Bianca Quintella Ribeiro Corrêa Amaro
Universidade Federal de Roraima
Places that need doctors the most are the ones with the least infrastructure, the poorest populations, most difficult access, lowest level of education and littlest professional growth opportunities. Medical doctors, on the other hand, are encouraged to pursue career goals and to keep on their studies, becoming state-of-the-art specialists. That is one of the causes for the phenomenon we know as brain drain, the immigration of physicians to developed places, leaving places in need uncovered. This phenomenon may go against a growing concept of medical education: social accountability – which might be the key to reach Universal Health Coverage (UHC); nevertheless, a powerful way of reaching an educational process that is transformative enough to diminish the brain drain and leave doctors where society needs them the most is by adopting Meaningful Student Involvement (MSI). MSI empowers students and gives them the tools to take the lead of their own educational processes. Thus, those will become doctors who have the ability to work as health advocates, especially in primary healthcare (PHC), where most of health issues and prevention processes should be addressed and where health education should come from. Therefore, promoting curricular changes to address reflections towards social accountability and letting students be their own leaders through this process is a powerful tool towards the revolution that PHC needs in order to reach UHC. Changing the mindset of doctors permanently starts by medical education.
Globalization brought more information about inequity. Currently, worldwide richness is about 24 trillions of dollars annually and counting – meanwhile, about 1,2 billion people live with less than a dollar per day and half of the world’s inhabitants live with less than 2. Nevertheless, poverty is also linked to people’s access to healthcare, nutrition and education: the people who are closest to extreme poverty are usually the ones who have the worst sanitary, social and environmental conditions, generating health inequities.
The difference in life expectancy rates reaches 27 years among the poorest and richest countries. Child mortality rates may reach 100 per thousand living-born in poor countries and remain about 6 per thousand living-born in wealthy countries. Within the same country, as well, inequities can be strong, when comparing the wealthy and the poor, with big differences in health indicators such as malnourishment and child mortality. As a parallel, the brain drain phenomenon is making the world face a shortage of doctors even though the number of medical schools is raising. The european continent had an increase of 5% in its physician supply between 2010 and 2020, but Romania’s public healthcare system lost 5 thousand doctors in the past 20 years and Europe could be facing a shortage of doctors that could leave 13,5% of the continent’s healthcare needs unsupported. Countries such as Latvia and Estonia have low amounts of doctors because theirs frequently settle in Germany, Scandinavia or the UK. Being Europe the wealthiest continent in the world, one can imagine how the situation goes for other continents, such as Africa or the Americas.
Meanwhile, WHO started to spread the concept of social accountability as “the obligation [of medical schools] to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve”. It turns out that each medical school must serve their own community’s needs and therefore it needs to acknowledge what is the community they serve. In the extreme north of Brazil, the state of Roraima, which holds over 20 different indigenous ethnicities, started to separate admission tests in medical schools only for indigenous people, in order to, afterwards, have them go back to their home places and bring healthcare – that is known as the hypothesis of the homecoming salmon, which has also been adopted by the University of Tromso, Norway. In the Brazilian Amazon, a public university implanted rural internship as an obligation and became the university that most depolarizes doctors in the country.
The WFME Basic Medical Education (BME) Standards settle items that must be accomplished by medical schools in their will to serve communities, with recommendations or enhancement. This document was basis for settling accreditation standards, which are useful for making sure universities meet minimal parameters of quality, and has spread around the world in a movement towards homogenization of quality but respecting regional differences. The concept of social accountability can be now found in many documents through the world and has been the key to changing curricula in many countries, despite the ghost of Flexnerian education.
Even though all of that happened, one thing may have remained the same: the teaching without critical sense for students. Medical schools throughout the world are familiar with every publication and initiative, set ground for research, advance in science… but won’t let students take the lead upon their own education. It is generational science: millennials wish to be recognized and respected for who they are. Therefore, having students raising awareness and stepping up for what they believe in may be the way to help millennials develop as professionals and become the leaders we need towards the healthcare crisis. In that context, the concept of MSI must be taken into consideration. The author brings up a “ladder” for MSI, in which the highest level of involvement is to have student initiatives, but shared decision making between students and teachers – student-adult partnerships. Put into perspective, student-adult partnerships are also part of the social accountability pentagon, in which academic institutions partner up with health professionals, communities, health administrators and policy makers to build a healthcare system based upon people’s needs.
