Social Accountability Mandate Research Articles

Medical learner perspectives on elements of an educational rural generalist pathway: survey outcomes

IntroductionThe Northern Ontario School of Medicine University (NOSM U) continues to be challenged in meeting its social accountability mandate of addressing the rural health human resource crises in its catchment of Northern Ontario. Its new educational initiative, the Rural Generalist Pathway (RGP) aims to graduate family physicians specifically prepared for rural practice. This study elicits the perspective of NOSM U learners on the various components being considered for this educational pathway.MethodsA mixed methods survey was created for each of two medical learner groups, undergraduate NOSM U students and its family medicine residents. Quantitative data was analyzed for frequencies and percentages and qualitative data underwent thematic analysis.ResultsWith a response rate of 24.6% for undergraduates and 37.9% for residents, the survey discovered undergraduates consider rural clinical rotations as the most valuable experiences in rural medicine. Among the findings, both the majority of medical students and residents (87.3% and 87.9% respectively) agreed that support for a resident’s family well-being and community integration was the element of the pathway most likely to influence them in pursuing the RGP. Mentorship by a practicing rural physician was an element highly supported by 81% of undergraduate and 81.8% of postgraduate learners as likely to influence them to take the RGP.DiscussionIncorporating learner perceptions into the development of the RGP could help focus institutional resources and enhance learner participation in this pathway, producing more rural family doctors to serve Northern Ontario.

Operation Remote Immunity: exploring the impact of a service-learning elective in remote Indigenous communities

BackgroundThe novel coronavirus, COVID-19, emerged in December 2019. Shortly after, vaccines against the virus were distributed in Canada for public use, but the remoteness of many northern Indigenous communities in Ontario posed a challenge for vaccine distribution and dissemination. The Ministry of Health partnered with the Northern Ontario School of Medicine University (NOSMU) and the air ambulance service, Ornge, to assist in delivering the vaccination doses to 31 fly-in communities in the Nishnawbe Aski Nation and Moosonee, all within Ontario. These deployments were considered “service-learning electives” for Undergraduate and Postgraduate medical learners from NOSMU who joined the operation in two-week deployments. NOSMU is renowned for its social accountability mandate and gives its medical learners opportunities to participate in service-learning to enhance their medical skills and cultural sensitivity. The purpose of this study is to examine the relationship between social accountability and medical learners’ experiences during a service-learning elective in northern Indigenous communities in Ontario during the COVID-19 pandemic.MethodsData were collected through a planned post-placement activity completed by eighteen Undergraduate and Postgraduate medical learners, who participated in the vaccine deployment. The activity consisted of a 500-word reflective response passage. Thematic analysis was used to identify, analyze, and report the themes within the collected data.ResultsTwo themes were identified by the authors, which formed a concise overview of the collected data: (1) confronting the realities of working in Indigenous communities; and (2) service-learning as a path to social accountability.ConclusionsThese vaccine deployments were an opportunity for medical learners to engage in service-learning and engage with Indigenous communities in Northern Ontario. Service-learning is an exceptional method which provides an opportunity to expand knowledge on the social determinants of health, social justice, and social accountability. The medical learners in this study reiterated the idea that learning medicine through a service-learning model leads to a greater depth of knowledge on Indigenous health and culture, and enhances medical knowledge compared to classroom learning.

Embedding social accountability in the medical school and its curricula: Patan Academy of Health Sciences, Nepal

Introduction: Patan Academy of Health Sciences (PAHS) was established in 2008 with a social accountability mandate and the mission to produce competent and committed health professionals to serve the rural and underserved population. Enrolment of undergraduate medical students started from 2010. This article describes the context and process for the establishment of the Academy, the approaches taken and some of the early outputs.
 Method: The information was collected from the policy documents, PAHS website, meeting minutes/ discussions, feedbacks and medial school records. All the information were compiled and presented under different headings/subheadings in a phase wise manner.
 Result: PAHS has been actively engaged in a multitude of partnerships from local to global and has chosen the best and most applicable innovations from around the world. The integrated suite of innovations the Academy has developed includes its admission policy, teaching-learning methodologies, community-based learning, scholarship-schemes and service bonds. The PAHS School of Medicine has successfully enrolled undergraduate medical students from all over the country, representing ethnic diversity, remote/rural background, underprivileged communities and gender balance. More than 50% graduates from the first five-batches are successfully deployed into primary level peripheral health facilities of the government health system.
 Conclusion: The initial reports and observations confirm that the integrated measures taken by the Academy have been effective in enrolling the right students, educating them in an effective way and deploying them to address the country's need. A longer follow-up on rural retention and performance evaluation is needed to conclusively establish the outcome of the school.

