History of the Movement
The concept of “social mission” in medical or health professions education in the United States was not much used before 2010.
Approaches to addressing social and structural determinants of health were identified, but no unifying frameworks described the responsibility of training institutions in improving health equity.
Flexner at 100 Years: 1910-2010
Dr. Fitzhugh Mullan; Source: GW School of Medicine and Health Sciences
The term “social accountability” of medical schools was endorsed by the World Health Organization (WHO) starting in the 1990’s and has gained some traction in mission statements and policy discussion in Europe and Canada. The term “social mission” first drew broad attention in 2010 when an article entitled “The Social Mission of Medical Education: Ranking the Schools” (Mullan, Chen, et al., Annals of Internal Medicine, 2010;152:804-811) lit up a national debate about social mission in medical education. The study, conducted by researchers at the George Washington University (GW) and the Robert Graham Center and funded by the Josiah Macy Jr. Foundation, measured the social mission “outcome” of the nation’s allopathic and osteopathic medical schools. It ranked the schools on three core indicators of social mission graduates – 1) what percent were practicing primary care, 2) what percent were practicing in high physician shortage areas (HPSAs), and 3) what percent were underrepresented minorities. The results indicated that the nation’s three Historically Black Colleges and Universities (HBCUs) as well as many rural and public schools far outperformed more research-oriented schools – schools that are often ranked highly by the US News and World Report – in social mission. That debate catalyzed the concerns of many educators, students, and policymakers about the lack of attention given to social mission in the programs of medical schools and residency programs in traditional rankings.
In the same timeframe as the “Social Mission Rankings” paper, the GW team carried out case studies of six schools concentrating on social mission in medical education. That work, sponsored by the W. K. Kellogg Foundation (WKKF), focused on eight aspects of school activity that were judged to be social mission enhancing — mission statements, pipeline programs, admissions, curriculum, location of clinical experience, tuition management, mentorship, and preparation for residency. The studies at the six schools and the unrest created by the “Social Mission Rankings” paper led to the convening of the first “Beyond Flexner: Social Mission in Medical Education” Conference in 2012.
The name, Beyond Flexner, was chosen because of its succinct statement of the social mission challenge. Abraham Flexner, author of a 1910 report highly critical of medical schools of the time, called for adherence to science and quality standards in medical education. Flexner’s work has been celebrated as the blueprint for 20th century medical education and, indeed, health professions education in general. Flexner’s contributions to establish scientifically sound medical education, however, were silent on the medical school as an agent of community health or social change. His recommendations did nothing to address the increasingly evident disparities in health and health care that were then, and are now, omnipresent in US and global populations. The concept of Beyond Flexner, then, is not to dismiss science or rigorous instruction as values in health professions education, but rather, to go beyond those precepts to create a movement of institutions committed to advancing health equity and the challenges that health professionals face in working toward it.
The Start of the Movement
The first Beyond Flexner Conference was co-hosted by Gerry Clancy, then president of the University of Oklahoma School of Community Medicine in Tulsa, OK, and Fitzhugh Mullan of GW. Keynote speakers were the former Surgeon General, David Satcher, and Jack Geiger, who is recognized as the father of the community health center movement and a leader in the field of social medicine. Many of the 200 participants at the meeting held important university positions in areas such as diversity and inclusion, rural health, and primary care but often felt marginalized in their home settings. Coming together with a social mission common ground was electrifying. The sense of purpose was strong, and participants left Tulsa reinforced in their missions with new concepts and new colleagues.
The timing of the first Beyond Flexner conference coincided with the implementation of the Affordable Care Act (ACA) and a national emphasis on health care delivery innovation, payment reform, and social determinants of health. Beyond Flexner succeeded in attracting a new generation of supporters, bringing together activists in primary care and service delivery with more established groups in diversity and community engagement – combining new tactics of social media and internet organizing with more traditional approaches to student organizing and curricular reform.
The Growth of the Movement
The second Beyond Flexner Conference took place in Albuquerque, NM in April 2015 and was co-hosted by the University of New Mexico (UNM). The UNM Health Science Center has a rich history of community engagement dating back to the opening of the medical school in 1965.
Two important decisions were made at that conference. The first was in response to the group consensus that inter-professional education for health professions students is essential to quality clinical practice and promotion of health equity in the future. Based on this view, the conference endorsed a change in the name and identity of the movement to “Beyond Flexner: Social Mission in Health Professions Education” with a commitment to broaden the agenda and the participation of nurses, PAs, community health workers, dentists, and others in future Beyond Flexner Conferences. The second decision was to create a formal organization, the Beyond Flexner Alliance (BFA), devoted to promoting social mission in health professions education.
The BFA would have core goals of reducing health disparities, enhancing diversity, advancing community engagement, and using health care resources responsibly. The number of organizations with increasing interest in pursuing social mission (by whatever definition) within health professions education was large and growing. The BFA was envisioned as a common ground that would provide a human and electronic platform for these people, organizations, and institutions as well as an accelerator for their common missions.
In March 2016, after receiving core funding from the Atlantic Philanthropies, representatives of the inter-professional education movement held a strategic planning meeting in which they created the BFA vision, mission, and core concepts and established a 12-member Board of Directors. Fitzhugh Mullan was elected Board Chair, Divina Grossman, Professor of Nursing and Former Chancellor at the University of Massachusetts – Dartmouth was elected Board Vice-Chair, and Leigh Anne Butler from the GW Health Workforce Institute as Secretary/Treasurer. The Board set out to build a communications presence (website, newsletter, blogs, webinars, etc.), a membership strategy, and a business plan. Additionally, they were tasked with overseeing Beyond Flexner national meetings, creating awareness of and recognizing best practices, and exploring additional sources of support and collaboration for the BFA.
