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

© Her Majesty the Queen in Right of Canada, represented by the Minister of Public Works and Government Services Canada, 2001 Cat. No. H39-602/2002 ISBN 0-662-66388-8 Social Accountability A Vision for Canadian Medical Schools Steering Committee Members

Paul Cappon Noni MacDonald Co-chair () (Council of Ministers of Education Canada) Nadia Mickael Robert McMurtry (Royal College of Physicians and Co-chair February to September, 2000 Surgeons of Canada) (Health Canada) William Rowe Jean Parboosingh (McGill University) Co-chair from September 2000 (Health Canada) Robert Shearer (Health Canada) Richard Cruess (McGill University) Joshua Tepper (Canadian Association of Sylvia Cruess Interns and Residents) (McGill University) Mo Watanabe David Hawkins (University of Calgary) (Association of Canadian Medical Colleges) Michael Whitcomb Brian Hennen (Association of American Medical Colleges) (University of Manitoba) Carl Whiteside Paul Grand’Maison (University of British Columbia) (University of Sherbrooke) Robert Woollard Jason Kur (University of British Columbia) (Canadian Federation of Medical Students)

Don Ling (PEI Ministry of Health and Social Services)

-1- Executive Summary

The Steering Committee on Social n Medical schools conduct curiosity-driven Accountability of Medical Schools adapted research and provide evidence-based care, the concept of social accountability, which testing new models of practice that has been promulgated by the World Health translate the results of research into Organization (WHO) over the past decade, to practice. produce a vision for Canadian medical schools. The expectation of the public is that n Medical schools work together and in governments and the professions work partnership with their affiliated health collaboratively to ensure that the highly care organizations, the community, other valued Canadian health care system continues professional groups, policy makers and to provide the necessary access and quality to governments to develop a shared vision of meet the needs of the population. Medical an evolving and sustainable health care schools have an important role to play in this system for the future. endeavour. Involvement of the community in identifying WHO has defined the Social Accountability of community needs, setting priorities, Medical Schools as “the obligation to direct their establishing and evaluating new models of education, research and service activities towards practice is seen as critical. The role of the addressing the priority health concerns of the medical schools and their partner community, region, and/or nation they have a organizations in education, research and mandate to serve. The priority health concerns are service is articulated within the social to be identified jointly by governments, health care accountability framework and the need for organizations, health professionals and the public.” the medical community at large to understand and demonstrate the concept of A set of principles of social accountability by professionalism is underlined. which Canadian medical schools should function include: The development of an effective social accountability model for medical schools will n Medical schools emphasize to their provide the basis for all partners to work faculty and students the need to maintain collectively on meeting the needs of the their competence, the importance of the Canadian population in a collegial and patient-physician relationship, and an collaborative manner. understanding of professionalism and its obligations.

n Medical schools respond to the changing needs of the community by developing formal mechanisms to maintain awareness of these needs and advocate for them to be met.

-2- Introduction

At the beginning of the new millennium, the namely education, research and service. expectation of the public is that governments Academic freedom and clinical autonomy are and the professions work collaboratively to other values entrenched within the Canadian ensure that the highly valued Canadian health academic and clinical communities, which care system continues to provide the must be weighed in any assessment of the necessary access and quality to meet the role and functions of medical schools. needs of the population. Medical schools have an important role to play in this endeavour.

By identifying and responding to the needs of The definition of social accountability the community, whether defined by risk or by of medical schools is the obligation to geography, and by ensuring that individual direct their education, research and service graduating physicians understand their role activities towards addressing the priority in society, Canadian medical schools, along health concerns of the community, region, with their partners, have a major role to play and/or nation they have a mandate to in influencing the changes in the health care serve. The priority health concerns are to be system that are necessary to ensure an identified jointly by governments, health effective, efficient, accessible, equitable and care organizations, health professionals and the public. WHO, 1995 sustainable system in the 21st century.

