|PRACTICAL ADVICE PAPER
|Year : 2014 | Volume
| Issue : 2 | Page : 152-157
Accounting for social accountability: Developing critiques of social accountability within medical education
Stacey A Ritz1, Kathleen Beatty2, Rachel H Ellaway3
1 Medical Sciences Division, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
2 Director of Equity and Quality, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
3 Human Sciences Division, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
|Date of Web Publication||31-Oct-2014|
Dr. Stacey A Ritz
Northern Ontario School of Medicine, East Campus - Laurentian University 935 Ramsey Lake Road, Sudbury ON P3E 2C6
Source of Support: None, Conflict of Interest: None
Background: The concept of the social accountability of medical schools has garnered many followers, in response to a broad desire for greater social justice in health care. As its use has spread, the term 'social accountability' has become a meta-narrative for social justice and an inevitable and unquestionable good, while at the same time becoming increasingly ambiguous in its meaning and intent. In this article, we use the lenses of postmodernism and critical reflexivity to unpack the multiple meanings of social accountability. In our view, subjecting the concept of 'social accountability' to critique will enhance the ability to appraise the ways in which it is understood and enacted. Discussion: We contend that critical reflexivity is necessary for social accountability to achieve its aspirations, and hence we must be prepared to become accountable not only for our actions, but also for the ideologies and discourses underlying them.
Keywords: Critical theory, critical reflexivity, medical education, postmodernism, privilege, social accountability
|How to cite this article:|
Ritz SA, Beatty K, Ellaway RH. Accounting for social accountability: Developing critiques of social accountability within medical education. Educ Health 2014;27:152-7
| Background|| |
The medical school is the mechanism by which the medical profession perpetuates itself, and through which society ensures the sustainability of a skilled and competent physician workforce. There are arguably two intertwining discourses in medical education: A formative discourse regarding the most effective way to train physicians, and a moral discourse that links this training to the social contract between the profession and society. The former has dominated Western models of medical education for a century or more, but the moral discourse is gaining strength, reflected for instance in the recent pursuit of social accountability for medical schools.
The Flexner report  was a watershed moment in North American medical education, and the reforms that followed shifted medical education and practice toward an increasingly technological and biomedical character. Although concerns were raised that this emphasis on the medical sciences was displacing altruistic and humanistic aspects of medical practice, , the dominance of biomedicine in medical education has lasted for more than a century.
Until relatively recently, accountability to patients, the public, and the profession, were generally held to be the private and moral concern of individual physicians, rather than the collective responsibility of institutions or the profession as a whole. , While some considerations of accountability (conceived as a component of professionalism) continue to affirm its basis in the individual social contract for medicine , there has been a growing focus on institutional as well as personal responsibilities in medicine and medical education. 
A number of initiatives in the 1980s and 1990s aimed to address the accountability of medical schools with respect to accreditation and other quality assurance mechanisms. ,, The addition of the modifier 'social' followed from the alignment between medical education programs and the contexts of healthcare delivery and the needs of the communities in which these programs were situated.  The contemporary movement for the social accountability of medical schools can be traced most concretely to a 1995 resolution of the World Health Assembly, calling for medical education to make its responsibilities to society more explicit. This was in part a response to the 1978 Alma-Ata Declaration that called for widespread change to address gross health inequalities in the context of the 'New International Economic Order'.  The World Health Assembly declaration was followed by a position paper by Boelen and Heck,  in which they defined social accountability for medical schools as "the obligation 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" (p3). There has been a growing interest in social accountability as a responsibility of medical schools ever since, with some new schools being founded with social accountability as a fundamental part of their mandate (including our own). 
