Which social accountability competencies make a good physician? A qualitative investigation of the patient perspective on social accountability

Abstract

Objective

Social accountability is an emerging theme in health care education. In previous literature, the perspectives of patients regarding the competencies that they think are required for physicians to demonstrate in this domain are scarce. This study aims to get insight into the competencies in the domain of social accountability that, according to patients, should be demonstrated by physicians.

Methods

Online semi-structured interviews with 18 patients in the Netherlands were conducted as part of an exploratory qualitative study. Snowballing and convenience sampling techniques were used to recruit participants. The grounded theory method was used to qualitatively analyze the interviews.

Results and conclusion

Patients identified five competencies of a physician in the domain of social accountability: (1) Taking patient’s characteristics into account and tailoring care to the individual patient, (2) Taking the broader community into account, (3) Balancing between care for the individual patient versus concern for society, (4) Providing guidance to patients in the navigation within the health system, and (5) Taking climate impact into account. Patients stated that the importance of these competencies are dependent on the specialism.

Practice implications

The formulated competencies can be used to better align medical education focussing on social accountability to the expectations of patients.

Keywords:

• Social accountability
• competencies
• patient perspective

Practice points

• Patients consider social accountability competencies as dependent on specialism.

• Patients distinguish five social accountability competencies a physician should master on the micro and macro level of healthcare.

• The patient-centered perspective triangulates with the perspectives of healthcare professionals and medical students.

Background

What are the characteristics of good performing physicians? Most competency frameworks for medical professionals postulate a high level of (pre)clinical knowledge and skills (Netherlands Federation of University Medical Centres 2020; Royal College of Physicians and Surgeons in Canada 2015). The past years, the theme of social accountability is gaining more attention in healthcare education. In 1995, the World Health Organization already underlined the responsibility of medical schools to fulfill their social contract with society by integrating societal health into the curricula (Boelen and Heck 1995). Due to the changing healthcare system (e.g. the transition towards a more integrated healthcare system) and the changing society (e.g. the increase of an aging population and multi-morbidity of diseases), social accountability competencies such as context-based medicine, interprofessional collaboration and a broad psychosocial view are even more important than in the past (van Vliet 2016; Damoiseaux and Soethout 2017; Simpkin and Walesby 2017). Social accountability education can equip future and practicing physicians to better meet society’s needs. In 1995, Boelen and Heck formulated social accountability in medical education as follows: The obligation of medical schools to direct their education, research, and service activities towards addressing the priority health needs of the community, region and/or nation they have a mandate to serve. The priority health needs are to be identified jointly by governments, healthcare organizations, health professionals and the public (Boelen and Heck 1995, p. 3). Based on this definition and a study with interviews with educational staff members and medical students on their perspectives on the construct of social accountability, the following definition of social accountability in medical education was evolved: ‘A global obligation of medical schools to respond to the priority health needs of the population to be served. This obligation involves a reciprocal relationship between medical schools and society. This relationship is expressed in directing education, research and service activities towards current and significant social factors such as diversity, sustainability, and moral issues. Learning objectives, learning activities, and evaluation tools are co-constructed to measure the impact of each other’s actions’ (Oudbier et al. 2023). This definition of social accountability is used in this study. It should be recognized that the definition of social accountability is not absolute and is dependent on the situation, context, and person (O’Meally 2013; Grandvoinnet et al. 2015).

In recent years, a small number of studies have been conducted to define the competencies that are needed to be socially accountable as a healthcare professional. In these studies, views and perceptions professors and general practitioners, hospital and community health facility staff related to education, and medical students were used. According to these studies, the following competencies are a part of social accountability: cooperation with healthcare team members to promote health and prevention, commitment to practice in rural communities and with underserved ethnic and cultural populations, patient-centered care, and advocating for patients and communities (Adib et al. 2018; Woolley et al. 2019; Naidu et al. 2020).

