Flexner, Educational Reform, Social Accountability and Meta-Curriculum

To the Editor: Frank Romanelli has written an important viewpoint titled, “Flexner, Educational Reform, and Pharmacy” that was published in the March 2017 issue of the Journal in which he points out that Flexner’s “relentless attention to task grounded in sound educational principles might still serve as a model to present day educators forced into the shoes of reformers.”¹ Romanelli also mentions that Flexner’s 1910 report “addressed almost every aspect of medical education from prerequisites to the education of women and minorities.” The intent of this letter is to expand on Romanelli’s commentary and speak directly to the issue of social mission in health professions education as described by the Beyond Flexner Alliance (BFA). One of the authors of this letter served as an investigator in the 2010 Beyond Flexner Study headed by Fitzhugh Mullan, chair of the BFA.

One of the unfortunate consequences of the Flexnarian revolution was the disproportionate closing of proprietary medical schools that served underrepresented populations such as African-Americans and women. Many of these schools could not meet the standards suggested by Flexner. Sadly, the result of the revolution, even 100 years post-Flexner, is that the health professions workforce is not representative of the population it serves. As Mullan states, “The vision laid down by Flexner was of educational and institutional improvement but was silent on issues of social reform or the role of health professions schools in addressing the manifest health inequities of the society in which they existed.”² An aim of the BFA is to forward “the contribution of the (health professions) school in its mission, programs, and the performance of its graduates, faculty and leadership in advancing health equity and addressing the health disparities of the society in which it exists.”³

Schools such as the University of Oklahoma’s School of Community Medicine in Tulsa and the Northern Ontario School of Medicine in Sudbury and Thunder Bay, Ontario, are highlighted in the Beyond Flexner Study as examples of schools that are not only teaching social accountability but also are producing a health professions workforce that resembles the population its graduates will serve. Central to the curriculum reform efforts in these schools included is a focus on social accountability by paying attention to the hidden and meta-curriculum. If generalized, these approaches could transform health care throughout the United States.

Several authors provide guidance on how to attend to hidden curriculum in reform efforts. Martimianakis and colleagues identified three distinct, yet related, thematic categories concerning discussions of hidden curriculum and humanism-based reform effort: the objectives of the reform efforts (eg, to increase humanism); the mode/format of the reform efforts; and “who”/”what” the reform efforts are targeting.⁴ Haidet and Stein suggest that attention to relationship-centered care based on the tenets of relationships in health care ought to include the personhood of the participants, affect and emotion are important components of relationships, and all health care relationships that occur in the context of reciprocal influence is necessary in humanistic curriculum reform efforts in that fostering improvement in relationships between teachers and students is central to the development of humanistic socially accountable practitioners.⁵

Boelen and Woollard argue that an association with excellence should be reserved for educational institutions which verify that their actions make a difference to people’s well-being. The graduates they produce should not only possess all the competencies desirable to provide quality, equitable, relevant and effective care to society, but should also use these tools in their professional practice. Further, they add that there is an urgent need to foster the adaptation of accreditation standards and norms that reflect social accountability and only then can educational institutions be measured and rewarded for their real capacity to meet the pressing health care needs of the society.⁶

Specifically, when addressing the social accountability meta-curricular message, Ritz, Beatty and Ellaway propose that moving social accountability to the forefront in curriculum reform is a multifaceted and ongoing process and it requires that we must reexamine ourselves constantly, acknowledging and critically analyzing our own power; and we must be willing to act and address injustice and appraise our impact in a material and substantive manner, not just in a cognitive and rhetorical one. For example, they suggest that advocacy would form an inherent part of any initiative to address the health needs of an underserved or under-represented population.⁷ Commenting on the Tulsa community, Clancy and Duffy point out that communities with health and health care deficiencies can take advantage of this current time of great change to advance community-wide health system transformations. They believe workforce training transformations can and should be paired with these health system changes.⁸ Duffy and colleagues, reporting on these efforts at the School of Community Medicine in Tulsa emphasize that it took a high level of university commitment to improve the health of the entire community by focusing its education, service, and research capabilities on the prevailing health inequities in the community. They highlight that culture change is hard (as does Romanelli in his first bullet point concerning curriculum reform) and that transforming the culture of a medical school to focus on health disparities and community medicine is daunting and requires strong leadership, planned experiential learning, action-based participatory research, and a deep immersion in the community. They also highlight the importance of inter-professional education as a critical success factor toward developing a culture of community medicine.⁹

In summary, Romanelli is correct in drawing attention to Flexner’s approach as we undertake curriculum reform in our schools and colleges of pharmacy. And, we must also pay attention to the hidden and meta-curricular issues that are essential to be built into curriculum reform efforts so that the social accountability issues that were, in part, created as a consequence of the Flexnerian revolution are properly addressed.

• © 2018 American Association of Colleges of Pharmacy