Monday, April 27, 2015

Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!

I recently attended the “Beyond Flexner 2015” conference in Albuquerque, NM. Originally titled “Beyond Flexner II”, it was a followup to the 2012 “Beyond Flexner” conference in Tulsa, OK, which I discussed in my June 16, 2012 post “Beyond Flexner: Taking the Social Mission of Medical Schools to the next level”. The first conference was itself in part stimulated by the 2010 publication of “The Social Mission of Medical Education: Ranking the Schools” by Mullan, Chen, et al. in the Annals of Internal Medicine.[i]  Fitzhugh Mullan, head of the Medical Education Futures group at George Washington University, was co-director of this recent conference along with Arthur Kaufman, Vice Chancellor for Community Affairs at the University of New Mexico Health Science Center. The organizing committee was a “Who’s Who” of leaders in the movement to make medical schools more accountable for meeting the actual health needs of the people of the United States, including Gerry Clancy, host of the 2012 conference in Tulsa, and several of the other authors of 2010 paper.

The attendees at the 2012 conference in Tulsa were captured in a posed photograph, crowded but with  recognizable faces. This would not be true of the nearly 400 people in Albuquerque, who also represented a much wider group. In addition to more university sponsors (including Florida International University, which will host the next conference in 2017), several other foundations have joined the Josiah Macy, Jr. Foundation, which helped sponsor the first conference as well. The bulk of the attendees were medical school faculty, with some residents and students, but others from a wide swath of those with an interest in the impact of medical school output on health were in attendance. Notably, this included people from the cooperative extension services based at our nation’s land grant universities, who have been collaborating with health sciences centers to create “health extension” programs in a number of states (The Primary Care Extension Service, July 12, 2009);  New Mexico’s HEROs (Health Extension Rural Offices) program is one of the national leaders.

There were a number of stimulating and provocative speakers, including Camara Jones, about whom I have already written, who spoke about racism and the Social Determinants of Equity. Don Berwick, founder and senior fellow at the Institute for Healthcare Improvement, and former interim Administrator of the Center for Medicare and Medicaid Services (CMS), gave a powerful talk about the direction of healthcare in the US. His most powerful metaphor was of the Choluteca Bridge in Honduras, which was so well built that it withstood Hurricane Mitch in 1995. Unfortunately, the hurricane relocated the river, so that now it no longer functions for its intended purpose! Dr. Berwick also noted that if the US spent 15% of its GDP on health care, instead of the current 18%, it will still be higher than #2, Switzerland. If the US had spent at the per capita rate of Switzerland over the last 25 years, it would have spent $15.5 TRILLION less. That is real money, and could have been used to address many of the social determinants we are always told there is not enough money to do.

Perhaps the most stirring talk was given by H. Jack Geiger, former Dean of the Sophie Davis (now City University) School of Medicine in New York. Accurately described as a “living legend”, Dr. Geiger founded the first two community health centers in the US, in Charlestown, MA near Boston and in Mound Bayou, MS. He was a founding member of the group Physicians for Social Responsibility (PSR), the US affiliate of the International Physicians for the Prevention of Nuclear War (IPPNW), and Physicians for Human Rights (PHR). In his introduction we were reminded that Dr. Geiger was once chastised by a federal bureaucrat for writing prescriptions for food for his patients in Mississippi, and told that the federal funds supporting his program were to be for treatments. His now-classic response was that “the last time I checked my medical textbooks, the treatment for malnutrition was FOOD!” He noted that the last decade might be called that of raising consciousness of the Social Determinants of Health, but that because many of these are determined by (and are currently being eroded by) the political process, called for the next decade to be that of the Political Determinants of Health. He did not mention, but I note, that while IPPNW won the Nobel Peace Prize (1985), the Nobel Prize for “Medicine” in fact goes exclusively to researchers in the basic sciences. How wonderful, fitting, and appropriate would it be to go to someone like Jack Geiger, whose life’s work had really made a difference in the health of people!

In writing about the 2012 conference I suggested that certain goals be the focus of the “Beyond Flexner” movement:
·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?
·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?
·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?
·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?
I believe they are still valid. The Social Determinants of Health (SDOH) were discussed everywhere in the conference, and Health Disparities are the central focus of addressing them, or in Dr. Jones’ phrase, the Social Determinants of Equity. Community Engagement was emphasized through the broader participation in the conference (such as the people from Extension services) and one of its highlights was an afternoon of tours of such community-engaged programs in Albuquerque. I went on a visit to the city’s International District, and the East Central Ministries, which operates an innovative clinic driven by community health workers, an Urban Farm, and a small factory manufacturing ollas, unglazed clay jugs used for low-water-use irrigation.

Diversity was certainly addressed by many of the conference speakers, including Dr. Jones and Marc Nivet, Chief Diversity Officer for the Association of American Medical Colleges (AAMC), who pointed out how poorly our schools have done. In the 1990s The AAMC had a goal for minorities of “3000 by 2000”, but in the last 35 years African-American applicants have increased by 1000 and admissions by only 250. Jose Rodriguez and his colleagues writing in Family Medicine note that African-Americans peaked at 8.1% of medical students in 1994, and was down to 7.23% in 2010, Hispanics are up to 8.25% despite a much higher % of the population, and underrepresented minority (URM) faculty in medicine has increased from 7% to 8% from 1993 to 2010 despite an increase in those same groups in the general population from 23.1% to 31.4% in the same period.[ii] In the accompanying editorial, which I wrote, I call for an immediate, dramatic, and comprehensive effort to change both the socioeconomic and racial makeup of our medical school classes.[iii]

If anything was a little disappointing to me at the conference, it was the degree to which the audience was less willing to pick up on the issue of lack of diversity. While there was applause for the comments of Drs. Jones, Nivet, and others, most of the questions and comments focused on the SDOH. These are extraordinarily important, and emphasizing the need to teach them in medical school is as well, but poverty will not be solved quickly. Diversity, on the other hand, could be; our medical school class next year could look dramatically different if we changed the criteria by which we admit so that half the class came from the lower 50% of income and we had double the percent of minorities.

Many of the conference attendees were from newer medical schools, whose goals are more tied to SDOH, Community Engagement and Diversity, and they were celebrated from the podium. But while they may deserve this celebration, the older medical schools need to be held responsible as well; unless they change their admissions practices and their goals to serve the communities, the impact of the newer schools will be only at the margins.

There is a lot to do, and to accomplish it will take a movement. Hopefully a movement growing from “Beyond Flexner” can start the process.

[i] Fitzhugh Mullan, MD; Candice Chen, MD, MPH; Stephen Petterson, PhD; Gretchen Kolsky, MPH, CHES; and Michael Spagnola, BA. The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med. 2010;152(12):804-811. doi:10.7326/0003-4819-152-12-201006150-00009
[ii] Rodriguez JE, Campbell KM, Adelson WJ, Poor representation of Blacks, Latinos, and Native Americans in Medicine, Fam Med 2015;47(4):259-63.)
[iii] Freeman J, Diversity goals in medicine: it’s time to stop talking and start walking, Fam Med 2015;47(4):257-8.

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