners who are socially and emotionally close to them and who can thus relate to the everyday realities of life in the areas in which they work and live.2
The current health workforce’s inability to deal with such disparities was starkly exposed during the COVID-19 pandemic. Nevertheless, this global crisis has reignited interest in addressing the root causes of health inequities and inequalities. If this opportunity for change is taken, it could lay the ground for fundamental medical education reform through social innovation. Such reform could help prepare the next generation of doctors to tackle these inequities and practice in a socially just way. Unfortunately, examples of social innovation that positively influence health outcomes are the exception rather than the rule. The current ecosystem of medical education and clinical practice often leaves individual clinicians feeling powerless to address the wider social determinants that they know have a direct influence on their patients’ health outcomes. Reforming the healthcare ecosystem to ensure that social innovation occurs because of medical training and not despite it, requires fundamental shifts in the design and delivery of medical education curricula and practices.
Our work has been informed theoretically by the notion of inclusive pedagogy and enhancing ‘practitioner agency’ as a means of advancing medical learners to develop as ‘agents of social justice and change.’3 Through developing an inclusive pedagogical approach, learners are better able to challenge the status quo, to work purposefully with patients and other stakeholders to draw attention to and challenge social injustice and exclusion.4 Our lens also included Amartya Sen’s capabilities approach, a human rights-based theory that emphasises flourishing as a product of the conditions under which people live. Practitioners can focus on realising human flourishing among those who are marginalised offering them a sense of their freedom to pursue the lives they have reason to value.5
There is an opportunity for doctors and healthcare workers to move from a doing, or an influencing role, to being an ‘agent of social innovation’ in the communities they serve. Of course, social innovation is not unique to any given sector.6 It can be driven by other institutions, such as academia, as well and a wide variety of actors both inside and outside health systems.7 This makes it possible to (1) support local working initiatives, (2) mobilise the power to regularise social innovation in the complex culture of health and other organisations and (3) forge links and working together with other sectors outside of healthcare. Halpaap et al recognise that ‘health innovation is often developed in response to local challenges, driven by frontline health workers responding to unique needs and opportunities. Yet, ‘the power to scale up innovation is often vested in high-level authorities that have limited understanding of local contexts.’8 (e633) It is insufficient for social innovation approaches to be a mere disrupter of established systems of health services delivery8 because there is now growing evidence that supports social innovation for health systems.9 10 ‘Social innovation can best be understood as innovation in social relations, in power dynamics and in governance transformations, and may include institutional and systems transformations.’11 (p.1) Furthermore, we believe that doctors trained in the community could potentially attain various sustainable education goals for positive community health outcomes. The conditions for medical education reform could not be more suitable for the purposive training of doctors in social innovation for local settings.8 Thus, the overall purpose of our work is to nurture a commitment to social justice as part of learners normative expectation and to develop competencies needed for inclusivity and a social justice curriculum.
Methods
Design
We conducted two multidisciplinary roundtable discussions which were organised as a series of focus groups with four designated facilitators, two in each group (CM, NK, PB and SSM) with clinical and academic backgrounds. The discussions were organised as consecutive focus groups (rather than concurrent), so that all members could participate in the entire integrated discussion. Using a phenomenological approach,12 we explored the following topics: how we currently teach and assess medical knowledge, the skills and attitudes of medical students interested in learning, health disparities, the social determinants of health and inequity. The phenomenological approach in our study considered and explored the preliminary conditions for the constitution of social distance and silence around social inequalities. We framed this article using the Standards for Reporting Qualitative Research.13
Sampling and recruitment of participants
Our purposive sampling strategy aimed to produce data that are ‘information-rich.’14 We populated the discussions with leading national and international medical figures, and divided the potential participants into sectors including representatives with a healthcare policy and medical education background, and from different healthcare organisations. We sent out invites to 47 people. 23 agreed to participate, 16 declined and 8 did not respond (international) (see table 1).
Sample detail
Setting
The round table discussions took place in June 2021. The round table focus groups were conducted as a webinar-style conference using the Zoom video teleconferencing software.
Data collection and handling
The event was arranged around two panels and two main topic areas (see box 1). The topic guide was created in cooperation with the authors and was sent to participants for clarification before the conference, which resulted in minor adjustments relating to more comprehensive areas of the topics that were debated.
Key topics discussed
Panel 1:
How can we create and manage a set of educational conditions—a curriculum and assessment plan—that focuses on teaching how inequity, inequality and the social determinants of health impact the communities in which students/trainee physicians will eventually work?
Panel 2:
What do we think of when we talk about health disparities, the social determinants of health, social justice, inequity and inequality, and structural and systemic racism? What are the key elements to include in medical education?
