Practising social accountability

The 4 principles as a foundation of social accountability

The capacities and roles of family medicine are expressed in the 4 principles and the roles are defined in the CanMEDS–Family Medicine tree (Figure 1).⁹ The roots and foundation of our opportunities and obligations are grounded in and expressed by the 4 principles. Requiring excellence of practice in a relationship with a patient or a particular population and based in an obligation to community, the 4 principles set the expectation of social accountability. In this context, how could we not know, care about, and respond to the particular needs of our patients, communities, and society? Indeed, social accountability is “at the heart of family medicine.”¹⁰

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Figure 1.

CanMEDS–Family Medicine tree

Reproduced from the Working Group on Curriculum Review.⁹

Family medicine’s unique responsibility and perspective

Medicine has a long tradition of defining and calling its practitioners to develop and attend to the doctor-patient relationship. The essence of family medicine is this relationship that lives between doctor and patient, extending across life’s stages, including events of both illness and health, while attending to all the things that influence health. This is qualitatively different than other medical specialties that focus on particular diseases or technical skills. While the doctor-patient relationship has been diminished by an increasingly fragmented health system and subspecialization leading to episodic and technical care, family medicine cannot escape the fact that it is relationship-based care that endures over time and place. Further, because family physicians are community-based and take the constant view of both illness management and prevention, we are obligated to contextualize our care with the knowledge of what makes our patients healthy or not.

If our eyes are open, this enlargement of the scope of our relationships puts us in the face of needs beyond the purely clinical. It forces us to consider the social causes of ill health at the level of the individual (micro level) and beyond. Thus our gaze extends from our patients and their families to their neighbourhood and community (meso level) and to the society in which we all live (macro level). To this end, we must understand and address the social determinants of health (SDOH).¹¹

Each level of this continuum influences every other level. Through our enduring relationships, we can learn to map the connections upon which we might have some influence.

Medicine as social justice

A cardinal value of social accountability is social justice.

[Social justice is a] concept based upon the belief that each individual and group within a given society has a right to civil liberties, equal opportunity, fairness, and participation in the educational, economic, social and moral freedoms and responsibilities valued by the community.¹²

Social justice plays a strong role in shaping how we consider health inequities within populations and how to target interventions toward specific health issues (Figure 2). The College of Family Physicians of Canada recently released a Social Justice Lens¹³ tool to evaluate the characteristics of its own activities—as well as the activities of other actors and organizations at the meso level. This is a modern-day expression of a historic call to social justice by members of the profession going back as far as Hippocrates and Ibn Sina.

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Figure 2.

Components of social justice from a family medicine perspective

Throughout the history of medicine, physicians have been called upon not only to be moral in the care of individual patients, but also to use their skills and their power to advance human society and the human condition. This is most succinctly expressed in the words and career of the 19th-century physician and politician Rudolph Virchow. In reporting on his study of the deadly cholera epidemic in Silesia he observed: “If medicine is to fulfill her greatest task, then she must enter the political and social. Do we not always find the diseases of the populace traceable to defects in society?”¹ He further observed: It is the curse of humanity that it learns to tolerate even the most horrible situations by habitation .... Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.¹⁴

Virchow leads us into the meso and macro levels of our social accountability. This concept of social accountability bridges our 4 principles, grounded in serving individual patients, with our obligations to look “upstream” and to influence the social determinants that contribute to our patients’ illness and disease.

Levels of socially accountable care

The 3 subsequent articles in Canadian Family Physician in 2016 will focus on the concrete aspects of bringing social accountability to life at the 3 levels (Figure 3).¹³

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Figure 3.

The 3 levels of socially accountable care

Reproduced from the College of Family Physicians of Canada.¹³

At the individual patient level (micro), emphasis will be placed on the importance of a relevant social history, including the use of tools like the poverty screening tool.^2,3 It will illustrate how the SDOH affect a patient’s ability to follow through on treatment recommendations, raise awareness of how to have flexibility for those with special needs (eg, mental illness, addictions, or homelessness), and demonstrate how to access the kind of social supports our patients need in order to improve their health.

At the community level (meso), we will learn that family physicians should collectively establish systems of practice that meet the health care needs of people in our particular communities. For example, in rural or small-town Canada, practising as a true generalist is a socially accountable way to ensure that people receive the right care, at the right time, and in the right place. Communities of varying sizes and with variable demographic profiles and needs require groups of physicians who collectively adapt to meet those needs. Services that might be supplied by high-volume non–family physician specialists (surgeons, interventional obstetricians, anesthetists, etc) in densely populated cities might quite appropriately be provided by generalist practitioners in the rural setting with focused skills that allow the safe delivery of such needed services—safer and healthier than would be the case in their absence. As we strive toward the interprofessional Patient’s Medical Home,¹⁵ the demographic characteristics of a population would determine the kind of health professionals that should be available to meet the population’s specific needs.

One clear implication of this is that our educational and health systems must produce the optimal number of physicians and other health care providers, as well as achieve the appropriate ratio of family physician generalists to other specialists. Meso-level social accountability in family medicine is about the convergence of primary care with public and population health. Leadership, advocacy, and planning for particular services that are needed in the community are the essence of social accountability at the meso level.

Finally, we will discover that macro-level social accountability is about connecting politics to public policy, bringing to the fore that unique, trusted voice of physicians and recognizing the power of physician advocacy. The physician role in bringing about health equity in Canada will be described and ideas about how physician organizations can participate to address the SDOH to allow for more “upstream” effects and care will be provided. That physicians bear daily witness to ill health gives us the perspective, credibility, and necessity to engage in advocacy at this societal level.

Socially accountable medicine in the 21st century

The history of medicine in the 20th century could be described as an uncritical and unrequited love affair with specialization and technology. This has led to the unfortunate separation of personal and population health, and of health professional schools and schools of public health. Balancing the wisdom needed to use technology appropriately with meeting individual and population health needs is in the realm of true generalism. This represents the core of what socially accountable family practice must offer society in the 21st century.

Helping family physicians individually and as a discipline find our niche in the continuum of socially accountable practice is the objective of this series. Understanding and meeting the obligations of our social contract with our patients at all levels can reconnect many of us to the reasons we chose family medicine as a career in the first place. The pursuit of better health for our patients and a more just society are conjoint features of the future we can and must build together as individuals and as a discipline.