Reflection on the future of medical care: Challenges of social accountability from the viewpoints of care providers and patients.

INTRODUCTION: Clearly, there are some challenges and difficulties in fulfilling social accountability which should be identified and dealt with in order to reach the ultimate goal. The main objective of this study was to identify the challenges associated with social accountability.
METHODS: In this qualitative study, focus groups and in-depth semi-structured interview were used to obtain the opinions and experiences of 35 people with 4 focus groups of students, faculty members, patients and their companions in Jahrom University of Medical Sciences. Purpose-based sampling was performed. The participants asked "What is social accountability?" And then it continued with the more specific question, i.e. "What factors increase or decrease social accountability?" After identifying the categories and sub-categories, conventional content analysis was used to analyze the data.
RESULTS: Overall, 97 codes were extracted from the text and five main categories were revealed: notification, sense of responsibility, practical education, and professional status and ethics.
CONCLUSION: Since there are numerous challenges in the field of social accountability, it is essential that we understand the challenges and barriers and take effective steps to implement reforms.

Introduction

Social accountability is the solution or strategy that gradually stimulates changes in medical sciences and improves public health through influencing professionalism and technical abilities (1).

Although the concept “accountability” has attracted considerable attention among medical societies in recent years, the history of medicine shows that this goes back to the time of Hippocrates (2). The existence of such a long history shows that social responsibility is an integral part of medical education. A physician, as the healer of the sufferings of the patients in all cultures, especially in the rich Iranian culture, has been responsive to social issues related to the health status of the community. Today, social responsibility is one of the basic concerns of medical and health care institutions throughout the world. This issue is so important that Flexner, after providing a detailed report of the medical education system in North America, announced that the universities that are unable to train socially accountable doctors should be closed (3).

Ever since medical education began to become society-centered, the concept of social accountability has become increasingly important. In the definition of social accountability as provided by WHO, educational and clinical institutes are expected to direct their entire service, education, and research-related activities toward meeting the hygiene priorities of their societies (4).

Experts consider social accountability as a new paradigm in medical education and a cultural change that needs to be understood in depth. Moreover, some experts refer to social accountability as one of the four primary responsibilities of medical universities (5). The results of some studies show that failure to educate the doctors on social accountability can impart a sense of inability and start the professional life which in turn undermines new doctors' self-confidence and increases their anxiety in the early years of their practice (6). Though many experts and authorities emphasize the importance of social accountability and removing the obstacles in the way of its fulfillment, one of the major challenges medical education in Iran and many other countries still is faced with is training capable care-providers who meet the needs of their societies (7). Accordingly, it is necessary that, through a qualitative study, the challenges and defects of social accountability from the viewpoint of the providers and receivers of healthcare be identified and analyzed.

A Medical Education Conference was held in 2010 in South Africa and the global document of social accountability of medical schools was approved and adopted by all the participants (8).

That is why many medical universities around the world have started to review their educational systems (9-12). The universities’ attempts have been directed at teaching, research and services to respond to their societies’ 'health priorities in accordance with the definition of the World Health Organization (WHO) (13). Thus, identifying the health priorities of the society is the first step towards reaching this goal. Researchers believe that identifying the health priorities of the society is the responsibility of governments, health professionals and community centers and also members of the society (14).

Some evidence points to four values of social accountability: relevance, quality, cost effectiveness and equity (15). But achieving medical self-sufficiency was one of the biggest social accountability challenges facing medical schools and the government in Iran (12).

However, the curriculum and educational organizations' including a continuum of community-related activities throughout undergraduate education was not a sufficient response to the challenge of medical education (12).

In our country, this issue has attracted some scholars’ attention. And with respect to the fact that in the 2025 perspective of medical education, meeting the needs of the public health has been proposed as one of the basic pillars of this system, the importance of social accountability is clearly tangible (16).

Although research on social accountability in our country has begun, much of the conducted research has either been dedicated to discussing accountability in the management system of the country or has emphasized the necessity of social accountability of physicians. Yet no qualitative research has been carried out on the challenges of social accountability in the medical system. Thus, this qualitative study aimed at determining the views of providers and recipients of health care services in Iran. Hopefully, this study will contribute to standardizing our universities in the area of social accountability.

