Formulating a socially responsible curriculum for the Indian medical graduate: Charting the roadmap for creating socially accountable doctors

PRIYAMADHABA BEHERA; SURAVI PATRA

doi:10.25259/NMJI_97_2023

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Medical Education

38 (

); 226-231

doi:

10.25259/NMJI_97_2023

Formulating a socially responsible curriculum for the Indian medical graduate: Charting the roadmap for creating socially accountable doctors

PRIYAMADHABA BEHERA¹, SURAVI PATRA^2,

1Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

2Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Correspondence to SURAVI PATRA; patrasuravi@gmail.com

Published: 2025-10-09

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

[To cite: Behera P, Patra S. Formulating a socially responsible curriculum for the Indian medical graduate: Charting the roadmap for creating socially accountable doctors. Natl Med J India 2025;38:226-31. DOI: 10.25259/NMJI_97_2023]

Abstract

Background

Competency-based curriculum has opened new opportunities for teaching appropriate attitudes and clinical skills to medical students by focusing on one-to-one training. Foundation training in social responsibility (SR) sets the stage towards integrating SR in the longitudinal training course. Adapting principles of SR during clinical visits to field practice areas alongside vertical integration of community medicine departments with clinical departments with a blueprint of assessment can achieve the integration.

Methods

We describe the concept of social responsiveness, its contribution to medical ethics and professionalism and the opportunities for SR training within the competency-based curriculum. Socially relevant medical services established per local societal needs by individual medical colleges are discussed with methods of integrating SR training and assessment in the curriculum. Barriers to implementing such a curriculum with suggestions for opportunities are also highlighted.

Results

Integration of SR values within learning domains, careful selection of learning objectives and devising appropriate teaching strategies, together with incorporating elements of SR during the summative assessment, can work towards integrating SR in the curriculum.

Conclusion

A socially responsible competency-based curriculum should be able to create future doctors with a first contact with global standards of clinical skills sensitive to local social, cultural and financial needs.

INTRODUCTION

‘Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction’.

—Rudolph Virchow

It is said that physicians are the natural advocates of people with low incomes. Medical ethics and professionalism are rooted in the principles of Hippocrates and Paracelsus, which emphasize the pursuit of benefit, the value of human life, the avoidance of harm or mischief, and the pursuit ofjustice. The harmony between the triad of disease, patient and physician was understood as the core element of patient-centric medicine. Over the centuries, medicine has evolved from a patient-focused to a community- focused discipline, while maintaining the ethical principles of Hippocrates.¹

To enhance patient care and honour the social obligation of privileges that society has given, medical education strives towards excellence in providing patient care and embraces social responsibility (SR) in its ethos.² This has made medicine relevant for society, ensuring education, service delivery and research to aim for more socially meaningful outcomes. It has been demonstrated that curricula that move higher in social obligation towards social accountability and higher levels of professional involvement in designing services, research, and teaching have the highest impact on societal outcomes.³

The competency-based medical education (CBME) curriculum has scope for including SR for the Indian medical graduate (IMG), which can improve the quality and relevance of medical training and services, making the outcomes socially meaningful.⁴ We discuss the concept of SR in terms of its definition, its place within medical ethics and professionalism, SR in the medical curriculum, challenges in implementation, existing examples of SR integration with medical education, available opportunities and suggestions for better integration.

DEFINITION OF SR IN THE CONTEXT OF MEDICINE

Physicians are historically considered healers and are guided by the Greco-Roman tradition and the Hippocratic oath, which embodies values of competence, morality, integrity, altruism, and working towards the greater good.¹ The medical profession, in spirit, includes a sense of SR, an implicit contract between society and the medical profession. Professionalism and competence inherent to medicine envisage SR in the form of duties and responsibilities of the physicians towards the individual patient as well as the broader community which they serve in the form of promoting health, treating diseases, hence responding to the health needs of the local community ⁵

CONCEPT OF SR, SOCIAL RESPONSIVENESS AND SOCIAL ACCOUNTABILITY

SR, social responsiveness and accountability are often confused to mean the same and are used to convey the social obligation of a medical institution. In an intuitive sense, SR is the principle of commitment to societal welfare. Social responsiveness explicitly identifies societal health needs and organizes teaching, services and research to meet these needs.² Social accountability is the ultimate way of meeting the social obligation of a medical institution, wherein the teaching, medical services and research are organized to meet societal needs. These activities are conducted in collaboration with policymakers, local service providers, and stakeholders, and a collaborative approach is adopted towards formulating the respective goals.²

The WHO defines the social accountability of a medical school as: ‘an obligation to direct education, research and service activities towards addressing the priority health concerns of the community, region and nation they have the mandate to serve’. It has also provided a framework of social accountability for medical schools to guide their training and research.⁶ Relevance, equity, cost-effectiveness and quality are identified as values of social accountability by the organization in the domains of teaching, service and research (Table 1).

