The time is now! Or is it not? Exploring when trainees are ready to learn health advocacy

More than a century ago Dr. Rudolph Virchow wrote, “The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”¹ Today, there is increasing discussion about how to train clinicians in preparation for the role of health advocate. But how and – perhaps more importantly – when is the right time for advocacy training?

Advocacy has long been discussed among medical educators as a component of leadership training in healthcare professions training. In Canada, the CanMEDS physician competency framework includes developing health advocates as one of the core competencies for physicians in training.^2-4 The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements for residencies houses advocacy under the core competency of system-based practice.⁵ Advocacy is not only a component of leadership but also an important piece of the social determinants of health education. Once a health-related social need has been recognized, the provider’s response is and should be one of advocacy. Dobson, Voyer and Regehr describe two different advocacy skill sets that healthcare providers can utilize in addressing the social needs of a patient. The first is provider agency where the provider links the patient to medical or community resources, effectively “working the system” one patient at a time. Alternatively, providers can individually or through community partnerships address social needs at a higher level, “changing the system” for entire communities and populations. This is called provider activism.² Indeed, the ACGME advocacy requirement that residents demonstrate competence in “advocating for quality patient care and optimal patient care systems” speaks to both types of advocacy, agency and activism.⁵

Anecdotally, it has been easier for me to develop trainee engagement when discussing provider agency. It is immediately applicable to my learners – family medicine residents – as they can readily see the uses. Furthermore, they have already developed the skill to some extent as they link their patients to community resources during the course of the clinic session. Conversely, activism has required a greater leap of faith from my residents. Despite my trainees’ desire to be community physicians, leaving the walls of the office behind in an effort to change public policy has proven decidedly challenging for them. After I presented a workshop on how to talk with members of congress including a review of relevant health issues at local, state and national levels, some of the learner feedback included statements like “physician responsibility for advocacy is debatable.” This is not surprising, and similar views have been expressed in the literature.⁶

However, when I discuss the challenges of advocacy training with other practicing clinicians, they are often in a different place than my learners. They see the need to move beyond helping one patient at a time and embrace the idea of systemic change that can help many patients at once. So, when is the right time to teach advocacy, especially the brand of provider activism?

During a brief literature search (see figure 1), I found a compelling article that helped me to put into context the gap between trainees’ desires to promote the health of entire communities and the lack of participation in such activities that align with that value (i.e. provider activism). It turns out context is everything. The authors theorize that the culture of medicine especially during training plays a large role.⁷ There are too many expectations, too little time, and a sense of being overwhelmed that inhibits meaningful participation in advocacy activities that go beyond provider agency. Cynicism grows during third year medical school.⁸ Students and residents are exposed to other learners and teachers who parrot the notion that addressing social needs is not in the purview of clinician and should be delegated to our social worker colleagues. And yet multiple qualitative studies suggest that seeds can be planted during training that may blossom later in a career, after experiences with vulnerable populations and exposure to role models allow for a re-framing of the concept of advocacy and the clinician’s role within a community.^7,9,10

View Figure 1

My own experience mirrors that path. I was initially drawn to medicine specifically by the desire to provide quality care with empathy to those who need it most. I was fortunate to find a residency program that focused on that mission. However, during my three years of residency training I was consumed with my own daily survival, of meeting requirements, checking the boxes of completing my charts, signing paperwork, rounding with the attending and so on. Even my first years as a practicing physician were much of the same. It was only after achieving sufficient mastery of the medical knowledge and patient care that my brain found the space and time to begin exploring larger systemic issues that were clearly impacting the health my patients and the surrounding community. My early experiences were important in developing this perspective, even if I didn’t have the mental, physical or emotional bandwidth to meaningfully address the social and structural processes at the root of the health inequities in my community.

My current philosophy of care requires me to act in the face of injustice, both on an individual level with my patients and on a larger scale by continually participating in the slow and grueling work of social change. In an attempt to do this work, I joined the public policy committee of my specialty’s professional society state chapter. I now sit on a county-level civic board, focused on addressing gender and race inequities in the region. I joined our clinic in in a letter writing and phone call campaign this past November and we were able to convince city council to fund the maintenance of a senior center for low-income older adults. I do not require residents to participate in these activities with me but I do talk about my experiences and do my best to model what their future role as a community doctor might look like.

But is it enough? We know that role modeling advocacy behaviors are not enough to train clinicians as health advocates¹¹. Hubinette and Dobson continue to be the thought leaders for physician training in advocacy, and they recently published a health advocacy curricular framework³. To successfully design such a curriculum for any program or institution requires us as educators to consider where our learners are and to meet them at that point. For me, that has involved scaling back my expectations of what advocacy participation should look like, and instead focusing on teaching provider agency and ensuring that skill is robustly developed in all my residents. This includes a foundation in examining social determinants of health and local health inequities, as I believe until that knowledge is cemented, advocacy training cannot be achieved. When I encounter trainees who are ready to engage in advocacy at a higher level, I suggest methods of community involvement. I cannot single-handedly heal the sickness in the culture of medicine, nor do I completely control the learning environment in which my trainees are immersed. Together, these things make up the hidden curriculum and until that is addressed, I may not be able teach advocacy according to my vision. But I hope each of us educators will continue to plant the seeds within our learners that will one day bloom into health advocacy in partnership with patients and communities.

-Megan Rich, MD Community of Practice Member

Megan Rich, MD is an Associate Professor of Family & Community Medicine at University of Cincinnati and the Associate Program Director the Christ Hospital/UC Family Medicine Residency. Additionally, she is the fellowship director of the Community Primary Care Champions Fellowship in Cincinnati, OH and co-medical director of the new UC Student Run Free Clinic. She teaches on the social determinants of health with the residency. She is currently working towards her Master’s of Medical Education. If interested, you can read more at: www.meganrichmd.com  

References

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5. Accreditation Council for Graduate Medical Education. ACFME Common Program Requirements. Effective July 1, 2017. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. Accessed May 21, 2019.
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