Two facilitators (PB and SSM) led the first focus group, while two others (CM and NK) led the second focus group. Each session began with a brief introduction of the topic followed by a subsequent 2 min contribution by panellists.
Data analysis
We audiorecorded the event and analysed the verbatim transcription of the recording. The transcriptions were carried out by a professional transcriber. Audiorecordings were uploaded onto QDA Miner and analysed by NK, checked for accuracy by SD and AR. Verbal data were initially coded along with the four topic areas by NK. Special attention was paid to capturing emerging themes. These were created as we examined the transcripts in more detail to reflect recurring issues and ideas emerging from within the discussions. We drew on the work concerning health equity that is grounded in general theories of justice.15
Results
Twenty-three participants took part in the conference on the day. Two participants acted as Chairs in the conference proceedings. We had 10 participants in each focus group, and 2 of those 10 served as the facilitators in each group. We did not ask individuals to self-report ethnicity or race however we did endeavour to send a number of invitations to leaders from minority ethnic groups, (perceived ethnic minority participants 15) and all participants represented a variety of disciplines, sectors and levels of authority. We achieved a diverse group that ranged from public health, primary care, psychiatry, acute medicine and surgery (see box 2).
Characteristics of participants
(21 national) (2 international) 23 participated in the conference.
11 women and 12 men.
Two medical directors.
Six director of medical education.
Two academic researchers.
One deputy chief executive.
One vice president.
Seven professors and heads of departments.
One patient representative.
Two medical students.
One national clinical director.
The following key themes emerged from the discussions (see box 3).
Summary of themes
Social innovation training in medical education: a bridge to community engagement.
Linking community working with social innovation.
Future curricula development: fostering doctors’ roles as ‘change agents’.
Settings, context, environment and leaving the classroom.
Shifting the focus from the individual patient to the community
Developing links with third sector organisations and community settings, including low-income and middle-income countries.
Including learners’ perspectives and lived experience in medical education.
Medical roles are political and need political culture to be on their side.
Racism, diversity, class, inclusion and addressing power imbalances.
The results are presented below as themes, with additional consecutive themes are presented in table 2. The themes relate to (1) medical education as a bridge to community engagement, (2) linking community work with social innovation and (3) future curricula development: developing doctors’ roles as ‘change agents.’
Themes from the focus groups
Social innovation training in medical education: a bridge for genuine community engagement
The panel included students that embraced the idea of acquiring training through immersive experiences in local communities. It was clear that the complexity of healthcare work meant that patients’ problems were ‘unpackable’ without understanding patients’ lived experience. It was also agreed that the medical diagnosis framework was only one of several lenses through which to view a person’s individual situation and experience.
So, how do we actually therefore teach our medical students in context and which means that maybe that you have to have a pathway of community care more in that pathway so for example a patient has had a fractured neck of femur and the medical student has been in theatre with it you know when the surgery happened. Then it’s about taking that medical students into the community once the patient is discharged to see how that patient is then going to manage. What are the inequalities and inequities that patient has to face in that social environment that they live in, where they might be living on their own or they have do not have a bedroom downstairs. It’s little things like that, and you can't teach that enough, you know, in a curriculum. It has to be actually taught in an environment where they see it happening. So, that’s my viewpoint. (2P11)
Linking community working with social innovation
Participants agreed that experiential learning was important in understanding the context in which patients live and work. In the past, the conceptual model for diagnosis tended to exclude the environment in which patients’ problems play out. Resulting in a gap between interventions that work in clinical settings versus those that are unsustainable when patients’ leave the clinical environment. Furthermore, there is a lack of resources available for doctors to deal with such issues.
…then there’s the experiential issues. At the moment we teach medical students like they are going to the zoo. They see people in cages. They might see patients but they don't see them in their context, they don't see what’s brought them there, they don’t see how they interact with their environment. (CC02)
Participants raised concerns about how the complexity of the problems faced by patients might not lend to simple assessments in the curricula. As one participant explained,
…how do we translate that finding, that understanding, to teaching, to curriculum, to teaching and assessment …There is a real question about what you need to do …to make sure that these matters are assessed and clinically assessed. So, tell me how does racism account for this presentation of this person today. What has housing and unemployment got to do with them being unable to recover and unable to find a place to discharge him to and so on… it is actually a practical problem in the world of business function. (2P13)
The importance of translating evidence of health inequalities into action with respect to medical education was a consistent theme.
We're talking about communities themselves and marginalised communities and what they can offer in terms of lived experience and community-based practise with them. And you know what? I think medical students would love that. (2P09)
An important element in implementation related to current medical faculty members’ was related to the existing culture and processes that hold the power to allow for such developments to occur.
