Social Mission in Health Professions Education

Fitzhugh Mullan’s JAMA Viewpoint published this week is an essential document for the Beyond Flexner Alliance. It details why and how the Beyond Flexner movement has grown and why it is critical for health professions educators, leaders, learners, and community-based allies to join the BFA and move social mission to the top of the concerns and commitments of the health professions education community in the United States and elsewhere.

In May of 2012, 200 educators, policy makers, students, and community members met in Tulsa, Oklahoma in a conference entitled Beyond Flexner: The Social Mission of Medical Education. The previous two years had seen a growing discussion about the chronically weak focus on the social determinants of health in most medical schools and teaching hospitals. Fueled by a determination to provide more universal care and equipped with ever increasing documentation of disparities in health between rich and poor, urban and rural, insured and uninsured, etc., the participants in what is now called “Beyond Flexner 2012” wanted to see the educational system leading the movement for social mission by teaching it and practicing it.

The passion and resolve of that meeting led to two more Beyond Flexner meetings in 2015 and 2016 and the formation of a national organization -- The Beyond Flexner Alliance (BFA).  In that period, however, the vision of the movement expanded to include a strong commitment to interprofessionalism. The issues of inequity in health and health care were challenges for everyone in the healing arts.  Health disparities didn’t have boundaries called medicine or nursing or dentistry that made social mission more important for some professions and less for others. In fact, collaborative initiatives seemed to promise better and quicker prospects for disparity reduction in the population as a whole. Certainly the adoption of a common concern with the teaching and role modeling of social mission throughout health professions education promised a stronger and united front against ubiquitous health inequities and spotty focus on the part of teaching institutions. 
 
The name “Beyond Flexner” was chosen for the meetings and the new organization because Abraham Flexner and his 1910 report on the state of medical education in the country, in many ways, established the direction for health professions education for the 20th century. Not only were his views on the shortcomings of medical education strong and influential, but his work and perspectives stimulated the Rockefeller Foundation to sponsor the Welch-Rose Report of 1915 on public health education and the Goldmark Report of 1923 on nursing education. Flexner was involved in overseeing both of these studies.

All three reports drew similar conclusions about the deficiencies of instruction in the respective professions. They all recommended elevating requirements for admission, standardizing the curriculum, and promoting more rigorous teaching. All presumed the central role of the teaching institution (the university in the case of medicine and public health and the hospital in the case of nursing) in the improvement of health professions education and, eventually, practice. The vision laid down by Flexner and colleagues was one of educational and institutional improvement but was virtually silent on issues of social reform and the role of health professions schools in addressing the manifest inequities and social ills of the society in which they existed.

While Flexner can be properly praised for his emphasis on scientific rigor and pedagogic excellence, his absence of attention to the role of health professional schools as important potential agents of change and improvement in population health make his legacy problematic for the 21st century. Inequities in health care and health outcomes within and between populations are dramatic all over the world and stand as our most urgent local and global challenge in health. It is time to salute Flexner’s contributions to quality improvement in health science education but to move beyond Flexner to put social mission on a par with basic and clinical education in health professions education and training.

The Beyond Flexner Alliance