Concepts of Social Accountability and The relevance of the activities of medical Social Responsiveness schools implies that they, together with governments, the profession and other major WHO has defined the Social Accountability of stakeholders in the health care system, have a Medical Schools as “the obligation to direct their systematic approach to addressing priority education, research and service activities towards health needs, including issues of access to addressing the priority health concerns of the services, determining and educating the community, region, and/or nation they have a appropriate number and mix of physicians, mandate to serve. The priority health concerns are and facilitating the geographic distribution to be identified jointly by governments, health care necessary to meet the needs of the organizations, health professionals and the public.” community. High quality health care is Social responsiveness is a complementary evidence-based, comprehensive and culturally capability by which a medical school responds sensitive; the definition of quality, however, to societal needs and acts proactively to meet may vary over time and be dependent on the those needs. availability of resources. Thus, setting WHO has developed a framework designed to priorities and ensuring the cost effectiveness help medical schools evaluate their progress of care are important mechanisms by which towards achieving the goal of social medical schools, in partnership with other accountability. This framework addresses the key stakeholders, can demonstrate their four values of social accountability, relevance, responsiveness to societal needs at a local quality, cost effectiveness and equity, as they level. Equity means striving to make quality pertain to the activities of medical schools, health care available to all people; medical

-1- schools can assist by defining populations at n the optimal preparation of future risk through well-designed research, practitioners to respond to population identifying methods of removing barriers to needs; access and educating students in environments in which they are exposed to n the establishment and promotion of those in need. innovative practice patterns to better meet individual and community needs; These values are implicit in the Canadian health care system and are recognized by the n the reinforcement of partnerships with Canadian population at large, which is, today, other stakeholders, including academic better informed and more demanding of health centres, governments, better access and quality for the health care communities and other relevant system. At this time of reinvestment in professional and non-professional health by governments, an explicit organizations; acknowledgement by Canadian medical schools that these are important issues for n advocacy for the services and resources them, will show how they are in a unique needed for optimal patient care; position and are prepared to play a major role the definition and clarification of the in seeking to contribute to the sustainability n concept of social accountability and the of the health care system into the future. dissemination of methods for measuring responsiveness to societal needs;

Canadian medical schools are in a n the inclusion of the concept of social unique position and are prepared to accountability in the accreditation process play a major role in seeking to of medical schools and other health contribute to the sustainability of the institutions. health care system into the future. Medical schools exist within a larger health and social system, which involves all A Vision: The Leadership Role of determinants of health including wealth, Canadian Medical Schools education, the environment, housing and a spectrum of services from health promotion While recognizing the role of governments to palliative care. There are many health care and others in providing funding for health providers, in addition to physicians, who have care services and for research and education, obligations to meet societal needs. medical schools can play a leadership role in helping to contribute, in partnership with a wide variety of other parties and agencies, in Principles of Social Accountability the following areas: The following set of principles by which n the development of a clear and shared Canadian medical schools should function is vision of the health care system and of suggested. These will allow medical schools the health care providers of the 21st to identify where they stand with respect to century. This vision will have to be clearly responding to the needs of society and to articulated and constantly revised to continuously strive to ensure that they are respond to changing needs; doing so. Formal measurement of the social accountability of medical schools requires

-2- considerable resources. In a substantially Canadian society provides medical schools publicly funded medical education and health and the medical profession with certain care system such as exists in Canada, medical privileges and resources; these are justified schools work in partnership and in a climate only insofar as they are unambiguously placed of collegiality and collaboration to contribute in the service of those in need and the to the health and well-being of the people and community of which they are a part. The the communities they serve by incorporating primary goal of medical education is to the following principles: prepare graduates to practice effectively in reducing the burden of illness and improving n Medical schools emphasize to their the health of their communities. This goal faculty and students the need to maintain includes the concept of professionalism, i.e. their competence, the importance of the the social contract between a professional and patient-physician relationship, and an society, with its core values of scientific understanding of professionalism and its expertise and altruism. In order to meet this obligations. social contract, professionals in training should be equipped with the knowledge, n Medical schools respond to the changing skills and resources to meet societal needs. needs of the community by developing formal mechanisms to maintain awareness of these needs and advocate for The core values of professionalism them to be met. (the social contract between professional and society) are scientific n Medical schools conduct curiosity-driven expertise and altruism. research and provide evidence-based care, testing new models of practice that translate the results of research into Social Commitment and practice. Community Engagement

n Medical schools work together and in Medical schools should explicitly expound partnership with their affiliated health their commitment to social accountability and care organizations, the community, other social responsiveness in their general professional groups, policy makers and orientation, including in their publicly-stated governments to develop a shared vision of mandate or mission statement. They should an evolving and sustainable health care proactively define these concepts and identify system for the future. the actions to be implemented in order to demonstrate their commitment to be socially The balance between community relevance accountable and responsive. Included in these and the unfettered search for and actions is fostering the engagement of the transmission of knowledge is never a quiet community in their activities. one but an unambiguous dedication to the welfare of our collective future is part of the The public, as consumers, are demanding social responsibility of medical schools and more of all providers of consumer products academic health care organizations (the and services; this is reflected in the increasing academic health sciences centres). demands on the health care system to meet the needs of each and every person who uses the system. Identifying community needs,

-3- setting priorities, establishing and evaluating opportunity are more effective strategies for new models of practice are areas in which encouraging physicians to meet the needs of community participation is critical. society than are coercive measures.