The aforementioned studies provide limited insight into the competencies of a physician in the domain of social accountability. In those studies, these competencies are defined based on the perspectives of academics, general practitioners, and students or are mainly theory-based. Despite the fact that the aim of social accountability is to better meet the needs of patients and society, the perspectives of patients are often lacking in this domain. Therefore, the patient perspective should be included. This study aims to get insight into the competencies in the domain of social accountability that patients identify as competencies that should be demonstrated by a physician. This insight can be used to better teach future health care providers about social accountability by aligning medical education focussing on social accountability to the needs of patients. To reach this aim, the following question will be answered: Which competencies regarding social accountability do patients consider as important to be demonstrated by graduated medical students?

Method

Design

An exploratory qualitative design was employed to examine the patient’s perspective on the social accountability competencies that graduated medical students should be able to demonstrate. Semi-structured interviews were conducted and inductive analysis was used to examine the data. This research design was chosen, because it enabled us to more thoroughly examine the patient’s perspective. In order to obtain a comprehensive image of the population, the study population comprised of patients from a variety of groups (with differences related to ethnicity, socio-economic position, gender, age). A participant needed to be 18 years of age or older, have received medical treatment within the last five years or be receiving treatment at the time of enrollment in this study. They also needed to be competent in either Dutch or English or wanting to be supported by an interpreter. Subjects who did not fulfill all of the inclusion requirements were not allowed to take part in this study.

Ethics

This study was exempt from ethical review by the University of Amsterdam’s Medical Ethics Review Board in the Netherlands. Participants were informed that their participation in the study was optional and that non-participation would not affect them in any way. Furthermore, confidentiality and anonymity were assured. The conformity with the rules outlined by the declaration of Helsinki by the World Medical Association was ensured. Before the interviews, participants signed an informed consent form after receiving an information letter in the e-mail. Utilizing pseudonymisation, privacy was assured.

Sampling and recruitment

A combination of convenience sampling and snowball sampling was used to reach a broad patient population. Patients were recruited via our own network and the network of health providers. Subjects were asked to take part in this study by means of a flyer, a social-media post, and an e-mail in March 2021. By e-mail, convenient dates and times were set up.

Participant demographics

The average age of the participants was 48, the minimum was 22 and the maximum was 76. The variety of employment included being a teacher, secretary, personal coach, store owner, shop assistant, and courier. The participants received care from a variety of specialisms, including those in cardiology, ophthalmology, urology, gastroenterology, gynecology, internal medicine, throat, nose and ear care, neurology, surgery to endocrinology, general practice, orthopedics, and dermatology. The participants received medical care at various hospitals, out-patient clinics and general practitioner offices in the Netherlands. The completed level of education, highest completed level of education parents, and country of birth are presented in Table 1.

Table 1. Participant demographics.

Variable		N
Completed level of education	University	8
	Vocational degree	4
	University of Applied Sciences	5
	No degree	1
Highest completed level of education parents	University	5
	Vocational degree	3
	University of Applied Sciences	5
	No degree	5
Country of Birth	Netherlands	16
	Singapore	1
	Suriname	1

Data collection

Materials

To ensure consistency between interviews, a guide was developed based on the aspects of social accountability that are distinguished in the definition of social accountability we proposed in a previous article (Oudbier et al. 2023): community-based learning and working, patient-centeredness, diversity, sustainability, and moral issues. The following elements were included in the interview guide: (1) demographic questions, (2) general questions about what qualities make a good physician, what qualities a physician needs to be socially accountable, and the extent to which physicians currently are socially accountable, (3) specific questions about the extent to which patients think it is important for a physician to take certain aspects of social accountability into account in their actions. We have purposefully chosen to do not provide a specific definition on social accountability because we wanted to explore the construct of social accountability from the viewpoints of patients by making use of a grounded approach.

