Translating medical school social missions to student experiences

Context: There is a growing focus on the social missions of medical schools as a way of expressing an institutional commitment to service, responsibility and accountability. However, there has been little exploration of how a social mission translates to student experiences. Methods: This multicentre study explored how the social missions of eight medical schools (from Australia, Belgium, Canada, the Philippines, South Africa, Sudan and the USA) translated to their medical education programmes, and how their students perceived the mission. The study used a nested case study design involving interviews with final-year medical students. Constructivist grounded theory techniques were used to analyse the data. Cultural-historical activity theory concepts of externalisation and internalisation were used to structure the analyses. Results: The study identified substantial variation in the form, focus and depth of expression of each school's social mission, significant variation in how and to what extent the mission was externalised in the design of each school's undergraduate medical education programme, and significant variation in how students perceived the social mission and its translation to their training experiences. The translation of a social mission to educational outcomes depended on a cascade of externalisation and internalisation processes, each of which could alter or reinterpret the mission. Translation depended to a great extent on sensitising learners to the mission's values and issues and subsequently activating this knowledge in the context of direct clinical encounters that embodied the issues the mission was seeking to address. Conclusion: Whether a medical school's social mission is focused on equity of access to the medical profession or on its graduates serving particular community needs, the mission principles need to be translated into practice. This translation process involves a series of externalisation and internalisation steps, each of which determines how much and what aspects of the mission are translated.