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Medical Education  |   April 2016
Osteopathic Medical Education and Social Accountability
Author Notes
  • From the University of the Incarnate Word in San Antonio, Texas. 
  •  *Address correspondence to Robyn Phillips-Madson, DO, MPH, University of the Incarnate Word, 4301 Broadway, CPO 121, San Antonio, TX 78209-6318. E-mail: rmadson@uiwtx.edu
     
Article Information
Medical Education
Medical Education   |   April 2016
Osteopathic Medical Education and Social Accountability
The Journal of the American Osteopathic Association, April 2016, Vol. 116, 202-206. doi:10.7556/jaoa.2016.044
The Journal of the American Osteopathic Association, April 2016, Vol. 116, 202-206. doi:10.7556/jaoa.2016.044
Web of Science® Times Cited: 2
Abstract

The public’s trust in physicians continues to decline. As a way to begin regaining this trust, stakeholders, including physicians, medical educators, patient advocacy groups, and community-based organizations, have called for medical education to meet societal health needs, particularly the needs of those members who are most vulnerable, by incorporating social accountability into the medical school curriculum. The unique attributes of the osteopath-ic medical profession provide an enabling and conducive environment for broader social accountability in the health care system. Osteopathic medical schools must actively safeguard the profession’s unequivocal commitment to producing healers that are fiduciaries for their patients, communities, and populations at large.

This Medical Education theme issue introduces a new collaboration between the JAOA and the American Association of Colleges of Osteopathic Medicine (AACOM) to recruit, peer review, edit, and distribute articles through the JAOA on osteopathic medical education research and other scholarly issues related to medical education.

 
Those who choose to study and practice the healing science and art of medicine pledge a commitment to society to be competent, altruistic, and ethical. Yet, a 2014 study1 revealed that 42% of US adults surveyed disagreed with the statement, “All things considered, doctors in [your country] can be trusted” and reported that during the past 50 years, trust in physicians has decreased dramatically. To address this issue, several stakeholder groups and individuals (eg, physicians, medical educators, patient advocacy groups, community-based organizations) in the United States and abroad are calling for medical education to focus more on meeting society’s health care needs, particularly among those populations that are marginalized and most vulnerable to disparities in health outcomes.2 Meeting the health care needs of all members of society in this context requires preparing sufficient numbers of primary care physicians to work in underserved areas, training physicians to collaboratively address the social determinants of health using population-based health measures, and reforming a professional identity to explicitly focus on empathy and social justice. In the words of the preeminent educator, Ernest L. Boyer, PhD, “the crisis of our time relates not to technical competence, but to a loss of the social and historical perspective, to the disastrous divorce of competence from conscience.”3 
The call to physicians to reaffirm their duty to society comes with the realization that there is sufficient evidence4 of the detrimental effects of the social determinants of health and related disparities in health outcomes (biological, social, and environmental). Hence, the concepts of social responsibility and health advocacy are becoming a fundamental element of both medical education and practice.5 Although this call for educational reform includes a commitment to public safety, society expects medical educators to instill and nurture future physicians with social responsibility and health advocacy in their ethics, empathy, community service, interprofessional collaboration, and lifelong learning. Greater transparency and broader participation in social accountability is needed to determine how future generations of physicians are admitted to medical school, trained, and held responsible for meeting the health care needs of society.6 Patients can be disadvantaged when it comes to the lack of transparency around the cost of health care services and products—a transparent system provides quality reporting and disclosure of financial relationships that may lead to a compromise in fiduciary relationships with patients.7 Further, transparency helps patients choose physicians wisely and inspires physicians, hospitals, and other providers to improve their performances.8 
Social Accountability—Taking a Systems-Based Approach to Health Care
The 1995 World Health Organization report Defining and Measuring the Social Accountability of Medical Schools3 was written in response to many of the longstanding and ongoing aforementioned issues. The report states that medical schools have an 

…obligation to direct their education, research, and service activities towards addressing the priority health needs of the community, region, and/or nation they have a mandate to serve. The priority health needs are to be identified jointly by governments, health care organizations, health professionals, and the public.9

