The training of a new social-responsible generation of health professionals with a patient-centered vision

The challenges that Latin America faces in health are deeply related to others, such as access to clean water, the right to education, and housing. Health professionals that work in an environment where the population faces con-stant barriers to accessing care in the public health system or has limited resources to pay for it in a private sector will face an ethical dilemma, the question of how to honor the call to care for patients when there is not enough support system or infrastructure to do so. Within the schools of medicine and health sciences, the question is how to train students to face or resolve these conflicts. The social responsibility approach is a proposal that allows the alignment of education for health professionals and health systems to contribute to the creation of an effective, equitable, and sus-tainable system. The present article aims to dis-cuss this problem from the importance of training health professionals, ethical and committed to their communities, that have the skills and atti-tudes to implement a patient-centered vision. The involvement of universities and training institutions of the next generation of health professionals cannot be postponed.


Health professionals training
The students in health professions have participated for centuries accompanying the clinical expert, observing consultations, grand rounds, and even surgeries to learn from the practice in situ 1 . Although this has been the prevailing way for training new professionals 2 , the profession itself has advanced considerably in the last hundred years by developing credentialing, accreditation, and ethical standards processes 3 .
However, programs still need to transition from a science-based curriculum focused on health professionals as experts in the discipline towards programs in which graduates become part of interdisciplinary teams immersed in a health system 4 . Learning environments face the challenge of designing activities and fostering communities where students can be excellent physicians, psychologists, or nurses, prepared to compete in the international arena, resilient, and deeply committed to their community's benefit 5 .
The emergence of COVID-19 has again reawakened the need for the graduate's profile to support a social contract to anticipate the community's needs and patient-centered interprofessional care 6 . For example, institutions could train students to incorporate telehealth technologies and the efficient management of resources to reach those in remote areas and the most disadvantaged households.
Many undergraduate training programs have recognized the Hippocratic Oath as the start for this professionalism and medical excellence training. Some translated this statement as part of a specific course that provides the basic knowledge of future medical professionals 7 ; others integrate students' discussion of professionalism, patient rights, consent, and confidentiality in a clinical research course 8 . These programs have profoundly influenced the students to identify more with the Aristotelian-Thomist tradition that sees medicine as a relationship of trust between the patient and the doctor, which goes beyond the conception as a science or profession 9 .
Some trends on how to train this new generation of health professionals are evidence-based education and student engagement in social impact projects with the community 10 . These trends impact how the curriculum is organized in the sense that they lead to the design of an integrated curriculum that no longer teaches anatomy in the first semester expecting the student to recite muscle and bone locations by heart. Instead, it expects students to apply the principles of per-son-centered care and human dignity as soon as they interact with a patient. Another significant change is reflected in the place where the teaching-learning process takes place. Now, the university walls are no boundaries. To do this, universities have integrated technologies so that learning is more flexible and adapted to the student's needs and has allied with partner-trainers in different sectors such as civil organizations, hospitals, and research centers that provide challenges on-site solutions. This is especially relevant in the context of a crisis, such as the COVID-19 pandemic has been a challenge to overcome the interruptions in health professionals' training process. The first question that had to be faced was how the educational system could provide protection and security to the educational community. In particular, the added difficulty of guarantee academic continuity for medical schools, especially in developing clinical competencies, while continuing to honor social responsibility and rapid response to mitigate the virus's spread 11 .
Before this period in which SARS-coV-2, the virus that causes the new coronavirus, has caused more than 2 million deaths, to the day of writing this manuscript, and slightly more than 102 million cases have been confirmed 12 , some medical schools were already carrying out innovative efforts in teaching; however, his focus was the introduction of educational technology or the integration of a new teaching technique. Few of these educational innovations are focused on professionalism because self-reflection is needed to achieve these medical excellence transformations 13 .
Ethical training has a philosophical and anthropological basis that could potentially recover health professionals' patient-centered essence 7 . As health professionals immersed in the Latin American context, region that lead the coronavirus spread in early 2021, students will care for patients who bear scars of the social suffering that afflicts our communities 14 . Students need solid ethical training that allows them to be as prepared for the magnitude of these social problems; more importantly, society needs professionals who are socially responsible to face them.