In our work as medical educators, we find the idea of social accountability of medical schools both emotionally and morally compelling. However, it can also shield social accountability against critique; after all, who in medical education would argue that we should not be socially accountable? A central tenet of our own accountability as academics is that we problematize the constructs we use, such as social accountability, and subject them to critical scrutiny. Thus, the rationale for this paper is an attempt to address what we perceive as a gap in the discourse on social accountability in medical education. We contend that employing a vigorous critical reflexivity is necessary for the movement to realize its aspirations; our concern is that social accountability initiatives will fall short of their potential in the absence of such reflexivity, and they may even serve to perpetuate some of the very inequities that the pursuit of social accountability is intended to address. Our aim, then, is to examine different meanings of social accountability, to situate them within broader social and academic discourses, and to explore ways in which critical reflexivity can serve to make social accountability a more robust guiding principle for the design and practice of medical education.
Why Critique Social Accountability?
Although social accountability in medical education at one level seems to be an 'undeniable good', it can be situated in broader social and philosophical discourses that make it tractable to critique. Indeed the very notion of an 'undeniable good' situates social accountability at the intersection between Habermasian beliefs that there are undeniable goods that can resolve social problems  and postmodern perspectives that intrinsically challenge any such assumption. 
Foucault observed that "power is always already there…one is never outside it",  arguing that we should interrogate the ways that authority, power, and legitimation are transacted through language, and use critical and reflexive approaches to perceive and hold power accountable in all of our discourses. Following this argument, we should reject the assumption of the undeniable goodness of social accountability and instead critique social accountability in medical education, focusing on its meta-narratives, its underlying ideologies and assumptions, and the ways in which power and identity are expressed and negotiated through the social accountability discourse.
Social accountability is often distinguished from related terms such as 'social responsibility' and 'social responsiveness'. Whereas the social responsibility of medical schools can be understood as the obligation to respond to health needs, and social responsiveness as the courses of action taken to accomplish this,  social accountability is the practice of engaging with and being held to account by the community or communities the medical school has a mandate to serve.  However, in practice there is considerable slippage between these concepts, and 'social accountability' is often used as an umbrella term that includes aspects of all three.
There has also been a marked diversification of what is meant by social accountability in medical education. It is interesting to us that almost all of those taking up the issue of social accountability accept the authority of the World Health Organization (WHO) definition  as their starting point, but then tend to take up and accentuate certain elements while glossing over others, without critiquing the WHO definition explicitly. Some accounts appear to focus on the 'cost-effectiveness' aspect, emphasizing measurement and using capitalist metaphors of production to describe medical education. ,, In others, the equity principle is prominent with a more explicit social justice orientation, highlighting the role of the medical school in fomenting transformative sociopolitical change to address health inequities.  Still others stress the engagement of the medical school with the community as the paramount goal, manifested as consultation, collaboration, dialogue, or partnership, with a lesser emphasis on change as an end in and of itself.  Such diversification is probably inevitable and likely enriches the discourse. However, the challenge with such diversification of meaning is that the term 'social accountability' has come to mean so many different things to different people that its core meaning lacks coherence, and the diversity of ideologies that have been attached to the discourse has rendered the concept highly amorphous and unstable.
At the same time, it seems that social accountability has become elevated "to a realm of discourse where it appears to have an independent existence…the word becomes revered, imbued with mystical significance, and beyond the realm of critical analysis".  Like 'evidence-based practice', the merit of social accountability is so obviously undeniable that that it is virtually taken to be a truism;  and like the idea of reflection in education, it is so compelling that many medical schools are investing resources and energy into a vast array of activities all stamped with the label of 'social accountability initiatives'.
We are therefore facing something of a paradox where, as the compulsion to social accountability grows, its meaning becomes increasingly diffused. The problem is compounded by the highly privileged social positions (i.e. medical educators, physicians, and medical students) of those who are in positions to define and implement social accountability projects (including ourselves). The very nature of privilege is such that we are "'meant' to remain oblivious"  to it, and as a result we are not inclined to spontaneously criticize the very social structures that form the basis of our comfort. , Privilege can therefore make it difficult to see the ways in which we may be complicit in perpetuating social injustice even when our actions are intended to have the opposite effect. This can be exacerbated by our training to become members of professional communities, which requires us to develop "particular, professional ways of seeing the world and a way of constructing and maintaining the world".  As a result, the machinations of injustice, which create the health inequities we are most concerned about, may not be readily visible from the privileged standpoints of those of us working in medicine and medical education.  Given that the very point of social accountability is to redress these inequities, "the inability to see clearly here is particularly unsatisfactory". 