…in practice and getting this into a longstanding integrated curriculum, is faculty development, as we need to acknowledge that some of us may not be from a generation for whom this is a routine way of teaching and so it is about faculty development. (2P14)
Values guide and shape behaviours and this was discussed by the patient representative with lived experience. Panellists highlighted the role of and importance of ‘higher values’ in delivering person-centred care. It was seen as essential link to teaching inequity, inequality and social determinants of health. The intrinsic values of doctors were important to them, should be included and balanced with the actual routine work that doctors carry out.16 It was seen as essential link to teaching inequity, inequality and social determinants of health.
Report Core Values with Psychiatrists outlines values which provide a lens which would enable the shaping of perspective and enhance the focus on teaching how inequity, inequality and social determinants can impact on health and the delivery of person-centred care. (2P10)
Future curricula development: fostering doctors’ roles as ‘change agents’
Data were seen to play a significant role in setting benchmarks and in helping quality improvement processes.
it is (sic) absolutely taught us all sorts of things about where you live, whether it’s air pollution or overcrowding or, you know, other indices and the impact they had on your likelihood of getting coronavirus with severity with which you had it and the outcome. (C03)
The participants agreed that the first step in improving the health of individuals and populations is having a better understanding of what the main health problems are and of these, which are the most urgent priorities from the patients’ situation. Ascertaining what is the most urgent priority for the patient and what can be done using both quantitative and qualitative approaches, applied to their individual situation was paramount. Quantitative data can help develop an individual’s health portrait, and qualitative data can be used to better understand why the local population thinks that addressing certain health challenges should be prioritised to their ‘lived’ context. Interestingly, National Health Service England has implemented a programme, Core20PLUS5, that reflects this finding.17
Discussion
The medical leaders who participated in this study described medical education and medical practice as lacking the understanding—that people present to doctors with strengths and not just weaknesses that are embedded in a host of social situations.
A case-based lens that focuses on social situation of the presenting individual and a personalised form of medicine was now seen as a more fitting approach, especially with the inclusion of a voluntary and community-based practice approach, leading the arena for where genuine learning was possible. Our analysis showed that there was consensus around including community settings in the training of doctors. Medical students immersing themselves into environments that have not been the normal domain of healthcare work was acknowledged as beneficial both for medical students themselves and for their patients. The traditional work of healthcare was seen as propagating stereotyping of people into disease and clinical cases. This focus on individuals, as opposed to communities in which they are embedded, has largely ignored the science of the social determinants of health and cultivates doctors that are ill-prepared to deal with the clinical realities of their contemporary practice. For example, when doctors prescribe lifestyle changes without understanding the wider social context and constraints of individuals, it means that the prescribed changes are difficult or impossible for the patient to implement or sustain in their lives outside of the clinical environment. This sets up even well-evidenced clinical treatments to fail, and it most importantly fails patients.18 The task of social change can seem immense and can easily engender helplessness in doctors. Therefore, clinicians must be reminded that they can tackle these issues by engaging with everyday realities of people’s lives and are thus more able to ‘fearlessly’ advocate on behalf of their patients if they are equipped with the resources, training and means to do so.
Developing a (both quantitative and qualitative) data and evidence-driven approach to identifying key health problems and the impact of these problems on local populations is the first step in improving health at both individual and population level.19 Healthcare benchmarking data can play a significant role in delivering change by helping to identify variations in health outcomes in diverse communities and in identifying the impact of interventions.20 21
Implementing such an approach has been difficult as medical education has, up to now, not drawn sufficient attention to doctors’ role as social innovators responsible for the care of their communities. Traditional medical education has focused almost exclusively on doctors’ roles in diagnosing and treating dysfunction in individual patients, not communities or societies.18 Indeed, students have reported a lack of skills and tools to help individuals access relevant services. Our analysis suggests that current medical training can allow students to think in social innovative ways. Barriers posed by discrimination based on class, gender, race and other protected characteristics may seem insurmountable in clinical settings, however they can be successfully challenged if medical education transforms medical students and subsequently doctors from professionals desiring change to ‘agents enabling change.’ This possibility is not impossible as the the evaluation framework pilot study showed
social accountability can be assessed through a critically reflective and comprehensive process. As social accountability focuses on the relationship between health professions schools and health system and health population outcomes, each school can demonstrate to students, health professionals, governments, accrediting bodies, communities and other stakeholders how current and future healthcare needs of populations can be addressed in terms of education, research and service learning.22 (p.116)
