Racial and ethnic minorities continue to be subjected to a sustained pattern of disparate treatment in health care with no panacea for the confluence of contributing factors. In the 2003 provocative landmark report, Unequal Treatment; Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (IOM) exposed a painful truth about the health care system. When racial and ethnic minorities enter the clinical arena, they are less likely to receive routine medical procedures, appropriate cardiac medications, or essential clinical services. The differences in how minorities are treated in health care contribute to their higher rate of disability and mortality.
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Since the 2003 IOM report, the tendency for racial and ethnic minorities to receive an inferior level of care has not abated. A 2007 systematic review conducted by the Department of Veterans Affairs (VA) found that African American male veterans received less aggressive pain management for osteoarthritis, providers gave them less information about cancer, and clinical decision making varied based on the veteran’s race. More recently, the Agency for Healthcare Research and Quality revealed in the 2016 National Healthcare Quality and Disparities Report that “most disparities have not changed significantly for any racial and ethnic groups…especially among people in poor and low-income households, uninsured people, Hispanics, and Blacks.” Although the gap in health insurance coverage between minorities and whites has narrowed, differences have actually widened for quality indicators such as annual foot exams and prevention of lower extremity amputations among diabetics. Indeed, the persistence of health care disparities, which the Institute of Medicine defined as “differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness or intervention,” is alarming and depicts a dismal reality for ethnic and racial groups.

A medical school, by definition, is a professional school, preparing graduates for their future profession. What are we preparing graduates to do? As we debate the future of our health care system, we must decide if physicians are responsible for improving health in a broader sense, or only for diagnosing specific patient problems and prescribing treatments.
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Professions come with the expectation that you use your knowledge to improve people’s lives. Medical students prepare for clinical care, but do medical schools teach doctors to advocate for their patients holistically? Are doctors trained to meet the Triple Aim by promoting population health?

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.

As a safety net dentist, I’m sadly accustomed to my patients telling me that they are in pain. Even in Massachusetts, where most patients are insured and Medicaid provides dental coverage, the vast majority of my patients must wait unconscionably long to finally get a dental appointment, and often have not had reliable access to dental care. Yet the patient telling me this story wasn’t at a dental office – he was at a primary care visit with my preceptor, speaking to me as a first-year medical student.

​I chose to enter medical school because I was heartbroken by how the separation of medicine and dentistry harmed my patients. Throughout my medical training, I have only seen even more unaddressed dental need. I have met patients with endocarditis or pneumonia from untreated tooth infections, patients with malnutrition because they can no longer chew, and far too many patients with pain they simply cannot stop. This suffering falls disproportionately on the most vulnerable, including communities of color, older adults, low income people, people with a history of incarceration, people with mental illness or substance use disorder, and rural dwellers.

​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.

​Republicans and Democrats in Congress continue to battle over repealing the Affordable Care Act (ACA).  Whether ACA is carried out as planned or replaced with something entirely new, our physician workforce is unlikely ready to meet the changing healthcare needs of the nation. Shifts in demographics, the rise of chronic disease, and escalating health care costs are placing new demands on the knowledge and skills of our doctors.  Most American medical schools, however, continue to educate their student doctors in the same ways of decades past.The Association of American Medical Colleges predicts a shortage of 35,600 primary care doctors by 2025. We need more primary care physicians and a more diverse workforce, in cities as well as rural communities and formally designated health professional shortage areas.  We need a workforce that understands the importance of prevention and is judicious in its use of limited financial resources for health.Medical schools are a key part of the supply pipeline that can help meet the changing health demands of the American people, but are they aligned with the nation’s emerging healthcare needs?  Do they even consider themselves part of this essential pipeline?