Procedure

We piloted the interview script in April 2021 with one of the 18 patients and made minor changes in the script based on the participant’s remarks of the pilot interview. During May to June 2021, individual semi-structured interviews were conducted. Due to COVID-19 measurements, the interviews were performed over the phone or via videoconference. These techniques are regarded as effective substitutes for in-person interviews (Archibald et al. 2019; Lobe et al. 2020). The interviews lasted for approximately thirty minutes and were done by the principal researcher (JO). To ensure that we accurately interpreted the data and to improve the confirmability, we asked participants clarification questions. The interviews were audio recorded and a student-assistant transcribed them verbatim. Our research team, which included two educational scientists, a senior educator, a vice-dean of the faculty, and one student discussed the findings in order to be as objective as possible. We used participant quotes to increase the credibility. The analysis was reviewed among the team members to promote confirmability and interviews were conducted until saturation was reached to increase dependability. When more interviews did not yield any new data above those conducted previously, saturation has been attained and no more data was collected.

Data analysis

The grounded theory method was used to analyze the data (Boeije 2009). This approach was chosen since it allows a thorough analysis and is frequently applied to develop a new understanding. The analysis comprised the two steps segmenting and reassembling. Segmenting includes open and axial coding. Axial coding is the development of relationships between codes, whereas open coding is the fragmentation of texts and the labeling of the fragments with codes. The core category to which all other categories can be associated is identified during the analysis’s final step, known as reassembling. Segmenting and reassembling will produce main themes and sub themes that lead to a new understanding of the construct (Boeije 2009). All interviews were analyzed by two researchers (JO and JS). The differences were discussed until consensus was reached. The program MaxQDA was used for coding the transcripts. During the analysis, memos were created to write down ideas that arose during coding. The emerging themes were discussed in the research group.

Results

To get insight into the competencies in the domain of social accountability that patients expect a physician to demonstrate the interviews were qualitatively analysed. The abbreviation P is used for patient.

The analysis revealed five competencies: (1) Taking patient’s characteristics into account and tailoring care to the individual patient, (2) Taking the broader community and social determinants of health into account, (3) Balancing between care for the individual patient versus concern for society, (4) Providing guidance in the navigation within the health system, and (5) Taking climate impact into account. The patients stated that the importance of the competencies related to social accountability is dependent on the specialism. Specialists of specialisms which are more socially oriented and in which the contextual factors of a patient play a bigger role such as a general practitioner or an internist should master more social accountability competencies than other specialists. I think the importance of these competencies depends on the specialism. For surgeons, I can imagine that the communication barrier is less of a problem (P59).

Taking patient characteristics into account and tailoring care to the individual patient (1)

The participants mentioned that a physician should be able to tailor their care to the patient’s characteristics. One of these characteristics that should be taken into account is the environment the patient is living in. Another characteristic that should be taken into account is employment. It is important that a physician asks: what are the expectations at work, what are your working activities, when can you start working and when not. My physician protected me against going back to work too soon (P57).

In addition, participants mentioned that a physician should ask patients about their lifestyle in order to identify the underlying cause of the medical problem and provide prevention tips. Lifestyle is a broad construct. It is about the nutrition you put in your body, thoughts you put in your head, the people you are surrounded by and how you live. There are many things that can play a role (P62). Furthermore, the participants underlined the importance of knowing a patient’s income and the insurance that fits a patient best to reduce their healthcare costs. That the physician is aware of the different kinds of insurances and which insurance is the best for certain kind of patients (P44). In addition, they stated that if a patient has a mental disorder, this should be taken into account in the way treatment takes place. My brother actually has significant social anxiety. So he does not like to leave the house to go to the physician. I think if the physician could be trained or someone could be trained to deliver the healthcare to him to somewhere where he would feel comfortable, then it would be a huge difference (P46). Another important characteristic is a patient’s social network and the possibilities of informal care. During my hospital stay they asked me whether I had informal care possibilities, because you will not be able to get care arranged at home within 24 h (P49).

