Oandasan, Ivy F.; Barker, Keegan K.
The World Health Organization describes some of the qualities of the 21st century “five star doctor” as community oriented, reconciling individual and community health needs, and initiating actions on behalf of the community.1 Despite the recognition that the community should play a larger role in the work of physicians, there is little agreement on how this should be done2 or how it should be taught.
One aspect of responding to individual and community needs is the call for physicians to be health advocates.3 In medicine, advocacy involves working with and on behalf of patients to obtain services and resources; modifying policies and procedures that have harmful influences; and promoting new policies and procedures that are beneficial.4 Physicians may make changes and advocate for individuals and they may work for changes at community and broad institutional levels.4 Hence, physicians advocate on micro and macro levels, based on their unique relationships (individual or collective) developed with patients over time.
It is an expectation that Canadian postgraduate training programs teach trainees to be health advocates.5,6 The current structure of medical education emphasizes pedagogy related to the physician-patient relationship, and thus advocacy opportunities at this level. Although there has been a movement toward educating trainees on the role of the physician in the community,7–10 there is room for innovation in teaching the specifics of this role. Indeed, there is paucity in the medical literature of discussions of the physician’s role as a community advocate.11
This article highlights preliminary results of a larger study that explored how exemplary community-responsive family physicians responded to the needs of their practice communities. While a succinct articulation of community responsiveness is difficult to describe, this type of work is recognizable. In this study, we found that of the variety of ways family physicians responded to community needs, advocacy was by far the most common activity carried out among these participants. Few operational definitions of community health advocacy exist, thus creating an educational dilemma: If community advocacy cannot be defined, how can it be taught? We sought to characterize the nature, inclination, and impact of community-responsive physicians in their role as advocates to address this educational fissure.
The case study method12 was chosen to explore the nature of community responsiveness among physicians who seemed to practice this skill. As an initial attempt to develop operational definitions in a domain requiring much exploration, it was determined that purposefully choosing case study physicians who provided positive examples of community responsiveness, and who worked in communities that were easily definable, would generate a rich source of information for this study. Five communities were chosen to reflect the diversity of the contexts in which Ontario family physicians work: communities were based on geography (suburban, rural, and northern communities) and populations defined by disease (positive HIV status) and sociodemographics (homelessness).
Exemplary community-responsive family physicians were recruited by speaking with management personnel from social service and health-based community agencies. They were asked to identify names of primary care physicians exemplary in responding to their respective community’s needs. The physician who was consistently named the most responsive for each community was invited to participate in the study by telephone. Inclusion criteria ensured that the participants were general or family physicians practicing primary care at least two days per week for the past five years with no affiliation with the primary investigator (clinically or academically).
In two communities, two physicians were identified as community-responsive exemplars, and in another community a colleague of the case study physician also emerged as an exemplar. Hence all of these physicians were asked to participate in the study. In total, eight in-depth interviews were conducted representing five communities. In qualitative research, sufficiency of sample size is unpredictable, because the researcher looks for information from rich cases13 rather than a specific number whereby validity and reliability are ensured.
After giving informed consent (aligned with ethical approval from the Education Ethics Review Committee of the University of Toronto), the physicians participated in two 90-minute audio-recorded interviews using a semistructured interview guide with field notes taken. They were asked to share stories and describe instances when they believed they were community responsive. After the first physician interviews, the researchers contacted individuals (medical colleagues, community members, and patients) who interacted with these physicians for an interview. The information obtained from their interviews influenced the questioning and discussion for the second physician interviews. The focus of this article is on the interviews for each of the physicians. The present data set is informed by the information gathered from the medical colleagues, community members, and patients, but their specific data will be discussed in other publications.
The data were collected and analyzed in an iterative manner. All documents and transcripts were read by the co-authors. Through a constant comparison analysis method, themes were developed and discrepancies carefully discussed to ensure validity and accuracy between the examples and the transcripts.14 The software program NVivo15 was used to support nonnumeric unstructured data indexing.
This article focused on findings regarding the common characteristics shared by community-responsive physicians who were found to engage in patient and community advocacy activities. Three main themes revolving around the notion of advocacy were found among the physicians: knowledge, influences, and motivations. Under each of these main themes, subthemes are detailed and described with supporting quotes.
The theme of knowledge is reflected in the physician-participants’ knowledges of difference, social determinants of health, and the power and privilege of the physician role.