Method

This is a qualitative study with a conventional content analysis approach. These criteria describe three domains: 1. Data collection (including personal characteristics) , 2. Study design (participants’ selection and data collection), and 3. Analysis and findings (including data analysis and reporting) and then Rigor and trustworthiness.

The use of heterogeneous groups specified the depth of experiences and helped to enrich the content validity. Also, these strategies helped to attain maximum variance from the data.

The inclusion criteria for the students were being a student of medicine, nursing, operating room technology, or anesthesiology; having had at least two semesters of clinical training; and being willing to participate in the study. The inclusion criteria for the medical professors were having experience of clinical work and being willing to participate. The inclusion criteria for the patients and their companions were being hospitalized for at least five days in an interior or surgical ward and being able to describe their experiences. It should be noted that all of the students and professors were from Jahrom University of Medical Sciences.

Study design was done through semi-structured individual interviews and using focus groups. Each interview started with general interview questions in order to determine the main structure of interest in this project. And then this question "What is social accountability?" was asked. Then, it continued with more specific question of “What factors increase or decrease social accountability, in your own idea?” and the rest of the questions were related to the initial question. Then conventional content analysis was carried for their views. In this approach, through codes classification, were participants directly extracted from the interviews (17).

Conventional content analysis is generally used with a study design which aims to describe a phenomenon, in this case the emotional reactions of people (18,19).

The other method for gathering data was using focus groups. Focus group interviewing is particularly suitable for obtaining several perspectives about the same topic. The benefits of focus group research include gaining insights into people’s shared understandings of everyday life and events (20).

Conventional content analysis was used for content analysis. In this method, codes and classes are extracted from the raw data directly and inductively through a systematic classification process. In this way, the hidden key concepts and patterns are extracted from the data and data collection and data analysis are performed simultaneously.

Interviews were digitally recorded and the n transcribed verbatim, reviewed, coded and analyzed immediately. For the initial encoding, we used the words of the participants themselves and indicated the codes (researcher's perception of the words). Next, we used member checks and peer checking for credible data increase. Semantic units were extracted from the participants ’words in the form of original codes or unlocked codes from the interviews, and then the codes were reread several categories. The codes which expressed a single issue based on similarity and proportion were put in one category. Classification was based on separating dissimilar codes, frequent reviews and integration of similar codes.

Rigor and trustworthiness

Criteria for judging the rigor of such research include "credibility”, “transferability”, “dependability”, and “conformability” which were observed in the present research. To conduct credible research, we adhered to the guidelines of professionalism with integrity, intellectual rigor, and methodological capability. "Transferability is about whether the findings of a study apply to different contexts." We provided a rich description of experiences of participating in social accountability and its challenges. "Dependent ability considers whether findings of a study well be similar if the study is repeated" (21-22).

Conformability is another aspect to consider. To assess the participants' views, in addition to reflecting the words and experiences of the participants, the full text of the codes and the classes were submitted to 2 teachers who were familiar with qualitative research, and their views were used in the confirmation and correction processes. For peer-assessment, the full text with the classes and the codes were given to two faculty members and the comments of two experts in the field of qualitative research were used.

Ethical considerations

In order to comply with ethical requirements, the researchers tried to obtain the participants' consent for participation in the study, in addition to creating an intimate atmosphere in the group.

After considering the submitted documents and comments, two of the co-researchers separately studied the content and then, in addition to determining its compatibility, identified the categories and the sub-categories from the resulting content and performed an analysis. To enhance the liability of the study, the participants’ confirmation was obtained in this section before the final conclusions were made.

Results

From the results of the content analysis, four main categories emerged: 1) notification, 2) sense of responsibility, 3) practical education, and 4) ethics and professional status. Each category falls into several subcategories which are shown in Table 1.

Table 1

Themes and subthemes of the challenges of social accountability

Categories	Subcategories	Significant statement
Notification	Purposeful education	When nurses or doctors are performing a task, they can tell the patient what they are doing, why they are doing it, what problems will happen if they don't do it
	Patients' expectations
Sense of responsibility	Commitment	Doing something which you are not responsible for and can easily ignore, but you spend your time for it, as a human being, you feel you should spend time for it
	Concern for human life
	Self-direction
Practical education	Practical feedback	The courses on medical ethics are effective, but not very practical; we need to see them practiced in reality
	Effective education
	Role model
Ethics and professional status	Internalization of ethics	Unethical personnel ignore humanity, have no professional commitment; professional ethics must be internalized in every individual
	Love for humans
	Spiritual status
	Professional motivation

Notification

The category of notification falls into the two subthemes of purposeful education and patients' expectations. The participants stressed that the instructions that the patients and their companions receive, and even the instructions that students receive from professors should be purposeful and goal-oriented and fulfill the patients' expectations. Moreover, the patients' expectations were extracted from the collected data; one of the pillars of social accountability is fulfilling the patients' expectations.