Participants mentioned that good communication is important to enable tailoring care to the individual patient and comes from both sides, the physician and the patient. The way of communicating is very important, so a physician should try to understand the patient better and it needs to come from both sides so that they understand each other better and what the disease means for that person (P63). Furthermore, the communication should be aligned with the patient’s knowledge level and education. That the physician understands which things they should and should not explain. Otherwise, you can underestimate or overestimate someone and that gives both of them an unpleasant feeling (P59). Participants mentioned that good communication is important to enable tailoring care to the individual patient and comes from both sides, the physician and the patient. The way of communicating is very important, so a physician should try to understand the patient better and it needs to come from both sides so that they understand each other better and what the disease means for that person (P63).

Taking the broader community into account (2)

Another competence in the domain of social accountability that a physician should master is taking the broader community and social determinants of health into account. Participants mentioned that a physician should notice if a certain health related problem takes place regularly in a certain population group or geological area and counteract this problem. I notice that many young people have a problem with alcohol and nitrous oxide. I think: why do physicians not raise the alarm and why do they not combat this problem? (P58). Furthermore, they stated that physicians should be aware of the fact that a disease is expressed differently in different ethnic groups. I do not have a medical background, but I can imagine that a disease is expressed differently with people from background A than people from background B and they should be aware of this (P42).

Balancing between care for the individual patient versus concern for society (3)

The participants mentioned that a physician should be able to negotiate between different values. They stated that it is important that a physician balances between maximizing the benefits for the individual patient and minimizing the costs for society. When it comes to the implementation of extramural care, the outcomes cost-efficiency and effectiveness of care should be balanced. If care can take place at home, then it is fine. However, the past has shown that these changes also affect the quality. When these changes occur, it is often about money and cost-efficiency (P58). Patient-centeredness and sustainability are also mentioned by the participants as values that should be balanced. I think a physician should choose the option that is best for the patient and sustainability can play a role in that decision, but it should not be the main reason to exclude a certain option that might be better for the patient (P42). Furthermore, cost-efficiency and impact on the environment are considered as values that need to be in balance. I consider it as important that the costs will not be extra proportional and that people cannot demand everything. I think physicians should balance what is necessary and to be able to explain why a certain option is not necessary (P49).

Providing guidance in the navigation within the health system (4)

A physician should be able to provide patients guidance in the navigation within the health system. Patients mentioned that the first point of contact in the Dutch healthcare system for a patient is the general practitioner. Therefore, the barrier to visit the general practitioner should be low. Participants expressed that they experience the specialists as less approachable than their general practitioner. The patients considered the communication between the general practitioner and the specialists and the communication between different kind of specialists as crucial. This way, patients are supported when they are referred to a specialist by the general practitioner or to another specialist. I think it is important that the physicians are able to work with other professionals, also outside of the healthcare fields, so that they can figure out what is the best solution for that person (P46). Furthermore, the participants underlined the importance of specialists looking further than their own domain and forwarding the patients to the right specialism. At a sudden moment the specialist can say that they have no solution for the patient’s problem, but that it could be that the patient should go to another specialism, because they suspect the problem is in that domain. Those kinds of referrals should a specialist do (P57).

Taking sustainability impact into account (5)

Another competence underlined by the participants in the domain of social accountability is taking climate impact into account, unless the quality of care for the individual patient is affected. Participants mentioned, for instance, that the physician should try to reduce the waste to a minimum, because they realize that there is a lot of waste in the medical field. I have once seen a piece of art made by someone who had a heart surgery and of all the collected trash of one operation, they had made a piece of art. I can tell you that it was exceptionally extensive and big (P57). Another way to increase sustainability, as stated by participants, is reducing the patient travels, so, for instance, replacing a face-to-face consult by an online consult if it is not necessary to visit the physician’s office and if the patient does not have a strong preference for face-to-face. Furthermore, the participants stated that physicians should think about ways to reduce their own footprint. When they go to conferences by plane they should think about compensating by planting trees. In their own outpatient department there are also examples such as using sustainable paper for their investigation table, syringes and other materials (P38). In addition, participants underlined the importance of providing long-term solutions for medical problems. We are running through resources so quickly. So I think it is important to find sustainable solutions, especially for a physician (P46).