Ethics in health professions
There is a renewed interest in medical education and health sciences in retaking and formally introducing values and competence related to ethics and professionalism into curricular structures 15,16 . However, there is no uniformity on these conceptual constructs, the values that make them up, and their foundation. Therefore, this makes it difficult to define precisely how to teach it, if this is possible, but even more so how to evaluate the development of these competencies 17 .
Traditionally, ethics and professionalism in health sciences have revolved around traditional values whose paradigm is the Hippocratic oath 18,19 . Centered on altruism and charitable dyad -no maleficence that starts from the famous "first, do no harm", within the framework of a personal relationship between the doctor and the patient, of an individual and non-public nature, a framework that for centuries the socalled liberal professions assumed 20,21 .
However, from the eighteenth century on, a series of political and social revolutions were presented that emphasized values such as people's autonomy and later accepting social pluralism, diversity, and culmination, the search for equity for all groups traditionally violated by the hegemonic culture. Historically health care has lagged with historical and social changes, and only until the second half of the 20th century, with bioethics as a vanguard discipline, new values began to be included to reflect these changes, which led to the development and mandatory use of informed consent in clinical practice and research 22 . For its part, the search for equity revolves around health care as a right and therefore as a state responsibility, which forces, due to its complexity and costs, to organize in systems that seek to a greater or lesser extent fair access to health services of people to these resources 23 .
As mentioned before, medical education associations have proposed the need to develop ethics and professionalism competencies in medical curricula formally. In this sense, different authors have reviewed this construct, the values that compose it, and the way to teach and evaluate them. Louise Arnold and David Thomas Stern 24 propose four essential values to develop medical professionalism (Chart 1).
It is key to social responsibility that the professional is accountable to both patients and their families for the quality of care and advocating for future patients to receive the best care possible. To do so, the professional collaborates with other health professionals to lead or delegate leadership to others when be indicated.
Another critical perspective around medical professionalism is that health care has been gaining universal recognition as a fundamental human right, a situation that somewhat breaks the Hippocratic tradition and the liberal traditions on which our classical professional values are based. This recognition as a fundamental human right has its development in a series of declarations and pacts that most countries have endorsed. Based on the Universal Declaration of Human Rights and the International Covenant on Economic, Social, and Cultural Rights, which in its article 12 recognizes the right of everyone to the enjoyment of the highest possible level of physical and mental health 25 . General observation 14 specifies additional four essential elements: availability, accessibility, acceptability and quality (Chart 2).
It is also necessary to highlight that this right to health is interconnected and depends on other rights since they become determinants of health, such as the right to work, to housing, to food, to the availability of drinking water, a healthy environment, and peace 26 . Therefore, every country must guarantee access to care, goods, and services from a non-discriminatory basis. Related to health, countries must ensure an equitable distribution of all health facilities and adopt a national public health action plan that includes healthy nutrition, primary sanitary conditions, including drinking water.

Essential value Description Excellence
A commitment to exceeding ordinary standards in technical, ethical, legal, and professional competencies; includes continuous learning throughout life, improvement of care and reduction of medical error, and promotion of scientific knowledge Humanism Includes respect, empathy, and compassion, in addition to honor and integrity Altruism Which implies always putting the patient's interests above the doctor's or health professional's interests Accountability Health professional's processes justify and takes responsibility for performance What does it mean that health care is a fundamental human right? Health professionals necessarily become more than workers in a system but defenders of human rights. They must act in the first line as guarantors of the human right to health of their patients and society in general. The health professional acquires an unavoidable social responsibility based on the discourse of human rights.
The paradigm of professionalism based on individual altruism, understood as putting the patient's interests above those of the health professional, must evolve to social altruism. This social altruism construct does not clash with physician interests but from the tension between the interests of the patient and those of the public and private entities that mediate access to health care.
Due to access to knowledge and the social and work position that is attributed to health professionals, they are the ones who share a call to be the guarantor of the patient's rights, especially of those individuals who can hardly defend themselves. However, this responsibility also falls on the institutions in charge of training health professionals. Unfortunately, the training and development of Human Rights competencies are still not consistently included in the curricula. Then, health professionals do not consider the task of defending human rights within their professional duties, and they do not perceive that their work has a social responsibility beyond that of taking good care of their patients.

Social responsibility
The influence of corporate social responsibility (CSR) ideology, a stream of thought that iterates the importance of companies' duty to society as corporate citizens 27 , has significantly impacted how medical institutions approach their patients and society as a whole. Leveraging the idea of the possibility to establish a win-win scenario without a clash between a firm's profit-seeking interests and the well-being of societies 28 , healthcare providers and related institutions start to adopt practices that are pursuing the overall wellness of society and environment. This stems from the idea that CSR could lead enterprises to acquire social legitimacy and credibility while enabling them to mitigate their riskiness 29 . CSR ethos, therefore, puts forwards the notion that the liability of a firm, whether legal, social, or financial, can be mitigated with favorable action towards society 30 . It requires businesses to follows society's values, beliefs, norms, and needs to ensure its share and stakeholders' well-being while protecting their financial interests.
In order to achieve these, corporations must implement corporate policies and practices that correspond to the social expectations of employees, communities, and environmental concerns of while maintaining ethical and transparent management through obliging laws, rules, and regulations 29,31 . In other words, businesses should respond to societies' expectations beyond their revenue-generating pursuits. Failing to recognize these expectations and not addressing them through the appropriate course of corporate actions would give rise to fame, defamation, and loss of public trust. These notions precisely hold for the healthcare industry as well.
In the healthcare industry, public trust is one of the cornerstones to serving and delivering quality healthcare service. This accounts for how the public perceives the institutions, actors; and, overall, the system's accountability in delivering optimal service a patient would need 32 . Most of the time, there is a strong correlation between corruption, lack of transparency, gender equality, sub-optimal service, and fame decay 33 . The enforcement of the civil rights that belong to every citizen affects other social determinants of health 23 . These either translate into the high cost to access quality healthcare services, delayed opportunity to receive treatment, increased distrust to the effectiveness of treatment, and lack of confidence in placement of the right doctors to the right positions. It damages medical practices, the Chart 2. Essential elements of the right to health.