TABLE 1. The WHO social accountability grid for medical schools¹

Value				Domains and phases
	Education			Research			Service
	Planning	Doing	Impacting	Planning	Doing	Impacting	Planning	Doing	Impacting
Relevance
Quality
Equity
Cost-effectiveness

SR, MEDICAL ETHICS AND PROFESSIONALISM

Conventionally, medicine has taught values of integrity, morality, competence and altruism. Society considers medical practitioners as professional healers guided by their code of ethics. The social contract, implicit in the process, granted autonomy to medical practitioners over knowledge and self-regulation as a privilege in exchange for competence, integrity, and altruistic service to society. Autonomy to medical practitioners for the use of knowledge was granted, with the caveat that scientific knowledge would be used to train doctors, educate patients, caregivers, and society, and advance science. In the form of service, the medical profession must provide its services in a way that ensures equality in access and utilization. Selfless service, which is the sine qua non of the medical profession, warrants placing the needs of individual patients and society over ‘one’s’ good. Medical teaching, service and research are hence conceptually organized to be delivered for the benefit of humanity.⁴

SR IN IMG CURRICULUM

The National Medical Commission of India aims to produce an IMG of a global standard, encompassing knowledge, attitude, skills, values, and responsiveness, to serve as the primary point of contact for doctors in the community. The Attitude, Ethics, Communication (AETCOM) module has been rolled out to guide medical educators in developing local curricula in accordance with broad aims. The community doctor is envisioned to function as a clinician, leader of the healthcare team, communicator with patients, families, and society, and a lifelong learner who strives to develop their professional skills. He is expected to groom himself as an ethical, responsive professional accountable to patients, the community and his profession ⁴

The curriculum has charted learning objectives to recognize physician roles and responsibilities in the local society and broader community as part of developing a doctor’s identity, emphasizing professionalism, communication, and health advocacy in IMGs. SR is identified as one of the 39 core competencies delineated in the curriculum. However, further enumeration of the curriculum is required to formulate learning objectives, identify learning domains in terms of knowledge, skills, and attitudes, and detail the necessary didactic lectures, case scenarios, and assessment methods.⁴

The existing curriculum identifies SR as a learning objective conceptualized as a set of soft skills comprising reliability, trustworthiness, dependability, altruism and compassion. There is a need for the formulation of a curriculum that can be implemented longitudinally across the eight semesters to meet the learning objectives by incorporating locally developed social service opportunities for IMGs. This would help the IMG participate and develop SR attitudes and abilities. We suggest a model for integrating SR within the ethics component of the curriculum, incorporating principles of ethics and resulting social accountability (Fig. 1). The principles of social accountability can be taught alongside the four principles of biomedical ethics during the 2nd professional year in the AETCOM module. The suggested curriculum blueprint is described in Table 2. Committed faculty members with an inclination towards social work from multiple departments can combine their efforts to formulate learning objectives, prepare clinical social scenarios for student learning, and develop methods of evaluating the elements of SR within the existing assessment system.^6,7 Such a curriculum would be innovative and collaborative with society, hence requiring iterative development. Embedding SR in a curricular blueprint would result in transformative changes, leading to a sense of fulfillment towards the responsibilities of being a physician, as mandated by society.⁸

Model for integrating social responsibility with principles of ethics and resultant social accountability OOP out of pocket expenditure

TABLE 2. Blueprint for integrating social responsibility in the AETCOM module for medical student

