Sunday, October 2, 2016

Beyond Flexner 2016: Medical schools still need to up their social mission

The “Beyond Flexner 2016” Conference was held in Miami September 19-21, 2016. It was the third in this series of conferences, originally stimulated by the 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”[1]. The first conference, held in Tulsa in 2012, featured the authors of the article and leaders from many “community-based” medical schools founded in 2 rounds of medical school expansion, the 1970s and the 2000s, discussing their real or proposed innovations (Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 1, 2012). The second, held in Albuquerque in 2015, had major growth in attendance, and a group of national speakers who powerfully addressed the failures of both medical schools and our medical system to address the health needs of the American people, especially through (lack of) diversity in our health care workforce, equity (especially racial) in the care provided, and the inadequate numbers of primary care doctors being produced (Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!, April 7, 2015). The metaphor for that blog’s title came from a talk by Don Berwick, in which he compared the US health system to the sturdily-built Choluteca Bridge in Honduras that withstood Hurricane Mitch only to be useless because the hurricane moved the river. (Such a great picture I’m posting it again here!)

The Miami conference, again sponsored by the Josiah Macy, Jr. Foundation along with Florida International University, was very good, although it had some disappointing aspects, notably the attendance, about 350, which was a little less than that in Albuquerque. The speakers were again excellent, with several standouts:  Mona Hanna-Attisha, the pediatrician who exposed the Flint lead poisoning crisis, gave a powerful talk in which she observed that despite being in Michigan, the “mitten state” surrounded by the largest collection of fresh water in the world, Flint’s water even today is still not safe. Robert H. Brook, of the RAND Corporation and UCLA gave a talk where he challenged the “rights” of medical schools, suggesting that hospitals (especially academic medical centers, AHCs) that do not care for their fair share of Medicaid and uninsured patients should not be allowed to have residency training programs, and that, more than allowing community service to count toward promotion and tenure, we should not allow anyone to be promoted without community service. Julio Frenk, the President of the University of Miami, a public health physician who served as Secretary of Health in Mexico, spoke about the need for building social capital that did not just “bond” communities but created “bridges” between them. He also noted that education had to move from the “informative” (providing the knowledge to become a professional) to the “formative” (creating the character and roles that define a professional) to the “transformative”, where professionals could truly create change both in their professions and in society.

One of the new events was the presentation of the First Annual Josiah Macy, Jr. Foundation Awards for Social Mission in Medical Education. The Institutional Award went to Morehouse School of Medicine, the Individual Award to Thomas Curtin, MD of Massachusetts and a leader in establishing Teaching Health Centers, and the program award to the University of Florida for its “Putting Families First” interprofessional education program. The highlight was the presentation of the Lifetime Achievement Award to H. Jack Geiger, whose achievements, from establishing the first Community Health Centers in the US, Physicians for Social Responsibility, Physicians for Human Rights, to serving as Dean of the Sophie Davis School of Biomedical Sciences at CCNY, are enough for several such lifetime awards. Dr. Geiger, who spoke eloquently at the 2015 conference, again addressed the group. He is nearly blind but as powerful and articulate a speaker as ever; he noted that "I have lost most of my eyesight, but it turns out you don't need good eyesight to hang on to a vision!"

In my 2012 blog on the Tulsa Conference, I noted 4 areas I felt were important for focus, and reiterated them writing about the 2015 Albuquerque Conference. They were:
·         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  primary 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?

There was more emphasis on interprofessional diversity at this conference, with panels including two national nursing leaders (Divina Grossman and Randy Rausch), and a panel including a community (and FQHC) based Dental School Dean (Jack Dillenberg). There was great ethnic and racial diversity in the speakers and moderators, but somewhat less emphasis on diversity in the content of the talks than in 2015. Primary care was still emphasized, but I remain concerned that the conference still features relatively small programs in medical or health professions schools aimed at increasing diversity, primary care, and community engagement. This is, of course, because most such programs are small within their AHCs, and nowhere near as important as the provision of tertiary and quaternary medical care and obtaining NIH research grants. Until these can be scaled up, until producing a majority of graduates entering primary care, enrolling and graduate underrepresented minority and low-income students at least in proportion to their percentages in the population, and working in the community becomes the highest priority of an AHC, the movement is stalled.

It is sometimes tempting to think that AHCs are incorrigible, that they are set in their ways – and in the way that they are financed – and that achieving the goals I have outlined above, or even more modest improvements in social mission – are not going to happen, at least any time soon. The Association of American Medical Colleges (AAMC) supports in word – and to a limited extent in deed – the goals of diversity and community engagement, but not enough to change the core focus of their members. Indeed, tellingly, they continue to call for increasing the number of residency positions, but not on targeting them to primary care, as does the American Academy of Family Physicians (AAFP). The largest specialty in medicine, Internal Medicine, opposes AAFP’s proposal to fund only “first certification” residency positions, as this would not fund their subspecialty fellowships.[2] Thus, they put self-interest (having funded fellows in their subspecialties) ahead of the need for America to have more primary care doctors.

Yes, it can get frustrating to work with medical schools and their entrenched anti-social values. But this is where the medical students are, where they are trained, and where they get their ideas of what might be the most appropriate specialties to enter and what th

e professional role of a physician is – e.g., working in the community or not. They need both individual and institutional role models.

So the need to work for a social mission for medical – and health professions – education is still an important goal.

[1] Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M,“The social mission of medical education: ranking the schools”, Ann Int Med 15 June 2010, Vol 152, No. 12,
[2] Butkus R, et al. Ann Intern Med. 2016;doi:10.7326/M15-2917.

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