Table 2

Themes from the focus groups

ThemesConceptsFocus group data from panellists
4) Settings, context, environment, and leaving the classroom
Shifting the focus from individual patients to the community
The round table had an introductory keynote that presented the robust scientific data linking social inequity and health outcomes. Despite the growing evidence, this was rarely integrated into clinical practice or medical education.29 30 A prime example of this was the largely tertiary (hospital) settings of clinical education. Shifting learning to a community-based setting is not only possible but also desirable.“Primary care particularly embraced that message way back in 2005 so if you look at what’s happening… in primary care teaching, they are looking at students as problem solvers in their own right, they are adults, they can solve problems so they are getting them into this community practice.” (2P14)
5) Developing links with third sector organisations and community settings, including low-income and middle-income countries (LMICs)Data from the participants showed that they brought up third sector involvement. Forging links with third sector educators could allow collaborators from those sectors to be brought into teaching and assessment interventions for clinical trainees.
Taking a personalised approach, focused more on the positive strengths of individuals was advocated.
“So, training people in having that understanding of people’s strengths rather than just weaknesses, that seems to be fundamental to personalised medicine. There you go, I connected it! I think the other thing is, wouldn’t it be great if in medical training that practitioners spent time in voluntary and community organisations rather than always having to do, you know, if you learn all of your mental health training in a psychiatric ward you’re going to learn a bit but you’re never going to notice anyone recovering or never going to understand the social and economic context.” (1P05)
Participants in the focus groups extended the notion of community learning to include LMICs and suggested teaching that was less didactic and more interactive. The essence of structural racism was linked to the colonial past. The consequence of not understanding this history was indicative of some of the racism experienced by healthcare staff and patients.“(Firstly)… each medical student should be sent to a poor country for a month to do an attachment in a hospital. the second one is there should be a lesson in colonial history and the slavery in the curriculum for them to understand what is the root cause of structural racism is. the third one is there should be a lot more collaboration…” (1P07)
6) Including learners’ perspectives and lived experience in medical educationMedical education should be learner-centred and led by learner requirements. Stakeholders engaged in the training of future doctors have revealed an explicit appetite for the inclusion of social justice and the social determinants of health in medical education."The students that are currently studying medicine, that are coming in - this new generation are perhaps the most progressive generation of young students we've ever seen.” (1P04)
This notion of learners as ‘change agents’ wanting to be socially innovative was clearly articulated by 1P04. The teaching and practice of medicine should be embedded within the patients’ personal situation."They are the ones that are going to make the difference and they are already seeing how they can be that original model of a doctor to the advocate for the patient. Not to see the patient as a disease but to see them in the context of where they live.” (1P04)
Integrating the lived experience of patients and carers in medical education was identified as key to the enhanced role of doctors as change agents delivering truly person-centred care.“Patients are not objects for clinical care. A patient is a person. Understand that context.” (2P010)
7) Medical roles are political and need political culture to be on their sideThe participants also highlighted how contemporary healthcare work is concerned with the kind of regressive policies that negatively impact health service users. There was an undeniable link there and concern was related to political culture and its policies around social deprivation and poverty.“We coined the awkward phrase ‘proportionate universalism.’ We want universalist policies with effort proportionate to need. What we've got here is effort inversely proportionate to need: the greater the deprivation, the greater the need, the greater the need, the greater the reduction in spending. Could such regressive policies had contributed to worse health and increased inequalities? Yeah? I think they could. These policies didn't work n their own terms. We were told that the reason for this austerity was to get finances back on track to get the economy growing again.” (C01)
One of the barriers to enhancing doctors' role as social agents was the notion that ‘politicising’ medicine will detract from its scientific foundations. This misperception not only ignores the robust evidence linking psychosocial determinants and health outcomes yet can also potentially disempower doctors."We shouldn't be afraid to say the things that are political because that is the job of a doctor, doctor is political because… if I don't stand up for my patients, no one’s going to stand up for them.” (1P04)
The subtle but significant shift from being advocates for patients to ‘physician activists’ and speaking up for patients was also highlighted. Speaking up was linked to empowering others. The consequence of not speaking up was seen as both disempowering and ineffective advocacy."If you don't say anything and stay quiet then you are not empowering others to speak up. So, I think… we can all make a difference and change on the ground in the different roles that we do, and empowering others to do the same, is important.” (1P02)
How political decisions can impact health outcomes was brought sharply into focus through an awareness of realistic advice and ‘fearless advocacy.’ This transcended beyond the simple meaning of standing up for patients and to genuinely push for social and welfare support, and what is doable in the context of the patients’ lives versus not speaking up for patients.“Do you think there is agreement, then, as clinicians we should be more fearless and we should say this is what’s making this man or woman sick and there’s no point me wagging my long finger and saying eat better food when every single local supermarket discounts heavily processed foods and this patient has barely access to kitchen ingredients.” (C02)
8) Racism, diversity, class, inclusion and addressing power imbalancesSocial innovations aimed at improving health outcomes must not only focus on patients but also the workforce. There was concern about the minimal representation of doctors from a working-class background in medicine. Changes around admission of student with a working-class background in medicine was still low to effect substantial changes.
Tailoring medical education to create a workforce that is not only part of the change but one that actively works to shape change for the better was a significant aim for the panellists.31 Workforce Race Equality Standards data has clearly demonstrated the lack of gender and ethnic diversity in leadership positions in healthcare organisations. Decades of work that has been of qualitative nature has been ignored on the issues around racism, differential attainment and career progression of the ethnic minority workforce.
“We can see that inequality affects life expectancy and we're seeing inequality widening, not getting less… but also, remember that only 4% of doctors are currently working class. we’re working to improve this.” (1P03)
“I just wanted to talk about the bullying and racism in medical schools (sic)… stereotyping of especially ethnic minority students is so common. They are reluctant to stand up and ask questions.” (1P07)