S. No.	Competency domain	Domain of social accountability	Competency level
1.	Describe and discuss the role of non-maleficence as a guiding principle in patient care.	The principle of cost-effectiveness of a chosen intervention can be taught here wherein the student can help guide a patient to make an informed choice about an intervention based on cost-effectiveness	Knows how
2.	Describe and discuss beneficence as a guiding principle in patient care.	The principle of ascertaining the quality of clinical care can be taught here to the student in terms of evidence-based training interventions, hence meeting global standards of care.	Knows how
3.	Describe and discuss the role of autonomy and shared responsibility as guiding principles in patient care.	Choosing an intervention per the patient’s needs, hence training the medical student, the principle of relevance.	Knows how
4.	Describe and discuss the role of justice as a guiding principle in patient care.	The principle of equity in health care by teaching the medical student about the Ayushman Bharat digital mission.	Knows how

AETCOM attitude, ethics, communication

CHALLENGES IN IMPLEMENTATION

External factors: Political will and policymaker’s inclination, economic situation and health system structure influence

In a twin medical institution study conducted in the UK and Israel, the authors used a qualitative method to evaluate the perceptions of senior staff from the medical institutions regarding social accountability. The participants highlighted the challenges in funding due to economic instability and difficulty in fostering effective partnerships with voluntary agencies.⁹ In their Canadian medical schools’ study, Ho et al. reported funding difficulties and setting up a strategy for funding was also reported as a challenge.¹⁰

Institutional factors

In their qualitative study in the UK and Israel, Leigh-Hunt et al. reported that senior staff perceived academic prestige as an important deterrent in accepting social accountability. The participants felt that laboratory-based research is more valued by the medical institutes and the proportion of their medical students qualifying to become tertiary care practitioners. Hence, neither the research nor the training priorities of the institute were conducive to meeting the requirements of social accountability.⁹ The priority and values of staff and students, together with time constraints, levels of commitment, competing priorities, conceptual understandings, and the already heavy medical curriculum, along with the narrow focus of the curriculum, pose a continuous challenge in incorporating social accountability into practice.⁹ Similar results were reported from sub-Saharan Africa, wherein the participants, comprising faculty members and students, shared the economic constraints, deficits in knowledge and pre-determined research priorities of translational research hampered acceptance of social accountability in the medical institute.¹¹ Similar institutional constraints in terms of resources, time and institutional commitments were also reported by Reddy et al. in their qualitative research on stakeholders of graduate medical education in the USA, which included policymakers, medical teachers and institute members ¹²

In the current era of corporate healthcare, in many countries, medical practice is increasingly dictated by the corporate world, which controls the medical institute’s admission process, medical education, service delivery, and research activities. The financial interests of the governing body of such corporate-run medical institutions guide the quality and scope of services delivered to patients. In this process, even patients and services are selected according to the corporate body’s mandate. When the mode of payment, amount of money paid and financial profits become deciding factors, societal priorities and medical professionalism are sidelined. These conflicting interests have motivated social scientists to revisit the concept of medical professionalism for the greater good of society.¹³

In India, qualitative research conducted at a tertiary care medical institute revealed that faculty members shared a sensitivity towards accepting the concept of social accountability. Many were aware and even practiced SR in teaching and providing clinical services. However, the faculty also acknowledged their lack of awareness about implementing social accountability in practice.¹⁴

Implementation difficulties

In their qualitative study, Leigh-Hunt et al.⁹ reported the challenges in implementing social accountability in medical and institutional activities. The research participants shared their perception of the problem in developing assessment matrices to measure progress and the resulting fatigue in the process. Ho et al.¹⁰ reported difficulty in assessing the implementation of social accountability as a philosophy in 17 Canadian medical schools, as noted in their qualitative research. Similarly, Dandekar et al., in their Indian qualitative study, reported the perception of difficulty among medical faculty in understanding the exact ways of implementing the concept of social accountability in research, teaching, and clinical services.¹⁴

OPPORTUNITIES FOR SR EDUCATION

Postings in Community Medicine departments, which provide opportunities for visits to field practice areas under faculty guidance, are a rich source of medical education for IMGs. These visits demonstrate the local population’s healthcare needs, the existing healthcare systems, and the management of diseases within the primary care system. These postings, part of the routine longitudinal training of IMGs, are an excellent opportunity to teach elements of SR in terms of the equity, effectiveness, and relevance of healthcare services.¹⁵

