In “Education of health professionals for the 21st century, “ Lancet featured an international commission’s report that cited glaring gaps and inequities in health and health care outcomes, within and across nations, as constituting the most dramatic and incontrovertible evidence of the need to reform health education . To achieve the health profession’s potential for ameliorating health disparities, the Commission recommended profound health education reform, moving it from the tradition of informative learning, focused on transmitting knowledge and skills to produce experts, and beyond formative learning, which focuses on socializing students around values to produce competent professionals. Instead, the Commission urges us to champion transformative learning, which focuses on developing leadership competencies intended to produce enlightened change agents capable of creatively adapting global resources to address priorities in local needs.
The proposed health professions education reform for ameliorating health disparities comes at a time when we can build on existing and emerging knowledge about conceptual frameworks for understanding global health  and health disparities , translational research practices bringing the potential for preventing or alleviating suffering into communities , educational practices fostering health professionals’ responsive leadership skills,  and aspirations of medical students for acquiring expertise in ameliorating health care disparities .
Among the stakeholders influencing the design and evaluation of new medical school programs, medical education accreditation agencies hold considerable sway. Prior to 1998, medical education accreditation agencies focused their expectations on instructional objectives as a way for medical schools and residency programs to make explicit to trainees and to the public the knowledge, behaviors, and attitudes that the programs intended learners to acquire. Associated assessment measures echoed this focus, parsing measures of knowledge, skills, and attitudes .
Lessons learned from reviews of research conducted on attitudes of medical students and residents suggest cautions for current efforts intended to promote accountability of health education in preparing trainees to ameliorate disparities. Rezler characterized medical education research as often framing attitudes of trainees as a problem that medical education might hope to redress . In this tradition of approaching the study of attitudes of professionals in training as problems, studies of medical student and resident attitudes often documented declines in such valued professional orientations as altruism and empathy, with increases in cynicism, over the course of training. A recent review of longitudinal studies of empathy challenges the empirical evidence underlying the accepted wisdom about medical education’s insidious role in eroding attitudes assumed to inspire compassionate care, including empathic care of vulnerable populations . In this review, Colliver’s re-analysis of the data showed that the extent of attitudinal changes to be slight and variable in direction. Colliver also challenged the construct validity of the measures, which often used diffuse statements about attitudes.
Medical schools have been urged to develop curricula in ways that are congruent with theories of motivating medical trainees’ learning . Notable among these theories is Self-Determination theory, which emphasizes adults’ needs for competency, autonomy, and relationships . A concurrent critique of existing research on self-assessment recommends that medical education adopt approaches more aligned with promoting learners’ reflection and self-directed assessment seeking .
Although accreditation agencies have moved to an emphasis on competencies to promote accountability, medical educators caution that the very general characterizations of competencies left important work to be done for meaningful curriculum development and associated assessment, including grounding expectations for training in the context of real work responsibilities , and making explicit the likely scope of practice .
Particularly for competencies not represented in traditional medical education, the scope of practice might not be explicit and might not be consistently valued as definitive and necessary, especially for trainees with limited access to role models in emerging scopes of practice. For example, in the Canadian (CanMEDS) accreditation system, advocacy (defined as physicians responsibly using “their expertise and influence to advance the health and well-being of individual patients, communities, and populations)” constitutes an explicit expectation for every member in the profession . In the U.S. Accreditation for Graduate Medical Education (ACGME), advocacy is not explicitly defined as a goal of training for which a training program would be held accountable. Responses to Earnest’s  call to make advocacy, defined as “action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise” evoked markedly divergent responses, including protests that promoting advocacy would distort medical education .
Despite this ambivalence, medical schools are increasingly moving to provide instruction relevant to ameliorating global and domestic health disparities. A recent review of structured global health education programs in U.S. medical schools concluded that there was little standardization across programs in terms of their requirements for didactic, clinical, scholarly, and cultural components . In this emerging field, the development of a self-assessment measure for capturing students’ skills and career aspirations for their roles could inform our collective ability to develop and evaluate responsive curricula.
In this study, we explore the insights drawn from a competency-based approach to assessing medical students’ perceptions of their level of competency related to practice in ameliorating disparities in domestic and global health settings. We elicit the level of competency students see themselves as bringing to the table as they initiate participation in a co-curricular medical school pathway, and compare this to the level of competency they perceive that their future careers will need. Our study questions were:
what level of ability do medical students perceive themselves as having in defined competencies related to alleviating disparities, as they begin training for their careers?
what level of ability do medical students perceive themselves as needing to have for their careers as physicians committed to alleviating disparities?