Key drivers of social accountability in nine Canadian medical schools*

A social accountability mandate for Canadian medical schools formally emerged in Canada with changes to accreditation standards in 2015. However, how social accountability is defined and operationalized within medical schools has transpired independently. Key enablers of social accountability in Canadian medical schools have been largely unexplored. This paper is the first of a two part series that seeks to explore drivers of social accountability in a sample of Canadian medical schools. Nine key drivers of social accountability emerged from the data including a unified vision, committed leadership, accreditation standards, champions of social accountability, authentic community engagement, community-based learning opportunities, a supportive organizational and governance structure, diversity within medical schools, and measurement of progress and outcomes. This is the first study of its kind to examine what is driving social accountability across Canadian medical schools. An appreciative inquiry approach highlights areas of progress for future work to focus and build upon. This paper presents the findings from part one of the study – exploring the themes emerging from key informant interviews with senior leaders. A second paper will dive into the broader perspectives of faculty, staff and students, to explore more fully the varying perspectives of social accountability within colleges.

Training a Fit-For-Purpose Rural Health Workforce for Low- and Middle-Income Countries (LMICs): How Do Drivers and Enablers of Rural Practice Intention Differ Between Learners From LMICs and High Income Countries?

Equity in health outcomes for rural and remote populations in low- and middle-income countries (LMICs) is limited by a range of socio-economic, cultural and environmental determinants of health. Health professional education that is sensitive to local population needs and that attends to all elements of the rural pathway is vital to increase the proportion of the health workforce that practices in underserved rural and remote areas. The Training for Health Equity Network (THEnet) is a community-of-practice of 13 health professional education institutions with a focus on delivering socially accountable education to produce a fit-for-purpose health workforce. The THEnet Graduate Outcome Study is an international prospective cohort study with more than 6,000 learners from nine health professional schools in seven countries (including four LMICs; the Philippines, Sudan, South Africa and Nepal). Surveys of learners are administered at entry to and exit from medical school, and at years 1, 4, 7, and 10 thereafter. The association of learners' intention to practice in rural and other underserved areas, and a range of individual and institutional level variables at two time points—entry to and exit from the medical program, are examined and compared between country income settings. These findings are then triangulated with a sociocultural exploration of the structural relationships between educational and health service delivery ministries in each setting, status of postgraduate training for primary care, and current policy settings. This analysis confirmed the association of rural background with intention to practice in rural areas at both entry and exit. Intention to work abroad was greater for learners at entry, with a significant shift to an intention to work in-country for learners with entry and exit data. Learners at exit were more likely to intend a career in generalist disciplines than those at entry however lack of health policy and unclear career pathways limits the effectiveness of educational strategies in LMICs. This multi-national study of learners from medical schools with a social accountability mandate confirms that it is possible to produce a health workforce with a strong intent to practice in rural areas through attention to all aspects of the rural pathway.

University of Alberta Faculty of Medicine and Dentistry.

University of Alberta Faculty of Medicine and Dentistry.

Development of aCanMEDS-based instrument for evaluating medical students' perceptions of the key competencies of asocially accountable healthcare practitioner.

IntroductionNumerous frameworks and tools have been developed to assist medical schools striving to achieve their social accountability mandate. The purpose of this study was to design an instrument to evaluate medical students’ perceptions of the key competencies of a ‘socially accountable’ healthcare practitioner using widely accepted frameworks which contain clear measurable outcomes.MethodsThe instrument was designed in three phases: selection of a competency-based framework, development of items, and validation of the instrument through exploratory factor analysis. Medical students in the 6‑year medical degree program at the University of Cape Town, South Africa were invited to participate in the study. Descriptive and inferential statistical analysis was performed using Stata/SE version 13.1.ResultsOf 619 students invited to participate in the study, 484 (78%) responded. The CanMEDS framework was selected for designing the instrument, which comprised 35 statements reflecting five competencies for each CanMEDS role. Exploratory factor analysis of the student responses yielded a 28-item instrument. There was a significant difference in overall Perceptions of Social Accountability Instrument (PSAI) scores between men and women (p = 0.002) but no significant difference between the overall PSAI scores for students in the respective years of study.DiscussionThis study describes the design of an instrument to evaluate medical students’ perceptions of the essential competencies of socially accountable healthcare practitioners. Used longitudinally, the data may provide evidence of the successes of our programs and identify areas where further improvements are required.Electronic supplementary materialThe online version of this article (10.1007/s40037-020-00564-6) contains supplementary material, which is available to authorized users.