TOP-DOWN OR BOTTOM-UP

There are instances of student-led educational and clinical services in the local society that have been further refined and supported by faculty members of an organization. In studentled programmes, the role of faculty members should be to guide programme development, build collaboration with stakeholders, and define the components of service delivery. The organization should contribute in terms of resources and staffing. In the process, the multidisciplinary faculty team can formulate a curriculum that incorporates elements of SR in terms of knowledge, attitudes, and skills to be implemented throughout UG training. Assessment of individual core learning objectives can be appropriately evaluated; for instance, attitudes towards social contribution, soft skills of responsibility, dependability, and altruism can be assessed during fieldwork, whereas the knowledge component can be evaluated in a theoretical paper.¹⁶

Institutional social accountability

The capacity of institutions to meet the social needs of the populations they serve can be measured using accreditation standards. There are regulatory standards that have been formulated based on domains of conceptualization, production and usability. Conceptualization involves creating professionals to a standard and quality that a system of service requires. Production is the process of training and learning. Usability refers to the extent to which institutions ensure that their professionals are effectively and efficiently utilized to their fullest potential. The World Federation of Medical Education has set up international standards for evaluating these three domains of social accountability of institutions.¹⁷ Institutional social accountability can enable faculty to formulate learning objectives and learning experiences of medical students in tune with the core SR competency as per the CBME.

INTERNATIONAL EXAMPLES OF IMPARTING SR TO MEDICAL STUDENTS

Integrating climate change in the medical curriculum of the USA

A group of former students from a California medical college designed and implemented a study on the effects of climate change on health across preclinical, clinical, and residency periods. This group of physicians integrated the impact of climate change and existing social inequalities on undergraduate medical curricula, focusing on the health of low-resource communities. Integrating climate change with reproductive health courses through didactic lectures, case-based learning, and teaching counseling and advocacy across the longitudinal medical course helped develop a socially relevant curriculum that could yield socially relevant outcomes.¹⁸

Integrating social accountability in an urban CBME programme from Australia

The partnership between faculty members of an Australian medical centre and community members of their urban community health programme helped delineate the service needs of the local population, based on which health counselling for the marginalized adolescent population was carried out by medical students with appropriate training in medical ethics and health education counselling. Both medical students and participating adolescents reported the efforts as rewarding.¹⁹

SR in medical education curriculum from Africa

South African medical colleges have imbibed their culture of ‘holistic humanness’ in their medical education curriculum. Medical schools provide teaching in community-based primary health centres, and this teaching is imparted using a community- based curriculum. The selection of entry-level medical students is based on their domicile, with preference given to candidates from rural areas who intend to serve their communities after completing their training.²⁰

SR practised by medical students of Canada

The medical student-run medical services for the refugee population of a Canadian province provide a gateway for this population to access the existing family medicine services offered by the faculty of medicine. The medical students conduct a history taking session with basic health screening, providing the family with access to a family physician. During this exercise, medical students learn about cross-cultural healthcare and health advocacy for underprivileged populations.²¹

SR in medical education curriculum from New Zealand

The medical education curriculum for undergraduates at a medical institute has developed a socially accountable curriculum for the underprivileged Maori communities. The curriculum was developed in consultation with the community, taking into account their needs. Social accountability is embedded in the selection of a proportion of medical students from the community. It includes perspectives and concepts from the Maori community, as well as healthcare delivery and research, in terms of advocacy for the community’s health, stakeholder investment, and support from the institute. A joint effort between the medical institute and the Maori community formulated measures of social accountability. They were converted into an undergraduate curriculum to establish learning objectives, design and develop the curriculum, and assess the outcomes. The domains of relevance and equity are hence being addressed in this curriculum.²²

INDIAN EXAMPLES OF TEACHING SR TO MEDICAL STUDENTS

Mahatma Gandhi Institute of Medical Sciences, Sevagram (MGIMS)

MGIMS aims to provide quality medical education and healthcare services to rural communities. It has introduced several innovations to its curriculum, aiming to raise the social consciousness of medical students and hold them accountable for their social responsibilities.²³ The institute offers the village adoption programme and 3 camps: (i) Orientation camp, Social Service camp and Reorientation of Medical Education (ROME) camp to medical students. The Orientation camp is held at the beginning of the academic year for lst-year students. It aims to introduce students to the Gandhian Philosophy, the MGIMS community, faculty, and facilities, and to help them adjust to campus life. It includes team-building activities and orientation sessions.