In the subtheme of knowledge of difference, participants described a personal perception that emerged at a young age. This knowledge was separated into two distinct understandings: self-difference and other-difference. First, some physicians’ awareness related to their own personal difference from other persons (self-difference): They regarded themselves in relation to people around them and noticed “I am different.” One of the physicians in the study who was gay described how others viewed him growing up:
… you also hear a lot of negative comments and derogatory stuff made about people of your kind, in public, consistently, continuous … from your own parents from your friends, from other people that you think you trust and are your role models, so you realize … you are abnormal.
Other physicians described how life experiences led them to understand that people are not treated equally and that differences exist between people (other-difference). One of the physicians, while on holiday in Tangier with his family as a youngster, described the following experience:
… we were going through a bus ride and this woman was running down the street and this horde of … must have been 300 people chasing her … stoning her as she went down the road … I must have been … 10 or 12, being completely shocked to see that … my mom used to work outside the home as my dad did so there was no separation of man versus woman … [I] hadn’t realized there was a difference between the men and the women but then to see this. It sort of drove home a huge thing …
Most of the differences were related to inequities and unjust treatment among populations. The physicians learned to understand “the ebb and flow of the vulnerability of different populations and why some are in and some are out at different times.”
Another subtheme under knowledge was that of physician power and privilege. In recognizing that social and systemic factors have powerful influences on health, the physicians reported practicing critical thinking and questioning of the status quo: they saw the world with a critical lens. They also turned this lens on themselves, examining their own roles in maintaining inequity and power differentials, developing a knowledge of the power of the physician role, and the privilege that goes along with it. One physician said:
I believe that physicians are among the most privileged people in society, and I think physicians who fail to see that are self-centered. Maybe they’re burned out. … But I think, as among the most privileged people in all of our society, we should give back to society. And the greater good.
Finally, a knowledge of the social determinants of health was found among the participants. One physician said:
different things are key to a person’s health, and if you … believe in serving your clients … then you need to spend some energy correcting the other pillars of injustice that … keep making your work harder on every day level, right?
In summary, the physicians reported knowledge gained around the issues of power, privilege, difference, and the social determinants of health.
In the second thematic category (influences), physicians discussed two factors that inspired the way they practiced medicine: role models and exposure to marginalized groups. All the physicians had role models that shaped their perspectives. As one physician stated: “it’s like I’ve been able to see further than others because I’ve stood on the shoulders of giants … ultimately they sensitize me in ways that I don’t think anybody else could.”
Inspirational role models included both professionals and family members. One physician stated that his grandmother was his “hero,” propelling his community advocacy work, because she dedicated her life to helping the disadvantaged:
… she would help organize … smuggling the medicine from town to town to help the people who got sick through the wars … she would organize my grandfather’s [medical] practices so he would focus his energy on the poor people and the working class people rather than the rich people.
The second subtheme under influences was exposure to marginalized groups in clinical and nonclinical settings. Many of the physicians were exposed to populations that sensitized them to the issues of difference. All the physicians described experiences during their medical training or early in their medical careers where they worked with disenfranchised and underserved persons. This exposure was a strong determinant in their future decisions to work with similar communities. One physician, in describing her first experience working at a clinic serving the homeless, street-involved, and intravenous drug users stated that her eyes were “opened to the tremendous rewards and challenges in providing services to that marginalized population.” As this statement supports, the physicians gained personal satisfaction from doing this work. Exposure to marginalized groups was also experienced in medical school. For example, one physician described an experience with a police officer during a community health course, “ … She just drove us around and showed us the city … suddenly, you wake up and you see things.” Another described the positive impact of a third-world elective in which his decision to become a physician was reinforced:
I think that was the turning point for me in medical school, when I went to Africa and realized how much I didn’t know, how little sometimes we could do, but at the same time how important it could be for us [to be there to help].
The exposure to both role models and marginalized groups created an awareness of the needs and rewards gained in working with underserved communities.
The third theme, motivations, captured the internal forces that affected how the physician participants carried out their current medical work. These motivations included the desires to do the right thing, give back, make a difference, and remain challenged and interested in their work.
Most of the physicians identified “making a difference” as an important motivation, not only in their medical professional lives but also personally. They reported making active choices that afforded them the greatest opportunity to make a difference at individual, family, and community levels. All physicians shared a similar belief that no matter what our profession, each of us can make a “small difference.” “If each of us can make a small difference or each of us focus on even one area … it would make a little bit of a difference.”
Another motivation expressed was a desire to “do the right thing.” This motivation was described by one of the physicians: “If I see people dying with HIV unsupported, marginalized, stigmatized, and I can identify with this suffering and understand it, it would be unconscionable not do something about it, right?”
This motivation existed because the physicians considered their courses of action and determined what they believed was “right,” based on their personal standards and beliefs of ethical, just behavior that was within the scope of their capabilities. As one physician stated, “I try to let my things be determined by what would be good … that’s within my perspective … somebody else … they would see something that’s right and good as different.”