Our expert panel and our analysis both indicated that a transformation which integrated lived experience of individuals and communities in clinical education is a necessity. Developing links with community-based third sector organisations, and exposing medical students in high-income countries to clinical experiences in low-income and middle-income countries, are some ways in which the doctors of the future can be primed to engage in clinically transformative social innovations. van Niekerk et al also illustrated
the importance of addressing prevailing institutional voids, while holding steadfast the vision of what renewed institutional logics could achieve and providing an inclusive opportunity for all actors to move forward . In this way change occurs slowly, requiring multiple microshifts in individuals, communities and healthcare institutions to ensure sustainability and embedding.11 (P23)
The array of sectors represented in this study is a strength, including, as it did, students and patient representatives with lived experience. This was also indicated by the lively discussions and the participants’ passionate responses. Our results have real significance relating to current and future medical curriculum. Even so, there are some limitations. We aimed to increase the diverse sector representation, and this yielded a significant number of stakeholders joining from varied backgrounds and experiences. However, owing to the sizeable groups, each person may not have had the opportunity to participate to the extent they might have liked. In addition, some of the facilitators were not trained qualitative researchers, though they had academic credibility and were well-known healthcare leaders in the field. Further limitations of this research consist of the relatively small number of participants, a fact that could limit the generalisability of the findings, and the lack of representation from some sectors, professions, additional patients and learners. The research team mainly consisted of individuals with a substantive medical education background, and fewer with a healthcare policy background. However, our panels provided expert, qualitative experiential data in an area where little research has been done on integrating social innovation in medical curricula.
Conclusions
The results suggest that producing socially innovative medical practitioners requires, as one of the steps, the recruitment of greater numbers of medical students from working-class and diverse communities. This will enable better responsiveness to patients from marginalised and disadvantaged backgrounds. Fortunately, widening participation initiatives are helping more students from diverse backgrounds, including those with lived experience of mental health to be admitted into medical school.23 Medical students, we discovered, are also eager to pursue an agenda of addressing inequalities and promoting social justice.24 However, the ambition of medical students as nascent social innovators is made difficult through the institution of a hospital-based education and socialisation together with a health service configuration which makes health delivery partnerships with community groups difficult.25 Therefore, the next step is the transformation of medical education itself. Currently, traditional medical education promotes a tendency towards professional isolation from community groups. Nonetheless, there are examples that point to the considerable power of working with marginalised communities using new social innovations in response to the pressing health challenges. Take, for example, the outreach work of the Consortium of BAME (black, Asian and minority ethnic) Health Professional Networks to address vaccine hesitancy in the UK among ethnic minority groups.26 There are other promising sources of change such as the revised Outcomes for graduates from the General Medical Council with a greater focus on health promotion, community care, multimorbidity and managing physical, mental and social aspects of health together.27 28 Further, the Medical Education Reform Programme from Health Education England advocates for an immersive community-based learning approach. This approach aims to create a flexible, generalist, systems and data-literate workforce that can deliver improved population health outcomes and are precursors of this change. However, the impact of such initiatives will remain limited unless there is a fundamental social and cultural change in the way medical training is designed, structured and delivered across the UK. Medical education must do more to implement the necessary changes identified in this study. This requires significant organisational change that fosters and encourages medical students and doctors to become real ‘change agents’ and ‘social innovators in healthcare.’
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
No patient data were collected. The panel members gave informed consent via email confirmation to participate in the discussions. Names and places were anonymised when reporting data to protect the respondents’ identities.
Acknowledgments
We would like to thank colleagues from the Association of University Teachers of Psychiatry (AUTP) in particularly Treasurer Dr Deepa Krishnan. Thanks also to Sarah Mitchell for the very timely transcriptions. Special thanks to the healthcare leaders who freely gave of their time at the AUTP conference. The ideas expressed in this correspondence are the authors’ own and do not necessarily reflect the decisions and policies of the AUTP, any organisation, or the healthcare leaders who took part.
Footnotes
Twitter @DrKhan_do, @aerogers1, @drcolinm, @haritsa1, @gilliar_do, @pubmentalhealth, @sri_2050, @SimranSehdev, @DrAnnaSri, @subodhdave1
Correction notice This article has been corrected since it was published. Orcid id has been added for Alex Serafimov.
Contributors NK and SD designed the study. CM, NK, PB and SSM, facilitated the focus groups. NK led the analysis with SD and AR. NK led the writing of the paper and SD and AR contributed. All authors read, contributed and approved the final manuscript. SD is responsible for the overall content as the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the decisions or policies of PAHO or TDR. In any reproduction of this article there should not be any suggestion that PAHO or TDR endorse any specific organisation services or products.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.