The Beyond Flexner Alliance community is deeply heartbroken by the loss of George Floyd, Tony McDade, Ahmaud Arbery, and Breonna Taylor – and so many others in America’s black communities - who have suffered discrimination and inexcusable losses because of racism, violence and injustice. Racism pervades all sectors of society. Healthcare and education is no exception. The Beyond Flexner Alliance is built on the principle of dismantling racism and injustices in health professions education, health systems, and society. We are committed to continuing our work to integrate anti-racist curricula; support and advance health workforce diversity; and provide multidimensional, sustained professional learning experiences for providers, educators, and administrators that advance the health of all racial and ethnic groups. Let us highlight the final words of the Beyond Flexner Alliance’s founder, Dr. Fitzhugh Mullan, as he reflected on his life as a civil rights doctor and the need for medical schools – and all health professions schools – to reform.
 
"The civil rights doctor and many others have spent careers in pursuit of what we now call health equity, but the world has not moved as far as he would have wanted. Racism is still very much with us, as are massive and growing disparities in health and wealth. These disheartening realities account for tens of thousands of deaths and uncounted days of unnecessary pain and suffering every year. The civil rights doctor’s mission turned out to be changing the culture of medicine, making the idea of health equity central to the character of medicine, and positioning medicine as an agent of social as well as individual healing. Choices physicians make about where and how to practice can bring more compassion to the system but, ultimately, it is the U.S. medical education community that can do the most. Large, resourceful, and distributed, the nation’s medical schools and teaching hospitals have early and strong leverage to change the culture of medicine. The civil rights doctor may have worked hard and with purpose but it is only with a forceful, enduring, and community-wide commitment to social mission that medical education will realize its full 21st century capabilities to build a healing profession."
 
Fitzhugh Mullan, MD
The Civil Rights Doctor Revisited (Dec. 17, 2019). Academic Medicine
 

As federal officials determine when and how to reopen the country, numerous public health experts fear that the United States is significantly short of the public health workers needed to mitigate another occurrence and properly perform contract tracing. 

On April 8, 2020 JAMA published an editorial co-authored by Dr. Josh Sharfstein and Dr. Howard Bauchner proposing a public health response to the COVID-19 pandemic by electively suspending medical education for the medical students of the class of 2024 and implementing a National Service Program for interdisciplinary graduate students. 

Dr. Jamar Slocum, on behalf of the Beyond Flexner Alliance, recently sat down with Dr. Josh Sharfstein, to discuss his recent editorial and its impact on medical education. Dr. Sharfstein is the current Vice Dean for Public Health Practice and Community Engagement for the Bloomberg School of Public Health and Director of the Bloomberg American Health Initiative. He previously served as Principal Deputy Commissioner of the U.S. Food and Drug Administration, Commissioner of Health for Baltimore City, and health policy advisor for Congressman Henry A. Waxman.
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This discussion has been edited for length and clarity. 

Medical Schools Do Need an Overhaul. Doctors need to be trained in public health, health equity, and social justice.

COVID-19 is laying bare society’s underlying structural inequities that increase the risk of exposure, infection, and death for minority and disadvantaged communities across the US. The pandemic is also disproportionately affecting healthcare workers, who continue to work despite insufficient personal protective equipment and further, face disciplinary actions for speaking out.
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Despite these realities, Dr. Stanley Goldfarb in his April 13 commentary suggests “doctors should be trained in pandemics, not injustice,” and that “the medical profession should abandon the fantasy that physicians can be trained to solve the problems of poverty, food insecurity and racism.” Clinical care is estimated to account for only 10-20% of what ultimately impacts health outcomes. Social determinants of health – health behaviors, social and economic factors, and the physical environment – account for the other 80-90% (National Academy of Medicine). The attitude that physicians should focus solely on clinical care aims to disempower the profession and frankly, is dangerous.

My new patient sat in the clinic waiting room with a bandana covering his face, but when he turned, the cloth slipped and revealed the purple splotches. It was the early years of AIDS and I knew that I had no medicines to prescribe for his Kaposi’s sarcoma and little that would change the course of his fatal illness. But he taught me that there was much more than that to caring—he needed help with getting food and paying his rent, he wanted to find other patients with whom he could talk about HIV, and he wanted someone to fight for better policies to address the spreading epidemic. His requests taught me about the social mission that is such a critical part of being a health professional truly committed to healing.
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Thirty years later, the Josiah Macy Jr. Foundation has stepped up to sponsor a special awards program dedicated to celebrating leaders who have advanced the social mission of our profession. Joining forces with the Beyond Flexner Alliance, the Macy Foundation’s Awards for Excellence in Social Mission in Health Professions Education provide each of us the opportunity to recognize the work of our colleagues who are at the forefront of advancing social mission in health professions education. Social mission is defined as activities that teach, model, or improve community engagement, diversity, health equity, disparities reduction, value-based care, or engagement with the social determinants of health. The winners are recognized at an inspiring event at the Beyond Flexner Alliance Conference which includes a video of each winner’s accomplishments.

This blog was originally posted in the Josiah Macy Jr. Foundation Fall Newsletter on November 13, 2017.

Morehouse School of Medicine (MSM) was the first institution to receive the Josiah Macy Jr. Foundation Award for Institutional Excellence in Social Mission. We spoke with Valerie Montgomery Rice, MD, president and dean, to learn more about her institution’s efforts. 
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In your opinion, what does it truly mean when a school has a strong social mission?

I think about that question all the time. For me, when a school has a strong social mission it is leading the creation and advancement of health equity. I’ve boiled that down to mean giving people what they need, when they need it, and where they need it.

It goes beyond making sure our students have core medical knowledge. It is about ensuring our future clinicians understand the basic needs of the individual, the community, and the entire population. That means considering whether a patient can afford his or her co-pay, to understanding the barriers patients face with adequate housing, access to transportation and the ability to purchase fresh fruits and vegetables. These social factors are often the greatest barriers to people being able to reach their optimal health. If a school has a strong social mission, it is embedding these health equity themes into all of its education and training.

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”(1), Fitzhugh Mullan argues that medical schools should be committed to their social mission, which is “…about making health not only better but fairer—more just, reliable, and universal”. This means commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, and increasing diversity within the health professions. He cites some medical schools as having made significant advances, including Morehouse, Mercer, Florida International University, and the AT Still Mesa Campus. But he also talks about “mainstreaming”, the need for consciousness about, and more important implementation of, social mission in all medical schools.

I believe that the most important measures of a health professions school’s social mission are its outputs, the criteria used by Mullan and colleagues in their seminal 2010 article (2): Are its graduates diverse? Do they practice more in underserved areas? Are they in primary care specialties? Studies show that a well-functioning health system needs at least 40-50% of physicians in primary care; the US is well below 30% and decreasing.

​In today’s complex health care environment, given that stakeholders and policy experts commonly expect demonstrable evidence of quality, accountability and improvement, measurement has become an integral part of doing business. Now that social mission has been identified as part of the mission of health professions education, there is a desire to obtain and quantify data to advance health equity and reduce health disparities. The measurement of social mission performance in health professions schools is nascent. Various organizations such as THEnet and ASPIRE have pioneered the development of measurement tools. There is promising consistency in the philosophies that govern the measurement tools of these two organizations and leadership at schools using these tools have described great benefits in going through the assessment process. However, usage has been mostly limited to medical schools rather than health professions schools in general, and the tools themselves are primarily targeted to schools looking to excel in social mission, rather than all comers.