Commenting on the role of notification, one of the patients said: "The nurses should answer any question the patients ask them; when nurses or doctors are performing a task, they can tell the patient what they are doing, why they are doing it, what problems will happen if they don't do it; this won't take much of their time!" (35-year-old patient in …ward).

Similarly, the professors and students stress the importance of notification and response to patients. One of the students said: "It's important that doctors have sufficient knowledge in their respective fields; knowledge is really important, scientific and up-to-date information that can come in handy at work. For example, you need to know how to break bad news: if you have a patient with terminal disease, you need to be able to inform him of his condition appropriately and support him in the right way".

The second category is the sense of responsibility which, according to the participants, can feature such ethical and behavioral aspects as responding to the questions of the patients, filling personal information gaps, and fulfilling the patient’s expectations and demands. On the other hand, the participants expected health care providers to be committed and concerned with human life and also be self-directed.

The sense of responsibility is when your actions directly affect a person’s life; you need to be dedicated. Also, it is defined as acting in a way that is very thorough and careful.

One of the students stated "The sense of responsibility means doing your best, but not expecting anyone to appreciate your work; if you get paid for what you do in your shift, you are doing your duties, but having a sense of responsibility means doing something which you are not responsible for and can easily ignore, but you spend your time for it; as a human being, you feel you should spend time for it".

Another participant stated "Everyone should be conscientious, but it's not something you can force a person to be; it has to be a part of one’s professional life, taught by the family; if parents work honestly, their children will learn from them; upbringing is really important" (old patient companion, accountant).

One of the manifestations of accountability and responsiveness is democracy. "In every profession, people should act honestly and ethically and respect their clients. Becoming a permanent employee shouldn't make us ignore our patients; we shouldn't let time take our interest and enthusiasm away from us and make us feel less responsible for our patients" (focus group of anesthesiology students).

Practical education

As the third category extracted from the collected data, practical education falls into the subcategories of practical feedback, effective education, and role modeling. This category emphasizes in-depth training of care-providers in responsiveness through practice, role modeling, and internalization.

Commenting on effective education, one of the participants said, "Such matters should become included in the lessons that students are taught; what they are taught, what they learn, what they are expected to learn are what they have to offer here in practice. Are they qualified at all? Can I trust them with my patient?…" (32-year-old patient companion, high school education).

As to practical feedback, a participant stated, "The courses on medical ethics are effective, but not very practical; we need to see them practiced in reality; for example, they can give us access to the blogs of a medical ethics expert to teach us how to cope with various situations".

Concerning role models, one of the professors said, "The role of the professors is very important; the students follow our model; unfortunately, some teachers are not efficient enough and irresponsible individuals can ruin everyone; we should be perfect models of ethical behavior, dignity, and relationship".

Ethics and professional status

This fourth category includes the subcategories of internalization of ethics, love for humans, spiritual status, and professional motivation. All of the participants mentioned that being ethical is an intrinsic characteristic which should be internalized and can in turn lead to love for humans and receiving respect from others, all of which are effective in social accountability. Professional motivation was also referred to as an influential factor in social accountability.

Concerning the internalization of ethics, one participant said, "We can't just teach and train doctors and nurses without considering the society; it would be like training shepherds irrespective of the needs of the cattle; you'll end up with experts who are not familiar with the society they are to deal with. Unethical personnel ignore humanity, have no professional commitment; professional ethics must be internalized in every individual" (professors from the college of medicine with 30 years of clinical education experience).

One focus group of the participants stated "It's true that knowledge and experience are extremely important, but so are money and income. When your life is adversely affected by your job, when your income is not enough, your social status will suffer, too; you'll lose your motivation …" (a member of focus group of nursing students).