Discussion

Patients identified five competencies of a physician in the domain of social accountability: (1) Taking patient’s characteristics into account and tailoring care to the individual patient, (2) Taking the broader community into account, (3) Balancing between care for the individual patient versus concern for society, (4) Providing guidance to patients in the navigation within the health system, and (5) Taking climate impact into account. These competencies partly overlap with the competencies distinguished by healthcare professionals and medical students, including cooperation with health care team members to promote health and prevention and patient-centered care (Adib et al. 2018; Woolley et al. 2019; Naidu et al. 2020). In the studies, healthcare professionals and medical students did not mention the competencies of balancing between care for the individual patient versus concern for society and taking climate impact into account. In addition, participants of this study did not explicitly mention the competency advocating for patients and communities.

The difference in perspective between healthcare professionals and medical students and patients could be that patients reflect on the micro and maccro level of healthcare and that healthcare professionals and medical students reflect on all levels of care. The micro level includes tailoring care to patients’ individual social determinants of health, such as income, identity and demographic characteristics and education and employment (Goel et al. 2016). Competency 1, 2 and 4 are focused on the micro level of care. The macro level means affecting the broader community and the social determinants of health through, for instance, tracking the various causes of the disease and guiding interventions beyond individual care (Woollard et al. 2016). Competency 2 and 5 are focused on the macro level of care. The meso level includes advocating for the social wellbeing that determines patients’ health concerns by, for instance, joining or creating an organization that advocates with and on behalf of communities (Meili et al. 2016). This difference in perspective can be explained by the fact that patients reflect on the degree to which certain competencies of social accountability are important for their own medical treatment and the way physicians currently apply social accountability competences in their medical treatment. Healthcare professionals and medical students reflect more on what social accountability means for their (future) profession. Triangulation of the perspectives of healthcare professionals and medical students and patients is needed to identify the competencies that are important to be demonstrated by graduated medical students.

The distinguished competencies have already been partly included in competency frameworks for medical professionals, such as the CanMEDS. Examples of important CanMEDS competencies related to social accountability are ‘Work with patients to address determinants of health that affect them and their access to needed health services or resources’ and ‘Determine when care should be transferred to another physician or healthcare professional.’ These competencies are included in the roles of health advocate and of collaborator (Royal College of Physicians and Surgeons in Canada 2015). However, the CanMEDS are currently under revision because of a lack of attention for the new societal developments such as social justice and planetary health (Barnabe et al. 2023). Our study underlines the importance of including patient perspectives in the development of competency frameworks and the five competencies that were distinguished by patients provide novel insights into the roles of health advocate and collaborator of the new CanMEDS framework.

A strength of this study is the diverse team composition. A physician, a board member, an educational scientist, a policy advisor and an associate professor were among the members of the research team. This made it easier for many viewpoints to coexist in this study and made various interpretations of the findings possible. The study population is diverse based on age, employment history, educational attainment, parents’ educational levels, specialism, and hospital. This enabled us to get a picture of a wide patient population in the Netherlands. However, the study sample is small and therefore the transferability could be limited.

An aspect of improvement is the recruitment. This study used convenience sampling and snowball sampling. This could have caused bias in the study population. However, we have chosen these recruiting methods to get a broad picture of the general patient population in the Netherlands. We were not able to include as much patients from a variety of ethnic backgrounds as we aimed to. Unfortunately, we succeeded partly, because in the limited time available we did not have the time and finances to, for instance, translate the flyer and hire a bicultural recruiter. Furthermore, we did not explicitly include invisible diversity, such as mental illness. The study sample is relatively highly educated. Data from Statics Netherlands show that 11.7% has completed graduate or postgraduate education at the university of applied sciences or the university, 20.0% has completed undergraduate education at the university of applied sciences or the university, and 68.2% has completed primary school or vocational education (Statistics Netherlands 2023). Therefore, it is possible that we have missed difference in perspective. For instance, the role that biases and discrimination play in healthcare can affect the perspective of patients from minority groups in a different way. Future research should focus more specifically on the perspectives of a more diverse population in terms of level of education and people from minority groups.