Practice intentions at entry to and exit from medical schools aspiring to social accountability: findings from the Training for Health Equity Network Graduate Outcome Study

BackgroundUnderstanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions.MethodsThe Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet’s Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent.ResultsFindings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds.ConclusionsThese findings, from a diverse range of schools with social accountability mandates in different settings, provide preliminary evidence for the selection and training of a medical workforce motivated to meet the needs of underserved populations. These respondents are being followed longitudinally to determine the degree to which these intentions translate into actual practice.

Work settings of the first seven cohorts of James Cook University Bachelor of Medicine, Bachelor of Surgery graduates: Meeting a social accountability mandate through contribution to the public sector and Indigenous health services.

The James Cook University medical school's mission is to produce a workforce appropriate for the health needs of northern Australia. James Cook University medical graduate data were obtained via cross-sectional survey of 180 early-career James Cook University medical graduates from 2005-2011 (response rate of 180/298 contactable graduates = 60%). Australian medical practitioner data for 2005-2009 graduates were obtained via the 2015 'Medicine in Australia: Balancing Employment and Life' wave 8 dataset. Comparison of the range of work settings and hours worked by James Cook University medical graduates to Australian medical graduates. Compared to a similar group of Australian medical graduates, James Cook University Bachelor of Medicine, Bachelor of Surgery graduates are significantly more likely to work in government-funded 'public' organisations (hospitals, community health centres, Aboriginal Community Controlled Health Services, government departments, agencies or defence forces). In particular, James Cook University medical graduates were more likely to work in Aboriginal Community Controlled Health Services and community health centres and other state-run primary health care organisations than other Australian medical graduates. James Cook University medical graduates appear to work in a higher proportion of public settings; in particular, primary care settings, than Australian medical graduates. This is an appropriate mix for the predominantly rural and remote geography of Queensland and its associated medical workforce priorities. Reporting medical graduate outcomes by their nature of practice could be an important adjunct to other measures, such as geographic location and choice of specialty.

Enhancing Indigenous health research capacity in northern Ontario through distributed community engaged medical education at NOSM: A qualitative evaluation of the community engagement through research pilot program

The Community Engagement Through Research (CETR) program matches Indigenous communities interested in exploring their own health research questions with NOSM learners seeking experience in health services research, supervised by faculty experienced in community-based participatory research. Qualitative research was conducted using key informant interviews to examine outcomes of the matching of medical students with Indigenous distributed medical education (DME) communities in NOSM's distributed curriculum, in particular improvements for capacity for Indigenous health research in Northern Ontario. Interviews showed that community-centred research was appreciated by community, students and faculty and the social accountability aspect was acknowledged. Students and community members found meaning in the immediate applicability of the research to real community problems and felt inspired by it. The challenges that were identified were mainly related to time and resource constraints, including providing sufficient research training for learners, and the time period required for research ethics board approvals. The program successfully brought together communities interested in conducting their own health research, with medical students interested in learning about and conducting health research with Indigenous communities. It is therefore an example of successful community based participatory research supporting the social accountability mandate. Challenges are mainly administrative in nature. The program has the potential to be scalable and financially sustainable.

Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes.