The Social Service camp is for 2 weeks in the rural areas surrounding Sevagram, with the purpose of exposing students to the challenges faced by rural communities and developing their understanding of the social determinants of health. Students participate in community service activities, including health camps and health education programmes, during the camp. The students also observe how community leaders, social organizations and village health committees work together for health. Students interact with village health workers, village health committees, schoolteachers, and other stakeholders to understand their contributions to health. This community- academic partnership offers a unique opportunity to learn about the social and cultural determinants of health. The ROME camp is a 2-week residential camp conducted at a rural health training centre (RHTC). It is conducted at the beginning of the sixth semester for every batch of medical students. This camp provides students with exposure to the primary healthcare system and other support systems available in the community in India, demonstrating the implementation of national health programmes. It also provides an opportunity to impart skills to students to conduct community health needs assessments using quantitative as well as qualitative methods. The village adoption programme starts from the social service programme and continues for approximately the next 3 years.²⁴

Christian Medical College (CMC), Vellore

The college incorporates SR into its medical education curriculum by emphasizing community-based learning, ethical considerations, patient-centered care, interprofessional education, and social determinants of health. It has a village adoption programme similar to MGIMS Sevagram. At the same time, the Community Health and Development Hospital at CMC, Vellore has an innovative approach. The posting at rural field practice areas (RHTCs) and Urban Health Training Centres provides a unique opportunity for students to interact closely with the community and the healthcare delivery system, and to understand the importance of the social dimension of health.²⁵

All India Institute of Medical Sciences, New Delhi (AIIMS)

AIIMS has its own way of exposing students to social accountability. The focus remains on producing doctors who are competent in preventive, promotive, and curative knowledge and skills. ‘Students are given community-oriented training in urban and rural settings, whereby students are taught to carry out various activities under the guidance of faculty members’. The medical students have community exposure visits. Students also present clinical-psychosocial or clinical-social case studies or family presentations. The primary objective of this presentation is that students should understand the social model of disease beyond the medical model of disease. ‘They have to understand that there are larger social influences that are more, if not equally, important to medicine in determining who develops sickness or its consequences’.^26,27

Government Rehabilitation Institute for Intellectual Disabilities (GRIID), Chandigarh

The GRIID was established with the objectives of providing educational, rehabilitative, medical and vocational services. The services aimed at empowering people with intellectual disabilities and their caregivers are provided through multisectoral coordination with departments of education, health, housing, and employment, in consultation with local governments and international agencies. Local governments and service providers recognize this model of lifelong care and support for individuals with disabilities.²⁸ When exposed to serving the intellectually disabled in these settings, medical students can acquire the requisite knowledge, clinical skills and aptitude to serve people with developmental disabilities.

Postgraduate Institute of Medical Education and Research, Chandigarh (PGIMER)

The neuroscience laboratory of PGIMER has set an example of academicians SR in line with the philanthropic concept of corporate SR. The laboratory has been able to recruit volunteers who contribute in terms of time and physical labour, maintaining cleanliness and hygiene around the premises of the neurosciences centre. The School of Public Health trainees are now contributing to patient empowerment and satisfaction by implementing patient-centred care.²⁹

THE WAY FORWARD

Individual institutions have the task of charting of their competency-based curricula while focusing on the needs of the local population and existing systems of care. Joint engagement of faculty, residents and students in clinical activities carried out in community settings in a socially accountable manner provides and can help provide care to the local population. This effort would also train socially accountable doctors. Both top-down and bottom-up approaches towards service delivery should be equally promoted with opportunities for mutual respect and learning, resulting in benefits to society and the training of doctors. Collaboration with stakeholders can further reduce the healthcare disparity and promote healthcare provision for those in the greatest need. This can help reduce the existing disparities in healthcare in India. Furthermore, preparing models of medical education that train students to be generalists rather than specialists, able to work in multidisciplinary teams, and choosing to work in the local community is possible by developing a socially accountable curriculum.

Such a socially accountable curriculum can help reduce the disparity in healthcare in our country and reach the most vulnerable populations.³⁰ Developing local service delivery models would work towards increasing access to care, formulating equitable care and hence contributing to universal coverage of health services. In principle, a socially accountable service delivery system would be more acceptable to the community and work towards reducing the growing intolerance and trust deficits towards doctors in Indian society.³¹

Conflicts of interest.

None declared

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