 
A review of policy reports from 2000 to 2010 calling for change in medical education revealed that social accountability featured prominently in recommendations for transformation, including the promotion of professionalism, diversity of the physician workforce, focus on underserved rural and urban settings, and the provision of primary care.10 In a Delphi survey that led to the Global Consensus for Accountability of Medical Schools,11 130 organizations and individuals from around the world with responsibility for health professions education, professional regulation, and policy-making agreed unanimously on the urgent need for medical schools to be responsive to societal health needs by reorienting medical education, research, and service priorities to focus on quality, equity, relevance, and effectiveness in health care delivery and providing evidence of the impact of these changes in education on people’s health status. 
So, what does this call to action mean for the osteo-pathic medical profession and the training of the next generation of osteopathic physicians? Demonstrating social accountability to patients, society, and the osteo-pathic medical profession has always been a key feature in osteopathic medical training. Social accountability has been emphasized throughout the history of the osteo-pathic medical profession. Osteopathic physicians have historically been committed to community involvement and public services for the common good. Osteopathic primary care faculty members are well positioned to serve as role models for socially accountable practice and the development of a professional identity that meets societal needs. The osteopathic medical profession has also traditionally focused on prevention and wellness, recognizing that practices and policies that fail to address disparities in and the need for health care among marginalized populations are unlikely to have the desired impact on health outcomes. 
In the 1894 Articles of Incorporation of the American School of Osteopathy, the primary objective of Andrew Taylor Still, MD, DO, was “to improve [the] present system of surgery, obstetrics, and treatment of diseases generally.”12 Still understood that although physicians may individualize their treatment approach to patients, they practice within a system. 
Although the tenets of osteopathic medicine13 are specific to the individual patient, they can also be applied to society in general. Societies have physical, mental, and spiritual needs, and their structures and functions are reciprocally interrelated. Osteopathic medicine’s duty to society has been addressed in A.T. Still Memorial Lectures. In “The Road Ahead—Revisited,” Myron Magen, DO, quoted Raymond Keesecker, DO: “The central position of the osteopathic profession is determined by its primary obligation to society: to furnish fully prepared doctors of medicine.”14 In his 1990 speech,15 Anthony G. Chila, DO, stated that, “[d]uring the final decade of the [20th century], the osteopathic medical profession must decide how its contribution will merit society’s support.” Specific reference to societal obligations also appears in physician oaths as well as medical association codes of ethics to further underscore the explicit duty the medical profession has to society as a whole. The Osteopathic Oath16 from 1954 calls on osteopathic physicians to be “ever vigilant in aiding in the general welfare of the community, sustaining its laws and institutions,” and the American Osteopathic Association Code ofEthics17 stipulates the moral duty of osteopathic physicians to society as a whole: 

The osteopathic medical profession has an obligation to society to maintain its high standards and, therefore, to continuously regulate itself. In addition to adhering to the foregoing ethical standards, a physician shall recognize a responsibility to participate in community activities and services.17

 
The Social Mission of Osteopathic Medical Schools
In 2010, the Carnegie Foundation’s Educating Physicians: A Call for Reform of Medical School and Residency18 recommended the transformation of undergraduate and graduate medical education toward preparing future physicians who had 

first and foremost a deep sense of commitment and responsibility to patients, colleagues, institutions, society, and self and an unfailing aspiration to perform better and achieve more.

 
The authors also recommended the use of social pedagogies as strategies for contextualizing educational environments in a community and called for “socially responsible physicianhood.” Yet, after decades of similar recommendations for reform in medical education, it seems that there has been no real or effective implementation. One possible reason may be medicine’s overwhelming reductionist and biomedical focus, with little attention to the broad range of social determinants that weigh so heavily on health out-comes.19 Martha Gaines, JD, described the reductionist phenomenon as the 20th century’s obsession with “thinking the world apart.” It’s time, Gaines argues, in “the 21st [century] [to start] thinking it back together again,” in a holistic manner.20 In other words, society can no longer be an afterthought in medical education and practice. 
A 2010 study21 brought much-needed attention to what is now an important direction for medical education. The authors ranked medical schools according to their commitment to a social mission as measured by criteria such as a focus on primary care, enrollment of underrepresented minorities, and turning out physicians who work in regions with a shortage of health care professionals.21 The study found that the higher the research funding level of an institution by the National Institutes of Health, the lower the primary care output. More importantly, it was found that 

[c]ompared with allopathic schools, osteopathic schools produced relatively more primary care [and] osteopathic schools continue to place substantially more graduates into primary care and marginally more graduates into underserved areas, suggesting that osteopathic medicine has continued to be influenced by its traditional focus on primary care and rural practice.21

 
The authors indicated that the best-prepared primary care physicians for underserved minority populations are those whose medical school had a strong social mission. 
To this effect, a cursory review of mission statements from osteopathic medical schools accredited by the Commission on Osteopathic College Accreditation22 revealed an expressed commitment to 1 or more of the following social accountability-related objectives: training physicians to be community responsive and in service to diverse populations; training physicians to work in rural and underserved communities; providing service to the state or region in which the school is located; focusing on primary care; providing patient-centered care; meeting societal needs; focusing on a holistic or mind-body-spirit approach to health care; training physicians to advocate for health care and to provide ethical care; and training under-represented minority students. The take-home message here is that osteopathic medical schools take seriously their social accountability, evidenced by the expressed curricular commitment to preparing future osteopathic physicians for addressing disparities in health, attention to diversity, community engagement, and interprofessional education. 
In the 2015 US News and World Report ranking of US medical schools that graduated the highest percentage of primary care residents, 7 of the top 10 and 13 of the top 25 were osteopathic medical schools.23 Michigan State University College of Osteopathic Medicine ranked first among all medical schools, with a 2011-2013 average of 78.9% of its graduates choosing primary care residencies. Of the 13 osteopathic medical schools in the top 25, all but 1 mentioned addressing societal health care needs. 
Conclusion
The osteopathic medical profession must lead the response to the call for social accountability in medicine by addressing and modeling it in osteopathic medical schools. The demonstrable effect of this leadership will be reflected through a continued commitment and implementation of specific indicators of social accountability. Since its inception, the osteopathic medical profession has established a strong track record for producing socially accountable primary care physicians committed to society’s health care needs. To ensure the trust of society in medicine, osteopathic medical schools must vigorously safeguard the osteopathic medical profession’s unequivocal commitment to producing healers committed to caring for patients, communities, and populations at large. 
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