Essential value Description
Availability Sufficient number of public health programs and establishments, goods and services Accesibility What is available must be accessible to all people referring to nondiscrimination, physical accessibility, affordability and access to information Acceptability What is available must be respectful and appropriate to the culture and medical ethics Quality The facilities, goods, and services must be scientifically appropriate and of good quality credibility of the institutions sink, and the health system operations. This is especially the case in the Latin American context. Data shows that about 26 to 66% of the population does not seek health care when they experience a problem due to long waiting lines outside health centers, the limited availability of medicines, and the lack of resources to pay for their care through private providers 34 . Families greatly suffer due to these factors and find themselves in the worst-case scenarios that would otherwise prevent incidences. Families are a crucial element in society's structure since it satisfies conservation, promotion, and recovery of health 35 . Also, they constitute the first support network that patients have for follow-up and adherence to treatment.
The general public, represented in the movement of patient associations, has gained more strength and relevance thanks to increasing awareness of for need to access medicines. Without a doubt, its incidence in politics for the defense of the right to health has been getting stronger 36 . To protect society and provide affordably, yet, high-quality healthcare, CSR practices must be part of Latin American countries. In this regard, institutions that provide medical training and universities must step up to raise awareness and promote CSR 37 . Their duty to society as institutions is to foster societal development, promote corporate citizenship, and illustrate the balance between economic gain and social justice. Failure to exemplify their ability to fulfill these responsibilities could burden the already fragile Latin American health system and put families and upcoming generations at a greater risk.
Even though the diffusion of CSR ideology among societies has become more prominent and trendy in recent years, it is not new. UNE-SCO declared that social responsibility in higher education as a commitment for all more than a decade ago 38 . However, there is still a scarce amount of information on approaching CSR in university and education settings. This pressing issue should be addressed. One way to address this gap is conceptualizing CSR application through establishing two main standpoints: CSR training as a competence 39,40 , and embeddedness of CSR practices in the higher education institutions 41 .
From this perspective, social responsibility is understood as a personal competency that can be invested upon to ensure others' well-being and the planet 42 . It can be defined as the intention and ability to take professional actions or omissions thereof that could positively impact the merits of society. In this sense, it represents a commitment to the well-being of citizens, preserving the common good and dignity of the individual in such a way that each person commits a positive act in their best personal and professional capacities to cooperate for the equitable development of all 39,40 . Besides, social responsibility links a practitioner's performance to their environment, livelihood, and specific capacities. It takes the "do no harm" oath a step further to a "do good." For this reason, when striving for social responsibility, specific instruments have to be developed to cultivate CSR related competencies of specific groups, such as university students 43,44 , eduadtors 45 , physicians 27 , and academics in health careers 46 . Yet, first, it is crucial to pinpoint what these skills are.
One of the earlier studies, Alvarado et al. 27 conducted a quantitative study in Chile among physicians, a heterogeneous group of 217 professionals, to determine what CSR are the common ones. As a result of the survey, scholars determined that 11 actions can be directly tied to CSR. After studying the results, scholars suggest that they could be grouped into three dimensions by factor analysis: orientation to the care of patients, orientation to the care of the work environment, and adaptation to the norms of the profession. They suggest these are the foundational values that all physicians should be educated to provide a wholesome health care service. Thus, in alignment with the previous literature, this study suggests that the development of social responsibility among students' prerequisites the bettering medical schools themselves as socially responsible organizations, which visions these schools to present and promote the three cornerstones mentioned above values through their key processes: management, teaching, research, and community engagement.
The Social Accountability Instrument for Latin America (SAIL) model was established on these values. The framework oversees medical schools' readiness to train students in social responsibility by identifying four domains: mission and focus on quality, public policy involvement, proximity to the community, and professional integrity 47 . This social responsibility model explains how the actors of the different interest groups contribute to generating effective solutions for the priority problems of society 48 . It underlines that Universities and training institutions have the arduous task of reconciling this apparent clash between internal and external groups' needs in a coherent proposal to train the new generation of health professionals.

