In this study, we looked at the integration of social accountability values such as relevance, quality, equity and cost-effectiveness into the case scenarios (total 70) used in the problem-based learning medical curriculum. Overall, we observed that significant amounts of these social accountability values were embedded through suitable triggers in the case scenarios. However, their consistencies across different units remained were varying. In reference to the relevance, we observed the majority of the case scenarios (73%) addressed the major health problems or social health concerns of the country. It is vital for the medical school to understand and frame its education, training and research directed towards the major health concerns of the community, region, and/or nation they have a mandate to serve [1, 3]. Similarly, 70% of the case scenarios had triggers addressing one or more social determinants of health. Improving our understanding social determinants of health such as environments in which people are born, grow, live, work and age, factors such as socioeconomic status, education, employment, and access to health care is critical to provide targeted healthcare and in shaping people’s health[16–18]
A majority of the PBL case scenarios (87%) reflected contextual integration of medical professionalism, evolving roles of doctors in health system (79%) and reflected healthcare referral system based on the case complexity (73%). We believe these traits are critical in providing good clinical care, maintaining good medical practice, relationships with patients, working with colleagues, probity, and health [19]. The medical profession now recognizes the importance of early introduction of professionalism into medical curriculum to provide learning opportunities, gaining experience and reflecting on the values of medical professionalism for better patient care [20]. In the same note, the role of doctor has undergone quantum shifts from the person who knew medicine to a manger, social worker, teacher, advocate, and leader to name a few. The doctors in the twenty-first century should possess the necessary skills for working in teams, utilizing resources effectively, providing patient-centered care, advocating for health care systems, and increasing accessibility for patients. Therefore, knowledge and understanding of the social determinants of health will provide the information and framework to understand the patient’s need and societal factors that are intertwined with health outcomes [21] .
Likewise, the bulk of the cases scenarios (87%) were able to reflect the involvement of different stakeholders in healthcare and integrate the relevant psychosocial issues rather than only disease-oriented issues in their content. Again, it is important for the socially accountable medical schools to recognize and involve the various stakeholders of health including the patient, healthcare provider, insurance provider, family, community, society, government, and non-governmental organizations. This will not only improve the quality of healthcare but will provide tangible contributions to the sustainability of the training programs [22].
Highlighting the importance of multidisciplinary approach to patient management, we observed only 29% case scenarios had successfully integrated it; similarly, around 49% cases had integrated health system management issues into their content. The case scenarios (59%) also lacked in triggers applying values of health promotion/prevention measures in patient management. We feel the lack of triggers in initiating learning outcomes particularly in the above mentioned domains need improvements. It is well known that multidisciplinary care model that brings together different providers such as physicians, nurses, social workers, and other specialists not only improve health care outcomes but also reduce potential for errors [23]. Given the need for doctors to actively collaborate with multiple professionals, it becomes a key necessity to introduce such learning modules early in the medical curriculum. Similarly, the medical students should be educated about the structure of the healthcare system they want to be a part, early in their curriculum. This will help them to integrate into the nation’s healthcare system and improve their understanding of healthcare legislations, concerns and issues within the healthcare system [24]. Medical schools applying the social accountability values should integrate health promotion and disease prevention approach into their curriculum in training their workforce to recognize the health problems for which preventive efforts can result in appropriate utilization of health resources and improvements in health status [25]. The case scenarios used in problem-based learning curriculum should ensure that these social accountability issues are intelligently introduced to the learner to build open their knowledge, understanding and practice early in their academic years.
In the equity domain of social accountability, the case scenarios used in our problem-based learning curriculum showed complete integration in addressing patient’s gender and age group. In comparison, the case scenarios failed to include underserved, disadvantaged or vulnerable populations in society (88%), patient ethnicity (77%) and address socioeconomic status of the patients in 54% cases. It is known that socially accountable medical schools focus on the priority health concerns in their own contexts. Collaborating with the local communities and government medical schools have a focused on medically underserved people or those who do not have access to healthcare services, including remote and rural populations, indigenous or minority groups, or ethically and linguistically diverse populations and the urban poor [26].
Similarly, majority of the case scenarios (91%) needs improvement in triggering discussion about treatment cost and providing alternatives with their patients. While most medical curriculum are good in training the students to discuss the diagnosis, treatment and drug side effects with their patients, they lack in sharing financial issues with them. Empowering the patient in their own healthcare decision-making especially the financial issues such as treatment cost and available treatment alternatives has become an important responsibility of the physician [27]. In order to inculcate these traits, students should be engaged in learning how to disclose the financial consequences and suitable alternatives with their patients. The case scenarios can introduces sufficient triggers in these topics to initiate discussion and opinions as learning objectives.
When we analyzed the applications of social accountability values in cases scenarios across different units such as cardiovascular, musculoskeletal, neurosciences, renal and reductive etc. we observed some degree of variability. These variations might be due to the nature of the unit content. For example, the cases used in endocrine and hematology systems are essential part of learning human physiology and pathology, but lacked in reflecting the application of social accountability values. However, we believe carefully revising them it is possible to infuse triggers to initiate learning of social accountability values without compromising their core learning objectives.