Rural recruitment and retention of physicians is a global issue. The Faculty of Medicine at Memorial University of Newfoundland, Canada, was established as a rural-focused medical school with a social accountability mandate that aimed to meet the healthcare needs of a sparse population distributed over a large landmass as well as the needs of other rural and remote areas of Canada. This study aimed to assess whether Memorial medical degree (MD) and postgraduate (PG) programs were effective at producing physicians for their province and rural physicians for Canada compared with other Canadian medical schools. This retrospective cohort study included medical school graduates who completed their PG training between 2004 and 2013 in Canada. Practice locations of study subjects were georeferenced and assigned to three geographic classes: Large Urban; Small City/Town; and Rural. Analyses were performed at two levels. (1) Provincial level analysis compared Memorial PG graduates practicing where they received their MD and/or PG training with other medical schools who are the only medical school in their province (n=4). (2) National-level analysis compared Memorial PG graduates practicing in rural Canada with all other Canadian medical schools (n=16). Descriptive and bivariate analyses were performed. Overall, 18 766 physicians practicing in Canada completed Canadian PG training (2004-2013), and of those, 8091 (43%) completed Family Medicine (FM) training. Of all physicians completing Canadian PG training, 1254 (7%) physicians were practicing rurally and of those, 1076 were family physicians. There were 379 Memorial PG graduates and of those, 208 (55%) completed FM training and 72 (19%) were practicing rurally, and of those practicing rurally, 56 were family physicians. At the national level, the percentage of all Memorial PG graduates (19.0%) and FM PG graduates (26.9%) practicing rurally was significantly better than the national average for PG (6.4%, p<0.000) and FM (12.9%, p<0.000). Among 391 physicians practicing in Newfoundland and Labrador (NL), 257 (65.7%) were Memorial PG graduates and 247 (63.2%) were Memorial MD graduates. Of the 163 FM graduates, 148 (90.8%) were Memorial FM graduates and 118 (72.4%) were Memorial MD graduates. Of the 68 in rural practice, 51 (75.0%) were Memorial PG graduates and 31 (45.6%) were Memorial MD graduates. Of the 41 FM graduates in rural practice, 39 (95.1%) were Memorial FM graduates and 22 (53.7%) were Memorial MD graduates. Two-sample proportion tests demonstrated Memorial University provided a larger proportion of its provincial physician resource supply than the other four single provincial medical schools, by medical school MD for FM (72.4% vs 44.3%, p<0.000) and for overall (63.2% vs 43.5% p<0.000), and by medical school PG for FM (90.8 % vs 72.0%, p<0.000). This study found Memorial University graduates were more likely to establish practice in rural areas compared with the national average for most program types as well as more likely to establish practice in NL compared with other single medical schools' graduates in their provinces. This study highlights the impact a comprehensive rural-focused social accountability approach can have at supplying the needs of a population both at the regional and rural national levels.

From pipelines to pathways: the Memorial experience in educating doctors for rural generalist practice.

This report describes the community context, concept and mission of The Faculty of Medicine at Memorial University of Newfoundland (Memorial), Canada, and its 'pathways to rural practice' approach, which includes influences at the pre-medical school, medical school experience, postgraduate residency training, and physician practice levels. Memorial's pathways to practice helped Memorial to fulfill its social accountability mandate to populate the province with highly skilled rural generalist practitioners. Programs/interventions/initiatives: The 'pathways to rural practice' include initiatives in four stages: (1) before admission to medical school; (2) during undergraduate medical training (medical degree (MD) program); (3) during postgraduate vocational residency training; and (4) after postgraduate vocational residency training. Memorial's Learners & Locations (L&L) database tracks students through these stages. The Aboriginal initiative - the MedQuest program and the admissions process that considers geographic or minority representation in terms of those selecting candidates and the candidates themselves - occurs before the student is admitted. Once a student starts Memorial's MD program, the student has ample opportunities to have rural-based experiences through pre-clerkship and clerkship, of which some take place exclusively outside of St. John's tertiary hospitals. Memorial's postgraduate (PG) Family Medicine (FM) residency (vocational) training program allows for deeper community integration and longer periods of training within the same community, which increases the likelihood of a physician choosing rural family medicine. After postgraduate training, rural physicians were given many opportunities for professional development as well as faculty development opportunities. Each of the programs and initiatives were assessed through geospatial rurality analysis of administrative data collected upon entry into and during the MD program and PG training (L&L). Among Memorial MD-graduating classes of 2011-2020, 56% spent the majority of their lives before their 18th birthday in a rural location and 44% in an urban location. As of September 2016, 23 Memorial MD students self-identified as Aboriginal, of which 2 (9%) were from an urban location and 20 (91%) were from rural locations. For Year 3 Family Medicine, graduating classes 2011 to 2019, 89% of placement weeks took place in rural communities and 8% took place in rural towns. For Memorial MD graduating classes 2011-2013 who completed Memorial Family Medicine vocational training residencies, (N=49), 100% completed some rural training. For these 49 residents (vocational trainees), the average amount of time spent in rural areas was 52 weeks out of a total average FM training time of 95 weeks. For Family Medicine residencies from July 2011 to October 2016, 29% of all placement weeks took place in rural communities and 21% of all placement weeks took place in rural towns. For 2016-2017 first-year residents, 53% of the first year training is completed in rural locations, reflecting an even greater rural experiential learning focus. Memorial's pathways approach has allowed for the comprehensive training of rural generalists for Newfoundland and Labrador and the rest of Canada and may be applicable to other settings. More challenges remain, requiring ongoing collaboration with governments, medical associations, health authorities, communities, and their physicians to help achieve reliable and feasible healthcare delivery for those living in rural and remote areas.