The complexity of the healthcare context
Training socially responsible physicians have become critical in a current context marked by the right to health, the social inequity in which the health system is inserted, and the growing social demands for a more comprehensive and respectful approach to diversity.
However, each country follows its unique healthcare system. Therefore, a one size fits of may not work for all Latin American countries. Instead, it requires leveraging some degrees of similarities and accounting local nuances. The commonalities across the borders are the existing mixture of public and private services, such as public hospitals, private clinics, and insurance companies. Among these, the most vulnerable one in the public domain. While private institutions can handle patient surges through funding and immediate hiring, this is not the case for the public health system. The cumbersome policy requirement and limited capital flow force hospitals to exceed the number of patients they can handle optimally. In the name of ensuring the social rights of the poorest, especially in the context of primary care, doctors try to take care of patients as quickly as possible while only being able to meet basic minimum standards 14 . However, they neglect patient-oriented services, the care of the work environment, and adaptation to the norms of the profession. In other words, they neglect the three pillars of CSR.
These have been well documented in the relevant Latin American health literature strand. In Colombia, Guerrero et al. 49 describe that the challenges lie in universality and efficiency in a context of solidarity. In Peru, Alcalde-Rabanal 50 assures that one of the most critical challenges lies in eradicating the health exclusion that still negatively impacts between 10% and 20% of the population. In Honduras, Bermúdez-Madriz et al. 51 assure that the greatest systemic challenge is integrating public health services to eliminate organizational duplications, maximize coverage, and eliminate equity gaps between population with access to services.
Unfortunately, low-income countries tend to turn to first-world countries to find solutions to big problems. The pandemic has not been an exception to this. The already overload healthcare professionals begin to experience a new surge of patients with COVID-19 due to a lack of prop-er policy building 52 . The demand for healthcare services has increased, while the overburdened systems have not received any additional funding from the governments 53 . Not all regions could implement proper cautions like lockdowns due to the economic instabilities. In countries such as Mexico and Colombia, instead of quarantine, people's participation in informal trade jobs increased. As a result, the ongoing pandemic causes even more tension and stress at impeding public healthcare due to the excess number of patients.
The health system's role in terms of responsibility lies in the efficient and effective management of resources that serve the population that needs it most. In this way, the universalization of the right to health is guaranteed, at least theoretically. Also, the system must focus on generating strategies to ensure its operational sustainability in the future. An effective way to accomplish this goal is raising awareness of healthier lifestyles among citizens through CSR Projects. This requires redesigning and repurposing the traditional care models based on practices that improve the socio-economic livelihood of the population 54 . In other words, the health system should be morphed in such a way to deliver value beyond diagnosis and acute intervention and teaches patients to how to lead healthy and sustainable lifestyles. This would change the society's health system from the final benefits receivers to the center-point of the health care service.
Finally, the traditional medical model of health as science is in question, because to some extent, it fails to strike a balance among resource allocation, longevity, and corporate citizenship. On the one hand, it focuses on the disease. It tries to provide insight on how to remedy and cure sicknesses in technical terms. However, it fails to address the more personal and spiritual dimensions of medicine. The conception of medicine as a science, originated from pathological and biomedical findings is more evident in countries isolated from complementary and alternative medicine knowledge 55 . But recently, there has been a shift towards personalized treatments. A focus on person-centered care is the holistic response necessary in Latin America to achieve a balance and biopsychosocial, cultural, and spiritual harmony of the person, family, and community 56 .

Discussion
Social responsibility applied to transparency of information and the pluralistic representation of demographic diversity, particularly gender, emerges as relevant themes 29,31 . In Latin America a patient-centered focus might be a key. According to the professional career students wish to pursue, they can choose to participate as clinicians, researchers, teachers, or a mixture of these roles 57 . This personal and conscious decision made by an individual for a profession could how they advocate for the needs and rights of holistic health 58 .
The guiding principle for health professionals must be patients' wellbeing, more than the absence of disease and its common theorical approaches to the ethics of care. These implies a solid commitment to their community provided by socially responsible practices. For this reason, it is crucial to promote the adaptation of CSR and corporate citizen values into the curricula and the dynamics of medical schools as organizations. Educators can further support this. They are solid professional models that might reflect that commitment and engage in service towards the community that could inspire others to seek a career outside of the traditional private provider role.
As a first step, the commitment of universities must be fostered by an ecosystem where instruments, incentives, and institutes are aligned to create value for the community. This ecosystem interrelates and organizes the educational experiences in health professional's training, granting a purpose in each academic project. Working in health, professionals should be able to acquire technical knowledge through their training but also being able to fulfill their calling as professionals through serving the community.