When I work with early third year medical students in the residency clinic, I notice that they focus on taking thorough clinical histories to better understand the etiology of a patient’s complaints so that the correct diagnosis and treatment can be identified. As students’ progress from the classroom to the clinical setting, they start to understand that getting to the “correct answer” is not even half the battle when providing comprehensive health care. In fact, research has shown that when looking at various drivers of health, including health behavior, social and economic environment, physical environment, and clinical care, clinical care only accounts for about 20% of a person’s health outcomes.1 Social Determinants of Health (SDOH) add several layers of complexity to the greater picture of an individual’s health. The CDC defines SDOH as “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes”.2 Based on this data, more robust curricula have been implemented in Undergraduate Medical Education (UME) across the country to better address SDOH so that students better understand the barriers to care that have very real consequences for patients.
We continue to discover new ways that the system in which we operate, and other various structural factors highlight and perpetuate inequities. Now that I am a third-year Family Medicine resident in a program whose mission encompasses healthcare for the underserved, I worry less about finding the “correct answer” and more about the real-life outcomes. When I was a student learning about the SDOH, I assumed that residency would be the place where I would be able to focus on solutions, and that healthcare advocacy would be part of my professional obligation. While I feel fortunate to be part of a residency with a culture that supports advocacy where inequities persist, I still too often hear that we “need to work within the broken system.” Have a patient that can’t afford Xarelto (rivaroxaban)? Reach out to the pharmacy team or use the internet to find a coupon code to help make the medicine more affordable. Insurance won’t cover that rehab stay for your homeless patient who just suffered from a stroke? Call the peer-to-peer hotline, reach out to social work and case management and when that all still fails to get your patient proper placement because of lack of insurance, well…. Too bad.
Agency is a branch of advocacy with which most of us are familiar. Agency is defined as “a variety of activities that involve navigating the system: providing information and education, making connections to community resources, making referrals to non-clinical professionals and helping navigate both the health care and other systems” 3 While agency is one component of advocacy, it is distinct from activism. Activism is defined as “action that brings about institutional (e.g., practice level, hospital-level, healthcare system-level), social, economic, or political change” 3. While I acknowledge that agency is important in helping patients navigate “the system,” I strongly believe that residents need to receive standardized training in both agency and activism. Experiencing residency through COVID, increasing racial tension, gun violence, the overturn of Roe v. Wade (the list goes on) has made me and my fellow residents feel powerless when it comes to enacting real change. Learning about SDOH and navigating through a “broken system” (agency) can only get us and our patients so far.
Physicians have a unique perspective when it comes to system-wide changes. It is our duty to protect those who are vulnerable or being discriminated against, and it is becoming increasingly difficult to do so with certain laws and policies in place. I sometimes wonder, why did I go through medical school and residency to become a physician if I am unable to provide the care that I know will be of benefit to the patient in front of me? I like to focus on solutions, so the next natural question is: what’s next? We need to push for a standardized advocacy curriculum not just in primary care residencies, but in all residency programs.
I have heard several physicians say that they “only want to focus on clinical care” and “leave the advocacy piece” to others. How can we continue to perpetuate this idea by not incorporating advocacy into our training when the evidence shows that our patients’ health is largely being affected by factors outside of clinical care?1 It could be argued that there is “no time” to address advocacy training when there is so much medical knowledge to be learned in residency. Clinical knowledge is important, and we need to be up-to-date on the most evidence-based medicine practices. However, as our former Program Director and current Department Chair states year after year in our didactics, “medicine is open book.” I can always look up recommendations for colon cancer screenings or treatment for atrial fibrillation. The skills needed to enact change via agency and activism are not so easily found or learned through a quick database search. There is no clear-cut algorithm for when and how to be an advocate, and there is no switch that flips “on” after graduating residency that will give newly minted attending physicians the ability to advocate effectively for their patients.
A systematic review of advocacy curricula found that primary care residencies account for the highest representation of advocacy work (likely due to the mission and role of primary care), with pediatrics residencies taking the lead4. The article states that the high volume of Pediatrics advocacy curricula “speaks to the role of accrediting bodies in driving curricular innovation”4. In order for a standardized advocacy curriculum to gain a stronger foothold, we will need to push for institutional and program support across the board (e.g., ACGME requirements for advocacy training). Other barriers to implementing an advocacy curriculum exist, but pediatrics residencies especially have shown that it is possible to prioritize this training in residency. However, even with institutional support, the curricula vary widely and do not have very clear or measurable outcomes4.
The structure of existing curricula involves anything from didactic seminars and modules to experiential learning and community-based advocacy. Even the length of training varies; some curricula last one half-day, while others are longitudinal and go on for several weeks. In addition, programs emphasize advocacy on different levels, ranging from community to state to federal. Some focus on taking action, such as writing letters to the editor or calling representatives, while others focus on research, grassroots advocacy, or public speaking4. All of these skills are valuable, but no two curricula are exactly alike, which makes something standardized difficult to be implemented across different residencies. Among existing advocacy curricula, the analyses for the efficacy of this training involve pre- and post-surveys, interviews, focus groups, and personal reflection. Are residents reporting better implementation of advocacy work simply because they have learned more about it, or will they actually take the skills learned with them into their clinical practices and beyond?
We still have a long way to go in devising a standardized advocacy curriculum, and it is tough to know where such changes will lead us. That being said, we need to take action so that physicians have a better ability to advocate fully for their patients and to empower patients to advocate for themselves. As for me, I will be using my elective time to research more about creating a more structured advocacy curriculum for my program, but I recognize that such changes cannot be made without institutional and cultural buy-in. We cannot afford to simply work within the broken system any longer; instead, we need to work together to develop systemic solutions.
-Emily Furnish, MD
Dr. Furnish is a third year categorical Family Medicine resident at The Christ Hospital/University of Cincinnati Family Medicine Residency Program. She is originally from Louisville, KY and attended medical school at the University of Louisville School of Medicine. She plans to pursue a Hospice and Palliative Medicine Fellowship after completing residency and hopes to work as a Primary Care and Palliative Medicine physician after fellowship.
- Park H, Roubal A, Jovaag A, Gennuso K, Catlin B. Relative contributions of a set of health factors to selected health outcomes. American Journal of Preventive Medicine. 2015;49:961-969.
- About Social Determinants of Health (SDOH). Centers for Disease Control and Prevention. https://www.cdc.gov/socialdeterminants/about.html. Published March 10, 2021. Accessed September 7, 2022.
- Maria Hubinette, Sarah Dobson, Ian Scott & Jonathan Sherbino (2017) Health advocacy, Medical Teacher, 39:2, 128-135, DOI: 10.1080/0142159X.2017.1245853
- Howell BA, Kristal RB, Whitmire LR, Gentry M, Rabin TL, Rosenbaum J. A systematic review of advocacy curricula in Graduate Medical Education. Journal of General Internal Medicine. 2019;34(11):2592-2601. doi:10.1007/s11606-019-05184-3.