From 2016 to 2022, four more national BFA Conferences were hosted by health professions schools known for excelling in social mission, including one virtual conference during the height of the pandemic.
Facing the Future, and Ourselves
The BFA Advisory Board brought to the 2022 Conference in Phoenix, AZ, a proposal to change the name of the Alliance to reflect not only the evolution of the organization, but also its aspirations for the future.
Two main forces drove the desire for change. The Board explained that the Alliance name needed to address:
1) Evolved purpose and broader reach
Since its origin, the BFA has evolved and expanded, as is common for new organizations. Originally focused on medical education only, our organization now includes people from many health professions as well as others with interest in societal change. Improving the nation’s health requires a team approach, leveraging the knowledge, attitudes, and expertise of many disciplines. We want a name that aligns with such inclusion.
2) Legacy association and conflicting ideology
We seek to address concerns about using the name of Abraham Flexner, whose beliefs are offensive today, and whose work embedded structural racism in medical education with long-lasting negative impact. Our current name says we want to go “beyond” what Flexner advocated. This is not enough. For a hundred years, Abraham Flexner was widely considered a pioneer in medical education. While the 1910 Flexner Report transformed medical education in many positive, ground-breaking ways, we seek to distance ourselves from Flexner’s racist and sexist views, and the structural racism his work engendered, by adopting a name and brand that reflect our mission, vision, and values.
The time was right for BFA to codify its evolution by adopting a name that was inclusive and relevant for all health professions. The new name needed to remove any mention of Abraham Flexner, whose views and legacy are antithetical to the mission and values of the organization. After careful consideration, a new name was chosen that establishes a name and brand that truly represent our commitment to social mission and to transforming health professions education.
Becoming the Social Mission Alliance (SMA) is more than a name, a symbol, a design, and an improved website. A new strategic plan outlines the four key functions that support the advancement of social mission in health professions schools:
- Measuring and amplifying social mission data
- Serving as a resource hub for institutional transformation
- Convening and mobilizing changemakers in health professions education
- Advocating for policy change that supports and centers equity
Looking ahead, the national conferences have been very successful as a way to learn from each other and grow the social mission movement. We also have programs, projects, and research to move toward transforming health professions institutions.
The Communications team shares newsletters, blogs, and developed a website for disseminating information to the BFA community. In addition, they are active on social media (Twitter, Facebook, LinkedIn and Instagram). We have co-hosted webinars with the American Medical Association and the American Medical Student Association. We also co-sponsored the second Fitzhugh Mullan Institute for Health Workforce Equity Summit.
- Josiah Macy Jr. Foundation Awards
In 2016, the Josiah Macy Jr. Foundation created a new awards program to recognize excellence for social mission in health professions education. The awards process was developed in collaboration with the Social Mission Alliance and was presented at the national conferences in 2016, 2018, 2021 and 2022. The awards are given in five categories: Fitzhugh Mullan Rising Star, individual, program, institution, and lifetime achievement.
- Social Mission Metrics Initiative
Funded by the Robert Wood Johnson Foundation, the Social Mission Metrics Initiative centers around the creation and use of metrics to measure social mission in dental, medical, and nursing schools across the United States. By providing school leaders with a self-assessment questionnaire to objectively assess the status of social mission at their school, the Initiative aims to advance the field of Social Mission measurement and enhance the national conversation around Social Mission in health professions education.
- Health Workforce Diversity Tracking Initiative
Funded by the California Endowment and the Josiah Macy Jr. Foundation, the Diversity Tracker monitors progress toward the goal of greater racial and ethnic parity in the health workforce through four major components:
- Collection and analysis of data on the diversity of the health workforce with a focus on the educational pipeline
- Dissemination of the data and findings
- Support for research on the impact of interventions/strategies to increase diversity
- Advocacy through targeted distribution of the findings and convening of organizations and groups supportive of the goal of more racial and ethnic parity in the health workforce
- Student Assembly
In 2020, a team of summer interns decided to form a student-centered arm of BFA, focused on bringing together interdisciplinary health profession students passionate about social mission. Launching officially in January 2021, the Student Assembly serves as a resource to bring students together to promote social mission, network, and organize around health equity. The Student Assembly created a webinar series addressing national issues from a student context.
- SMA Engagement Program
The SMA Engagement Program was designed to acknowledge other organizations and institutions in the social mission and health equity space. Allies endorse the SMA Mission, are acknowledged on our website and are invited to participate in our sub-committee work, webinars, social media, and at in-person networking events.
- Research Committee
The SMA Research Committee has worked with Mullan Institute leadership to develop a research agenda for social mission. They developed the resource pages on social mission and racial equity. It is anticipated that they will work with SMA staff to further develop a searchable resource database for the organization and to assist programs and institutions with developing social mission activities to move toward health equity and social justice.
Our vision is also to facilitate collaborative learning opportunities and provide detailed data reports that will be both of value to change agents and create sustainable growth for the Alliance.
The Social Mission Alliance continues to be a community of like-minded social mission warriors, standing on the shoulders of giants such as Fitzhugh Mullan and H. Jack Geiger, to grow the movement for transforming health professions education.