The Dangers of an Uncritical Social Accountability
Many theorists have noted the ways in which the institution of medicine functions to maintain the status quo, and the importance of medical ideologies and discourses as mechanisms of social control that support the established order. ,,,, Work by Waitzkin and colleagues highlights the ways in which physicians unwittingly help their patients adapt to troubling social conditions, and thereby end up serving the interests of the dominant social order. ,, It is possible that similar dynamics can be at work in the pursuit of social accountability by medical schools.
For example, some medical schools have described initiatives in which free, student-run medical clinics are offered to homeless people in urban centers as examples of their social accountability activities. Such initiatives are certainly well-intentioned and may meet a very real health need. However, at the same time, it is possible to understand these free clinics as supporting the status quo, in that they do not address aspects of the social order which permit such conditions to exist in the first place; by addressing a particularly visible and grisly outcome of poverty, they may even serve to blunt the impetus for the kinds of broader social change that would reduce the need for such clinics at all. While such free clinics provide a valuable service, we would like to raise the question of whether the operation of such clinics in the absence of any concomitant activities to address the underlying causes of poverty and homelessness can be said to be truly 'socially accountable'.
As this example illustrates, one of the most concerning slippages of meaning is between 'social accountability' and an ideology of 'helping'. Medicine is often understood to be a fundamentally altruistic enterprise, and so such slippage into 'helping' is not surprising, but can become problematic when such 'helping' activities are conceived in the absence of a critical framework. Without such a critical framework, they run the risk of reflecting the preoccupations and prejudices of the dominant elites, including the presumption that they know what is needed better than the people they serve.  Given that those who suffer from health inequities are more likely to have been marginalized by colonization, racialization, sexism, homophobia, poverty, and other forms of systemic oppression, uncritical 'helping' by the dominant elites will more than likely function to reinscribe and sustain inequitable power dynamics.
This becomes apparent in another common initiative, in which medical students are sent on placements in underserved communities. Typically, the rationale for such placements is that giving learners exposure and experience with marginalized groups will facilitate greater understanding of their needs, such that they will be better able to provide care, and develop a desire to address the inequities they witnessed when they are practicing physicians.  This may indeed be the outcome in some cases, particularly when students are well-prepared for such placements; in others, however, learners may return from these experiences with their prejudices about the marginalized community affirmed, and a conviction that the solution is for 'them' to become more like 'us'. Concomitantly, the communities which hosted these students may find that their suspicions about the hegemonic nature of the medical establishment are confirmed.
In order to mitigate such tendencies, most formulations of social accountability stress the importance of dialogue and engagement with communities, but this does not guarantee that the foregoing difficulties will not arise. The kinds of activities identified as constituting such engagement typically include 'maintaining awareness', 'identifying community needs', 'consultation', or 'dialogue', which can be relatively superficial kinds of engagement. Without a recognition of the imbalances of power or the friction of ideologies, these can reflect Freire's concern about attempts by the dominating class to dialogue with communities of which they are not a part as "alienated and alienating rhetoric".  In other words, if social accountability is defined principally by the privileged and powerful elites, it is ultimately a hegemonizing discourse, however, beneficent the intent.
| Discussion|| |
If we wish to truly serve the interests of the marginalized and disadvantaged, the onus is on us to find ways of doing so that do not simply reinstantiate the forms of dominance that caused the inequities in the first place. Otherwise we find, as Kumagai  did, that "my best intentions were met with suspicion, and that my attempts to form a bond between us were no match for the sheer weight of a history filled with unrighted and unrecognized wrongs" (p30).