A community-based strategy in medical education of the university of the philippines manila-school of health sciences - Lessons from innovations in human resources for health development in a developing country.

After nearly four decades of testing an innovative model for training health workers for marginalized communities, the evidence base for the impact of University of the Philippines Manila-School of Health Sciences (UPM-SHS) medical program needs to address important gaps. Has it succeeded in contributing toward socially accountable medical education where medical schools will be evaluated in terms of their contribution to society's health outcomes? To answer this question, this study examined human resources for health (HRH) inequity in the Philippines and reviewed the medical school's performance in terms of addressing HRH distribution. The evaluation of the school's performance was done through two phases. Phase 1 involved generating HRH inequity metrics for the Philippines through secondary data. Phase 2 involved gathering primary data and generating performance metrics for UPM-SHS. We found challenges that UPM-SHS needs to address based on the analysis of its student admissions from 1976 to 2011: targeting the right underserved communities, especially at the municipal level; addressing issues of high leakage and undercoverage rates in the program; ensuring mechanisms for return service are in place at the community level; and tracking and measuring program outputs and impact on community health outcomes. Given this study on the performance of UPM-SHS to produce a broad range of health workforce to address the needs of marginalized communities in the Philippines and in similarly situated countries, there is a need to reassess its HRH development strategy. If it wants to build a critical mass of transformational health leaders to meet the needs of poor communities as part of its social accountability mandate, it needs to accelerate this development process.

Views from the field: Medical student experiences and perceptions of interprofessional learning and collaboration in rural settings

ABSTRACTExploring the perceived environment where students are educated, as well as where they practice, is particularly important for educators and practitioners working in situations of interprofessional rural and remote health. In this study, we explored the perceptions of undergraduate medical students regarding interprofessionalism across their four-year undergraduate program which focuses on rural health. A thematic content analysis of the text-data was conducted on a convenience sample of 47 student responses to essay questions across four cohorts of a four-year undergraduate medical program. The medical program has an explicit social accountability mandate for responsiveness to the needs of a rural population and thus students have multiple opportunities to experience interprofessional education and collaboration in rural contexts. Participants reported (a) blurring and flexibility of roles in a primarily positive manner, (b) participating in unstructured interprofessional learning and collaboration, (c) experiencing the importance of social connections to interprofessional collaboration and learning, and (d) realisations that interprofessional collaboration is a means of overcoming barriers in rural areas. We discuss our findings using the socio-material perspective of complexity theory. These findings may be used to inform undergraduate programs in re-defining, re-creating, developing, and fostering interprofessional learning opportunities for medical students in rural communities as well as to support clinical faculty through ongoing professional development.

The impact of socially-accountable health professional education: A systematic review of the literature

This literature review describes the impact of health professional schools with a social accountability mandate by identifying characteristics of medical education found to impact positively on medical students, health workforce, and health outcomes of disadvantaged communities. A critical appraisal tool was used to identify the strengths and weaknesses of the published articles. Data are presented as a narrative synthesis due to the variety of methodologies in the studies, and characterized using a logic model. Health professional schools aiming to improve health outcomes for their disadvantaged local communities described collaborative partnerships with communities, equitable selection criteria, and community-engaged placements in underserved areas as positively impacting the learning and attitudes of students. Students of socially accountable schools were more likely to stay in rural areas and serve disadvantaged communities, and were often more skilled than students from more traditional schools to meet the needs of underserved communities. However, published literature on the impact of socially accountable health professional education on communities and health outcomes is limited, with only one study investigating health outcomes. The findings of this literature review guide schools on the inputs likely to maximize their socially accountability outputs and increase their impact on students, local health workforce and local communities.

Building a Generation of Physician Advocates: The Case for Including Mandatory Training in Advocacy in Canadian Medical School Curricula.