The Role of Medical Schools A well-rounded professional demon- Medical schools function in three major strates: knowledge, clinical com- arenas: education, research and, usually with petence, lifelong learning, evidence- other partners, in health care provision. In based practice, interdisciplinary addition, they are expected to manage their teamwork, balance between disease resources, relate to policymakers and other management and disease prevention/ stakeholders and be proactive and innovative health promotion, professional and in all aspects of their work, thereby helping ethical behaviour in practice, optimal to shape the external world in which they use of resources and consciousness of exist. well-being of self and colleagues.

1. Education Medical schools have the obligation to ensure that their learning environments respond to Canadian medical schools are responsible for the ever-increasing knowledge base, but undergraduate, postgraduate and continuing equally to ensure that they produce medical education as well as the training of well-rounded professionals. This includes future health scientists. The need to inculcate ensuring that students and residents the concepts of lifelong learning into teaching understand the contributions of other health and learning across all levels is increasingly care disciplines and have the ability to being recognized. The content of educational practice within an interdisciplinary team. A programs should be directed towards the philosophy that values health promotion and priority health problems in all sectors of the disease prevention as components of medical community, both hospital-based and care and an assumption that physicians have community-based, and to the range of health a responsibility in health promotion and issues from health promotion to palliative disease prevention are important to future care. practitioners.

The role of the medical schools in In addition to their role in educating medical postgraduate training is key to the production professionals, as knowledge expands and of a well-trained and appropriate generalist : health care becomes increasingly complex, specialist mix of practitioners to meet the medical schools have an obligation to impart need of the Canadian health care system. To that knowledge to the public as do individual achieve this, a national approach to physician physicians to their patients. resource planning is necessary in Canada. This requires that medical schools collaborate with the federal, provincial and territorial governments and the other national medical educational and licensing bodies to ensure that the right number and mix of physicians enter practice. To this end, it is recognized that individual volition and enhancement of

-4- 2. Research Basic biomedical research creates new knowledge and understanding of molecular A balance between the freedom to carry out and cellular mechanisms of health and curiosity-driven research and research disease and the biological pathways to the directed to meeting the needs of the determinants of health. Discoveries and community is essential, as is the need for a development in this arena have the potential, long term vision of research that through technology transfer, to contribute to encompasses multiple settings and a commercialization and the creation of jobs. collaborative approach. As the scope of Applied clinical research is involved in the medical research is expanding, funding for evaluation of the safety and efficacy of new research has increased significantly. Medical and existing drugs, treatments and schools must meet the challenge of a procedures and thus contributes to the changing research paradigm that includes protection of the health of all and areas that have not been of paramount to the quality of care provided. interest to academic researchers, while maintaining a leadership role in the Health services research evaluates the care of traditional research arena. The goal is to be individual patients and of new delivery responsive to the current and emerging needs models of community-based and of their individual communities, within the system-based care. As new models of delivery larger context of national and international of primary care are implemented, health trends, by continually profiling the health services research will play an important part status and health care needs of the in evaluating the impact of its individual community. components, such as interdisciplinary care, alternate funding mechanisms and While basic science and clinical and health registration of patients. At a systems level, services research have been priorities for health services research can contribute by medical schools, research in population evaluating the care provided in integrated health becomes ever more important to systems of care, such as cancer care networks. identify the needs of the communities served As the use of information technology and by medical schools. Where needs are telehealth expands, research will be needed to identified, mechanisms to meet those needs demonstrate their impact on the health care must be put into place; this may mean that system in terms of quality, access and medical schools take the initiative to develop cost-effectiveness. and implement interventions in collaboration with community health groups and other Medical schools and the social mechanisms sectors to improve the health care and health that fund research have an obligation to status of the communities they serve. recognize the potential influence that Evaluation research is key to ensuring that pecuniary considerations can have on the such interventions meet identified needs and priorities of the research endeavour. Medical to providing a strong evidence base for schools have a particular responsibility to be sustainability. Evaluation research into beyond reproach in conducting themselves in educational techniques and processes also such a way that the unfettered search for needs to be promoted so that the most knowledge is not unduly influenced by factors effective means of educating students, faculty other than the needs of society. and the community are developed.