The current study has distinguished social accountability competencies of which patients think physicians should possess these competencies. Future research can validate these competencies amongst a larger study population by means of a survey. To establish a validated competency framework of social accountability that can be used in different countries, this survey should be conducted in several countries.

This study provides a better insight in the competencies of social accountability that patients expect a good physician to have, these competencies may be easily integrated into the curriculum. We have related the social accountability competencies defined by the patients to several educational opportunities in curricula. We are aware of the challenges of designing and implementing educational approaches such as interprofessional education and community-based education, but there are successful examples. The first competence (taking patient characteristics into account and tailoring care to the individual patient) is about patient-centeredness, which can be addressed by emphasizing the role of teachers as role models by and stimulating a culture in which patient-centeredness is valued, for example in communication classes or during clerkship supervision (Alimoglu et al. 2019). The second competence (Taking the broader community and social determinants of health into account) can be taught by using community-based medical education (CBME), which exposes students to community settings and thus helps to understand the influence of the social determinants of health on certain population groups (Claramita et al. 2019). The third competence (Balancing between care for the individual patient versus concern for society) relates to value-based medicine which is about optimizing patients’ health outcomes, while minimizing the healthcare costs, this may be taught in ethics discussed in academic skills education (Bae 2015). To master the fourth competence (Providing guidance in the navigation within the health system), interprofessional education is of importance, which is ‘students from two or more professions learn about, from, and with each other’ (World Health Organization 2010). Interprofessioanl education may be integrated throughout the whole curriculum. The fifth competence (Taking climate impact into account) is about planetary health, a roadmap has already been developed to integrate planetary health into the preclinical and clinical teaching of the medical curriculum (Oudbier et al. 2023).

To meet society’s needs and to provide efficient and equitable healthcare, physicians should be aware of the necessity of being socially accountable. Since patients are an exponent of society, the patient perspective should be included in the development of competency frameworks.

Consent for publication

All authors gave consent for publication.

Author contributions

All authors defined the research theme and designed the study. JO and JS were responsible for the acquisition data and the analysis of data. All authors drafted the manuscript, helped to revise the manuscript critically, and approved the final manuscript.

Glossary

Social accountability: A reciprocal relationship between the institution of medical schools and society. This relationship involves the obligation of medical schools to direct their education, research and service activities towards current and significant societal factors such as diversity, sustainability, and moral issues. The community and the patient are central.

Acknowledgement

We would like to thank Paresh Binda for transcribing the interviews.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Availability of data and materials

Authors can confirm that all relevant data are included in the article and/or its additional files.

Additional information

Funding

This study is funded by the Dutch Research Council (NWO/NRO) as part of a Senior Comenius Fellowship. The funding source has no involvement in the study design, collection, analysis, and interpretation of data, writing of the report, and in the decision to submit the article for publication. I confirm all patient identifiers have been removed or disguised so that the patients described are not identifiable and cannot be identified through the details of the story.

Notes on contributors

Janique Oudbier

Janique Oudbier, Msc, is a PhD student at the Amsterdam UMC and her PhD focuses on social accountability. She also works at the Academic Centre for Dentistry Amsterdam.

Tobias Boerboom

Dr. Tobias Boerboom, PhD, DVM, is a policy director and educationalist at the Faculty of Veterinary Medicine of Utrecht University the Netherlands.

Saskia Peerdeman

Prof. Saskia Peerdeman, MD PhD, is a neurosurgeon. She is also vice-dean of education and training Amsterdam UMC- University of Amsterdam. She is a professor in transformative learning in health care.

Jeanine Suurmond

Dr. Jeanine Suurmond, PhD, is assistant professor and her research programme and teaching focuses on social accountability in medicine and on diversity-sensitive health care.