When a healthcare system is based upon people’s needs, it is socially accountable. When students know this needs to happen in order to enhance healthcare and healthcare access, they tend to become more socially accountable and perform their actions and decision-making with that in mind. Moving towards universal access to health must be achieved in three different ways: physical access, financial affordability and patient acceptability. This means that health services should be accessible in their opening hours, appointment systems and organization, as well as be paid for without financial hardship (which includes the costs of transportation, for example). Also, people should feel comfortable when seeking services – acceptability lowers when services are ineffective and/or cultural factors (language, ethnicity, religion) of the health providers become a barrier.
Healthcare access is the way to reach universal health coverage (UHC), but we are still far: 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on healthcare. Less than 40% of primary healthcare investments come from governments. As physicians, we must acknowledge how wide the range of healthcare is and be involved in every step we can to make sure we are the best possible health advocates. In that context, the Royal College of Physicians and Surgeons of Canada developed a competency framework for excellence training of medical students, the CanMEDS. In that framework, physicians have 7 roles: communicator, collaborator, leader, health advocate, scholar, professional and the last in the center, to integrate, as a medical expert. The medical expert is the person who provides high quality and patient-centered healthcare. The leader is the doctor who contributes to the vision of a high-quality healthcare system and, among other things, performs activities as administrator of the system. The health advocate must “respond to the needs of the communities or populations they serve by advocating with them for system-level change in a socially accountable manner”. Although the CanMEDS framework became the most acceptable of its kind in the world, it’s not widely taught to students around the globe.
The teaching of Medical Education science is not one of the BME Standards. Nevertheless, maybe it should. It promotes critical sense among students about their own education and makes them more enrolled. Also, with the growing number of medical students despite the shortage of healthcare professionals, maybe the most powerful way to address the change in doctor’s mindsets is to share responsibility between students and teachers. If curricular change included the involvement of students in the science of medical education, it could increase respect for professors, levels of engagement and help raise the number of professors in the future, since students have contact with all specialties but never get to see the beauty behind the academic part other than research.
Students must be involved in their educational processes not only scientifically, participating in active methodologies or in decisions towards the University, but also discovering for themselves what is behind that science. Meaningful student involvement could create more socially accountable physicians and citizens, able to fight harder for transformative public policies or even become the authorities to promulgate them. More socially accountable physicians could make significant changes in PHC, working with health protection, promotion and prevention and tackling the true gaps in healthcare coverage. They could be the ones to really widen access to healthcare, and, in that way, help reach UHC.
Universal health coverage [Internet]. [citado 25 de janeiro de 2020]. Disponível em: https://www.who.int/westernpacific/health-topics/universal-health-coverage
Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. Bull World Health Organ. agosto de 2013;91:546-546A.
The royal college of physicians and surgeons of canada :: canmeds role: health advocate [Internet]. [citado 25 de janeiro de 2020]. Disponível em: http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-health-advocate-e
Frameworks for meaningful student involvement – soundout [Internet]. [citado 25 de janeiro de 2020]. Disponível em: https://soundout.org/resources/meaningful-student-involvement/
Defining social accountability [Internet]. Social Accountability and Community Engagement Office. [citado 25 de janeiro de 2020]. Disponível em: https://www.mcgill.ca/med-saceoffice/about/social-accountability-statement/defining-social-accountability
Sen A. Development as freedom. 1. Anchor Books ed. New York: Anchor Books; 2000. 366 p.
The PLoS Medicine Editors. Thirty ways to improve the health of the world’s poorest people. PLoS Med. 23 de outubro de 2007;4(10):e310.
Pagliosa FL, Da Ros MA. O relatório Flexner: para o bem e para o mal. Revista Brasileira de Educação Médica. dezembro de 2008;32(4):492–9.
WHO | Universal health coverage and universal access [Internet]. WHO. [citado 25 de janeiro de 2020]. Disponível em: https://www.who.int/bulletin/volumes/91/8/13-125450/en/