-5- 3. Provision of Health Care engagement with the health care system and the communities in which it is embedded is a In addition to the role that they play in necessary basis for the expression of its social education and research, the part time and full responsibility. time faculty of all medical schools are involved in the provision of clinical services, usually under the aegis of an affiliated health Professionalism care institution. This arises in part because of Professionalism is the moral understanding the very nature of medical education and among professionals that underpins the clinical research but also reflects the active concept of a social contract between the partnerships with other institutions and profession and the public; under this communities that are the legitimate contract, professional occupations have been responsibility of medical schools engaged in granted authority to self-regulate and assessing and responding to community independence to control key aspects of their needs. Provision of tertiary and quaternary working conditions through accreditation, care to the community are almost exclusively licensing, credentialing and professional within the purview of the health care conduct review. The call to professional organizations linked to a medical school responsibility must be an articulate one that forming the academic health sciences centre. applies equally well to practising members of Participation by medical schools in secondary the profession as it does to those in training. and primary care reflects the learning environment required to appropriately educate physicians for community service. The whole of the learning environment for a The call to professional responsibility medical school constitutes the academic applies equally well to practising health sciences network. A balanced members of the profession as it does to integration of service and education, those in training. regardless of which sector of the health care system it takes place in, is essential to ensure the well-being of trainees and that the Professionalism of Individuals appropriate educational outcomes are achieved. Medical schools should ensure that individual physicians graduate aware that the profession Support for the establishment of innovative of medicine is one of constant change and, practice patterns and participation in defining thus, they need to be lifelong learners. and shaping the health care system of the Methods need to be in place to demonstrate future are other valued contributions that can that graduates have achieved an and should be attributed to medical schools. understanding of the concept of This future orientation needs the professionalism. Graduates need to be establishment of partnerships with external prepared to demonstrate their competence in health care institutions and policy makers. an ever-changing environment, to ensure that their practice is based on evidence and to Active, thoughtful engagement with other respond to the changing environment in medical organizations responsible for which they practice. This includes recognition certification, regulation and advocacy is part of the role of the patient in the of the expression of a medical school’s patient-physician interaction, advocacy on partnership obligation. Similarly a broad behalf of the patient, the willingness to work

-6- in a variety of settings where need exists for An explicitly articulated recognition by the medical services and recognition of the roles medical schools that they are listening and of other health care professionals. responding to their various publics is important to increasing the confidence of the Professionalism of Medical Schools governments and the public that the resources spent on them are justified. One Faculty and medical schools must be able to approach is for individual medical schools to demonstrate that the outcomes of their carry out specific projects consistent with a activities in these arenas make a difference. renewed emphasis on social accountability. They have the obligation to demonstrate to Governments will be more likely to recognize society that they produce physicians who the importance of this work, the medical recognize their role in society and that the community will be more satisfied with their application of their education, research and working conditions and more motivated to service activities have a positive impact on put forth additional efforts on behalf of their the health care and health status of the patients. population they serve. The development of an effective social Potential Outcomes accountability model for medical schools will provide the basis for all Faculty and graduates of Canadian medical partners to work collectively on schools will embrace their social meeting the needs of the Canadian responsibility through the provision and population in a collegial and promotion of health for all individuals and collaborative manner. groups. This requires a knowledge of and engagement with marginalized and vulnerable individuals and communities who will need The explicit incorporation of social unique strategies in order to facilitate accountability within the fabric of medical accessibility to health care. faculties will provide a basis for development of respectful partnerships for health with Faculty and graduates will recognize the government, health authorities, communities critical importance of the following concepts: and business. These partnerships will community consultation and community facilitate and encourage shared work on inclusion in the entire health care enterprise, health planning, problem solving, health disease prevention and health promotion, service delivery, health service evaluation and integrated and interdisciplinary care, lifelong health policy development. The development learning and continuing professional of an effective social accountability model for development, performance measurement and medical schools provides a pattern for other research. professions and partners in health to develop Faculty and graduates will foster collegial similar social accountability frameworks. It attitudes that promote interdisciplinary and also provides the basis for all to work multidisciplinary approaches to health care collectively on meeting the needs of the and ensure meaningful exchange with other Canadian population in a collegial and professions. collaborative manner.

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