The physicians reported that constant intellectual challenge motivated them to work with the communities they served. One said:
I’m not this altruistic person trying to help the homeless. I happen to have this strong interest to work here. I feel like I’m doing something but I’m also learning and getting much more from the patients I see probably more than they get from medicine.
Thus, internal forces, or motivations, propelled these physicians to carry out community advocacy work.
The findings of this study give some insight into the factors that shape physicians who are community responsive through advocacy with patients and communities. This study was based on the stories of eight physicians who worked primarily with marginalized communities of high need. It is acknowledged that physicians and health care professionals may be involved in other types of community-responsive and advocacy work not described in this study.
Physician-participants shared common characteristics, including early understanding of difference, and a personal ethical commitment “to do the right thing.” Because both the public and the medical community have stated that it is important to train physicians who are health advocates for both individuals and communities, we might argue that we should select medical school applicants who have dispositions rooted in advocacy. Medical schools have a unique purpose: selecting and educating competent, caring physicians capable of meeting society’s expectations.16 “There is probably no greater influence on the products of any educational institution than the raw material on which it exercises its influence … the students chosen for admission.”17
Selecting students with this predisposition may not be sufficient, because learning environments also encourage and sustain medical student development. Without curricular support for the role of the physician as a community advocate, the stresses and demands of medical school may flatten laudable advocacy aspirations.11 This is supported by a study that found medical schools’ emphasis on disease and technical procedure was at the expense of the development of the “caring” aspects of being a physician, which includes advocacy.18 Because physician advocacy is mandated as a competency for physicians, then medical schools are required to foster and encourage this skill in their students.
How do we help medical trainees develop as community advocates? Three educational strategies can be delineated from this study: student exposure to marginalized populations; exposure to role models; and explicitness about how current learning activities help in the development of the physician as community advocate role.
The recommendations to provide or require clinical exposure to marginalized and underserved populations is supported by the impact such exposure had on the community-responsive physicians in their decisions regarding where to practice after training. This recommendation is also supported by a study that concluded that students who had formal learning opportunities working with communities were more likely to incorporate this learning into their medical practices after graduation.19 Although the community-responsive advocates in this study stated that exposure was important in their career choice decisions, this may not be generalizable to all physicians. Most qualitative research uses nonprobability sampling techniques, which focuses on exploring the experiences of the participants with no illusion of a representative sample.13 More research with other physicians in other contexts needs to be conducted.
A second recommendation involves communicating to students that their medical schools regard advocacy an important educational domain. This communication can be achieved by appointing faculty who personify responsiveness, which may be role modeled to students. Students learn not merely what they are taught, but also what they gather from the behavior of teachers who serve as role models.17
Third, creating a clear link between existing areas of study in medical school (related to the social determinants of health, medical ethics, and community health electives) and the knowledge, skills, and attitudes needed to become a community advocate would improve the opportunities educators have in assisting trainees to develop community responsiveness and advocacy. Curricula should ensure that specific goals are infused into learning activities for students to aspire to attain. To develop socially accountable or community-responsive physicians, the educational component should include a continuum of learning activities from undergraduate education to residency and into practice.20
Successful advocacy work requires critical skills including persistence, patience, and assertiveness; negotiation, priority-setting, and conflict-management skills; and recognizing the needs for collaboration with other health care and social service providers.4 This article does not focus on the skills of the physician-participants but acknowledges the need to report on this in the future, as well as how these skill sets may influence pedagogical approaches to advocacy.
Limits of this study (and most qualitative research) include nongeneralizability, because the goal of qualitative research is exploration. However, this exploration can inform future research, including investigations regarding whether the characteristics of these participants apply to physicians working in less defined, more heterogeneous communities.
In conclusion, this study offers a thick description of community-responsive physician advocates. Learning from such exemplars can assist in the development of operational definitions for community advocacy, which is one form of community responsiveness. These definitions are necessary to help medical institutions develop physician advocates who will respond to the needs of individuals and communities. In the words of two physicians from this study: “Advocacy is a basic responsibility of a physician.” “You don’t arrive as an advocate—you develop into an advocate.”
This research was supported by the physicians of Ontario through a grant from Physicians Services Incorporated Foundation, Ontario, Canada. The writers thank Drs. Lorelei Lingard, and Glenn Regehr from the University of Toronto Faculty of Medicine Centre for Research in Education, University Health Network, Professor Linda Muzzin from the Ontario Institute for Studies in Education, and Dr. Wayne Weston from the University of Western Ontario Faculty of Medicine for their research advice and support.