Moving to a Critically Reflexive Social Accountability
In order for social accountability to achieve its potential, it is important to bring ourselves to a critical consciousness of the ideologies informing our practice, the ways in which we benefit from the current social order (i.e. our privilege), and the ways in which we are complicit in perpetuating the status quo. As we have argued, failing to address these issues renders us less able to take action to get at the root causes of health inequities. Because we are seldom spontaneously aware of our own ideological investments  or privilege,  we must make deliberate efforts to cultivate tendencies for self-critique. This is where critical reflexivity can serve us well.
Reflexivity is a process through which we come to recognize that our perceptions of things in the world are not neutral, but are in fact the products of a complex array of social processes that give them meaning.  Reflexivity is the practice of disrupting our 'common sense' about the world, and carefully examining the ideas that form the foundations of our thoughts and actions. Reflexivity becomes 'critical' when it explicitly addresses issues of power; it asks us to go beyond recognizing the fundamental assumptions that shape our worldview, and begin to interrogate the ways that power operates through us and on us as a result of our embodied social position.
In approaching social accountability, critical reflexivity can help us to recognize the ways in which unjust ideologies are entrenched in our everyday practices and contribute to the maintenance of the inequities we hope to address.  It can therefore help us to develop an awareness of the values and norms that we bring to our social accountability practices, and the ways that these are intrinsically embodied and historically situated. , By making these explicit, we are better able to recognize that there are in fact alternative frames through which we can understand the problems we hope to address, and thereby expand our opportunities to address them. ,
So what would it look like to enact a critically reflexive social accountability? We propose that this must be a multifaceted and ongoing process. First, we must reexamine ourselves constantly, acknowledging and critically analyzing our own power. , This requires us to recognize the cognitive authority of 'others', and include them in an authentic exchange in which we are willing to alter our purposes and objectives in response to their perspectives and contributions. ,, It recognizes that social accountability is situated, and must be rooted in the local social, political, and cultural context. It also requires us to be willing to use our power and resources to effect change that may sometimes devolve power and resources from our institutions and ourselves. We must strive to maintain humility, and be capable of admitting our weaknesses, mistakes, and limitations, both to ourselves and to the communities we serve. , We must be willing to take action to address injustice  and appraise our impact,  as a critically reflexive social accountability must be a material and substantive undertaking, not just a cognitive and rhetorical one. Finally, we must relinquish some control over the terms under which we define and evaluate our social accountability; it is surely a hollow 'accountability' when medical schools themselves retain exclusive power over the ability to determine whether it has been fulfilled.
In cultivating a critically reflexive social accountability, we will be better positioned to undertake activities that address the fundamental origins of health inequities: For example, advocacy would form an inherent part of any initiative to address the health needs of the urban homeless alongside the direct provision of medical care, and community placement would be explicitly designed to prioritize the needs of the community itself over the provision of an enriching experience for the learner.
A critically reflexive social accountability is also subversive, because its nature is inherently transgressive: It raises questions about the very foundations of our knowledge and understanding, and challenges us to effect change within ourselves and the social order in which we live.  We therefore acknowledge that cultivating the capacity for critical reflexivity is not a simple undertaking. Attempts to do so deliberately in medical education have been met with limited success thus far.  However, we believe that efforts toward developing a critically reflexive social accountability are both ethically and practically imperative if we hope to fulfill the promise of social accountability in medical education as a force for addressing health inequities.
| Conclusion|| |
This critique is not intended as an attack on social accountability or an attempt to expose its shortcomings; on the contrary, we wish to critique social accountability because it is so useful, powerful, and compelling.  We believe that social accountability in medical education has the potential to be an engine of transformative social change, in which physicians and the larger medical establishment can become important allies in the struggle to overhaul the oppressive social relations that cause the health inequities we witness in our work. But this can only be achieved if we are willing to become accountable, not only for our actions, but also for our ideologies and the discourses through which they are articulated.
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