There is an increasing focus on the social accountability of physicians as individuals, and of medicine itself. This has led to increasing emphasis on physician advocacy from a wide variety of institutions. The physician advocacy concept is now part of the Health Advocacy competency mandated by the Royal College of Physicians and Surgeons of Canada. Despite its growing prominence, physician advocacy remains poorly integrated into current medical undergraduate curricula. The authors recommend how and why curricular reform should proceed; they focus on Canadian medical education, although they hope their views will be useful in other countries as well.The authors discuss conflicting definitions of physician advocacy, which have previously hampered curriculum development efforts, and suggest a way of reconciling the conflicts. They review current gaps in advocacy-related curricula, suggest that these can be addressed by incorporating practice-based and skills acquisition elements into current didactic teaching, and offer several strategies by which an advocacy curriculum could be implemented, ranging from small modifications to current curriculum to developing new competencies in medical education nationally.The authors present a case for making an advocacy curriculum mandatory for every Canadian medical trainee; they argue that teaching trainees how to fulfill their professional responsibility to advocate may also help them meet the social accountability mandate of medical school education. Finally, the authors explain why making the development and implementation of a mandatory, skill-based curriculum in advocacy should be a priority.

Measuring organisational-level Aboriginal cultural climate to tailor cultural safety strategies

Australian medical schools have taken on a social accountability mandate to provide culturally safe contexts in order to encourage Aboriginal and Torres Strait Islander people to engage in medical education and to ensure that present and future clinicians provide health services that contribute to improving the health outcomes of Aboriginal and Torres Strait Islander peoples. Many programs have sought to improve cultural safety through training at an individual level; however, it is well recognised that learners tend to internalise the patterns of behaviour to which they are commonly exposed. This project aimed to measure and reflect on the cultural climate of an Australian rural clinical school (RCS) as a whole and the collective attitudes of three different professional groups: clinicians, clinical academics and professional staff. The project then drew on Mezirow's Transformative Learning theory to design strategies to build on the cultural safety of the organisation. Clinicians, academic and professional staff at an Australian RCS were invited to participate in an online survey expressing their views on Aboriginal health using part of a previously validated tool. Survey response rate was 63%. All three groups saw Aboriginal health as a social priority. All groups recognised the fundamental role of community control in Aboriginal health; however, clinical academics were considerably more likely to disagree that the Western medical model suited the health needs of Aboriginal people. Clinicians were more likely to perceive that they treated Aboriginal patients the same as other patients. There was only weak evidence of future commitments to Aboriginal health. Importantly, clinicians, academics and professional staff demonstrated differences in their cultural safety profile which indicated the need for a tailored approach to cultural safety learning in the future. Through tailored approaches to cross-cultural training opportunities we are likely to ensure participants are able to engage with the material and reflect upon implications of a challenging cultural climate on the health and wellbeing outcomes of Aboriginal people.

Outcomes of the Northern Ontario School of Medicine's distributed medical education programmes: protocol for a longitudinal comparative multicohort study

IntroductionThe Northern Ontario School of Medicine (NOSM) has a social accountability mandate to serve the healthcare needs of the people of Northern Ontario, Canada. A multiyear, multimethod tracking study of...

Impact of selection strategies on representation of underserved populations and intention to practise: international findings.

Socially accountable medical schools aim to reduce health inequalities by training workforces responsive to the priority health needs of underserved communities. One key strategy involves recruiting students from underserved and unequally represented communities on the basis that they may be more likely to return and address local health priorities. This study describes the impacts of different selection strategies of medical schools that aspire to social accountability on the presence of students from underserved communities in their medical education programmes and on student practice intentions. A cross-sectional questionnaire was administered to students starting medical education in five institutions with a social accountability mandate in five different countries. The questionnaire assessed students' background characteristics, rurality of background, and practice intentions (location, discipline of practice and population to be served). The results were compared with the characteristics of students entering medical education in schools with standard selection procedures, and with publicly available socio-economic data. The selection processes of all five schools included strategies that extended beyond the assessment of academic achievement. Four distinct strategies were identified: the quota system; selection based on personal attributes; community involvement, and school marketing strategies. Questionnaire data from 944 students showed that students at the five schools were more likely to be of non-urban origin, of lower socio-economic status and to come from underserved groups. A total of 407 of 810 (50.2%) students indicated an intention to practise in a non-urban area after graduation and the likelihood of this increased with increasing rurality of primary schooling (p = 0.000). Those of rural origin were statistically less likely to express an intention to work abroad (p = 0.003). Selection strategies to ensure that members of underserved communities can pursue medical careers can be effective in achieving a fair and equitable representation of underserved communities within the student body. Such strategies may contribute to a diverse medical student body with strong intentions to work with underserved populations.

Moral Distress and Moral Disorientation in the Context of Social Accountability.

Moral Distress and Moral Disorientation in the Context of Social Accountability.