#KeyLIMEPodcast 288: Social Accountability, #MedEd, and Unicorns (aka Boelen’s Greatest Hits)

Jason presents a paper on social accountability of institutions. In this narrative review, the authors set out to identify “common themes and indicators” across “large scale social accountability frameworks”.  How does your institution match up?

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KeyLIME Session 288

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Barber et. al., Social Accountability Frameworks and Their Implications for Medical Education and Program Evaluation: A Narrative Review. Academic Medicine (online ahead of print)


Jason R. Frank (@drjfrank)


Whose schools is more socially accountable, mine or yours? How would you know? Why do we care?

We live strange times in which global societies seem obsessed with both the absolute need to hold individuals and institutions accountable, while at the same time not really doing much of that.

However, the conversation in health professions education is a much longer one, perhaps going back millennia, depending how you define it. The idea that medical schools and academic health centres exist not for their own sake but to serve populations is as old as their founding. Talking about ensuring alignment is very much a discourse that grew in the 20th century and continues. You will find it packaged under several guises, including “quality”, “scientific”, “community-oriented”, “societal value”, and “socially responsive”. The term most used in the last 30 years is “socially accountable”.

Social accountability (SA) is a #meded “god term”, to borrow Lorelei Lingard’s rhetoric about MedEd rhetoric.  SA implies that our MedEd institutions have commitments and obligations in return to the resources and privileges given in a kind of “social contract”. SA is a term used A LOT at conferences and meetings to justify numerous policies and egos.

The problem is, what is SA anyway? And if you saw it, could you measure it? Would that help?


Enter Barber and 3 luminaries in MedEd (van der Vleuten, Leppink, and Chahine). In this Academic Medicine paper ahead-of-print, the authors set out to conduct a narrative review to identify “common themes and indicators” across “large scale social accountability frameworks”.

They are inspired by the writings of Boelen (2016) from the WHO famously said “…only 1% of medical schools are socially accountable, whereas 9% of medical schools are socially responsive, and 90% are socially responsible…”

Key Points on the Methods

The authors searched for social accountability frameworks to analyze using a predefined strategy applied to PubMed, Embase, ERIC, Web of Science, Google Scholar, and Google. They limited content to English documents since 1990 and only kept policy frameworks relating to social accountability and #meded. They don’t provide any detail in the main body of the article about how limited Google Scholar or Google. They are also vague about what exactly a “social accountability framework” is. They said they excluded anything that was a “sub framework” or derivative. 2 authors screened items and all authors met to include by consensus.

Analysis was thematic in stages: coding of text, identifying descriptive themes, and then analytical themes. They then mapped themes to the CIPP (context-input-process-product) program evaluation model, which they justified as a model used for program accountability and improvement.

Overall, the analysis was fairly standard. The methods would have benefited from clarity of the search, definitions, and inclusion, and rationale for CIPP.

Key Outcomes

33 documents were identified in the search and 4 were selected as “key large-scale social accountability policy frameworks”. The authors state that these 4 represent the “foundational values, principles, and/or parameters of social accountability in medical education”. All were the basis of later work.

These documents espoused some key content:

  1. Responding to local health needs
  2. Working with stakeholders
  3. Serving communities
  4. Increasing diversity of a workforce
  5. Addressing workforce shortages
  6. Ensuring competent graduates
  7. Ensuring curriculum reflects priority health needs.

All 4 frameworks were derived from 5 common core social values based on WHO work in the 1990s:

  1. Relevance
  2. Quality
  3. Effectiveness, and
  4. Equity.

The authors identified 6 themes and related indicators using CIPP:

  1. Context = objectives (e.g. community partnerships)
  2. Inputs = actions taken to achieve goals (e.g. diversity in admissions)
  3. Processes = activities and curriculum (e.g. community placements)
  4. Products = institutional outputs, outcomes, and impacts on societal health (e.g. number of doctors/region).

The 4 key frameworks were all inter-related and refer to the work of Charles Boelen:

  1. WHO 1995: Defining and Measuring the Social Accountability of Medical Schools
  2. Health Canada 2001: Social Accountability: A Vision for Canadian Medical Schools
  3. 2009: Social Accountability and Accreditation (aka CPU model)
  4. 2010: Global Consensus for Social Accountability of Medical Schools.

Key Conclusions

The authors conclude that these frameworks provide the basis of indicators that can be used to measure the degree of social accountability of medical schools.

Spare Keys – other take home points for clinician educators

  1. All health professions exist to serve, and our institutions must be oriented to the needs of the communities we are dedicated to. This makes this topic of social accountability important. It should be a “true north” for #meded, but often is not.
  2. It is curious to limit discussion to 4 Boelen-derived documents, when hundreds of institutions of all kinds have tried to articulate their own interpretation and application of SA.
  3. Should we measure big fundamental ideas like SA? Or would we fall into some kind of trap related to Goodhart’s law (“when a measure becomes a target, it ceases to be a good measure”)?
  4. When describing a search strategy using Google, it is good to elaborate on how you used the web. There are standard approaches to this.
  5. A rich, forgotten, hard to find resource on this topic is a 1990s Springer book: White & Connelly’s The Medical School’s Mission and the Population’s Health. Ahead of its time.

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