Commenting on love for humans, a participant explained that, "Once, there was a guy with a diabetic leg, and he was in the stage where amputation is inevitable; none of the staff was willing to bandage his leg, but I did it in accordance with the medical ethics and I'm proud of myself" (last-year medical students).

Discussion

Based on the findings of the study, the factors that are influential in social accountability can be divided into four categories: notification, sense of responsibility, practical education, and ethics and professional status. As the first category extracted from the collected data, notification was stressed by the participants as a very important factor in social accountability. In most of the interviews, the participants were initially unable to give a clear definition of the concept of social accountability and were able to express their views only after the interviewer had given some clues. Experts on social accountability believe that there is a need for a cultural reform for the concept to be fully understood; only then the doctors and patients can become acquainted with their rights and duties (15). A review of other studies shows that a major issue in medical education today is the inefficiency of newly-graduated doctors (14-16). In a study in England, only 4 percent of the medical students were found to believe that the curriculum was effective enough to produce capable doctors; about 40 percent strongly disagreed that it was effective (14). Likewise, the interviewees in the present study mentioned purposeful education and patients' expectations and stated that purposeful education can result in capable and responsive doctors who notify their patients effectively and meet their expectations.

The second category that emerged from the data and was found to be influential in social accountability was sense of responsibility. According to Boelen, the current system for accepting medical students is not efficient: accepted candidates should have a positive attitude on providing services to the society and empathy with people; unfortunately, the only criterion for accepting candidates is passing a multiple-choice test and such matters as innovation, humanity, commitment, sense of responsibility, and ethics are ignored (10). Therefore, in order for graduates to be knowledgeable and responsive, it is important that the methods for accepting medical students be revised. For example, universities in Iran can follow the example of many universities abroad where one of the conditions for being accepted as a medical student is having been engaged in social work for a certain period of time (21).

Professional commitment is up to 90% responsible for creating motivation to provide patient education (22).

Also, people who have higher professional commitment work harder, value their organizations more, and fewer faults are seen in their work (23).

The second category that emerged from the collected data was practical education. The interviewees believed that as long as "advocacy" (concern for the public) is not effectively incorporated into the medical curriculum, we cannot expect medical students to become responsive doctors in the future. According to Dharamsi, medical schools expect the doctors and medical students to adhere to professional ethics while they do not even superficially introduce them to the topic of ethics (24). Also, the participants in the present study believed that professors, as role models, play a significant role in the transference of medical ethics. Wallenburg claims that new doctors learn the principles of professional ethics from experienced doctors and, therefore, the role of medical professors as models should be emphasized (25). Similarly, Burdick believes that professors' approach to teaching is influential in determining the social accountability value of the curriculum (26). The participants in the present study mentioned that students should practice what they are taught at medical schools so that, through regular feedback that is taken from them, the weaknesses in their education can be identified and removed.

Ethics and professional status was the fourth category extracted from the collected data; the participants believed that effective social accountability was possible only when humanity and ethics are internalized by care-providers and attention is paid to their financial status and professional motives. Observance of professional ethics creates a sense of responsibility toward one's patients and medical organization; it makes care-providers become committed to working efficiently, not harming their patients in any way, and making sure that the care they provide leads to their patients' recovery (10). Thus, the internalization of professional ethics and love for humans is essential to social accountability in medical professions.

Moreover, the participants stated that having a respectable status can motivate doctors; some researchers believe that the curriculum should train doctors who not only have the ability to work in underprivileged regions, but are interested in working in such regions; it is also important that special privileges be given to doctors who are willing to serve the underprivileged to motivate them further (27-28).

The results of the present study are limited to the challenges of and influential factors in social accountability in the Iranian culture; accordingly, it is suggested that studies be conducted in other cultures to identify further implications for the findings of the study. Moreover, the small size of the sample limits the transferability of the results. The interviewees' points of view do not necessarily represent those of all students, professors, patients, and patient companions.

Conclusion

There is no doubt that the main mission of universities is to train committed, competent and accountable individuals. In order to achieve this objective, medical universities should identify the level of social accountability in the teachers, staff and graduate students, and specify the extent of failure to meet the standards. Moreover, in order not to lag behind the international community, universities should try to create adequate accountability in all the three areas of teaching, research and care provision by identifying the health care priorities of their communities. Undoubtedly, there are some challenges in this way that need to be identified and dealt with.