Verma, Sarita LLB, MD, CCFP; Flynn, Leslie MMus, MD, CCFP, FRCPC; Seguin, Rachelle MA, MPA
In 1993, the Royal College of Physicians and Surgeons of Canada (RCPSC) established the Canadian Medical Education Directions for Specialists 2000 Project (CanMEDS 2000)1 project that culminated in 2000 with the introduction of seven essential roles for specialist physicians. During this same period, the College of Family Physicians of Canada (CFPC) developed the four principles of family medicine. These roles and principles are now enshrined in medical education in Canada and have been integrated into the accreditation standards for postgraduate training programs.
The seven CanMEDS roles are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. The CFPC's four principles of family medicine require certificants to be skilled clinicians, to be community based, to be a resource to that community, and to keep the physician–patient relationship central to their practice. Although no formal attempt has been made to “harmonize” the four principles of family medicine with the seven CanMEDS roles, they are complimentary. For instance, the principle of the skilled clinician corresponds to the CanMEDS roles of medical expert, scholar, communicator, and professional. For an example of how the two sets of roles and principles could be harmonized, see Figure 1.
As the CanMEDS roles are integrated into Canadian medical education, it is important to ask which are most difficult to teach and evaluate. In a 2001 RCPSC survey, faculty reported that manager and health advocate were the two roles most difficult to teach and evaluate.2 The RCPSC has required health advocate certificants to be able to identify the important determinants of health affecting patients, contribute effectively to improved health of patients and communities, and recognize and respond to those issues where advocacy is appropriate.
The challenge of teaching the role of health advocate to residents occurs at a time when there has never been a greater need for physicians to act as health advocates. The public is uncertain about universal health care and access to many services in Canada.3,4 The role of the physician as health advocate is in danger of being lost between the competing needs of the physician and the individual patient, and the availability of health care resources. In our Medline search of the literature using the terms “health care advocate,” “postgraduate medical education,” and “advocacy,” we found no studies on the curriculum of health care advocacy in residency education in Canada. A further search on the Web search engine Google revealed many papers on teaching and evaluating the health care professional and professionalism, but these papers blurred the distinction between the health advocacy role and the professional role. There is, however, a difference between the health advocate and the professional, an important yet difficult difference to chart in the literature. Although an extant literature exists on patient advocacy and the roles of allied health professionals such as nurses, social workers, and therapists in health care advocacy and social activism, there is a dearth of medical literature on health advocacy and the resident physician's role as health advocate. This literature deficit is concerning, especially given the front-line nature of residents’ work and their ability to intervene as health advocates.
In this study we explored how faculty and residents defined their roles as health advocates and identified their perceived barriers to teaching and evaluating health advocacy.
The study was conducted in 2002 at Queen's University, Kingston, Ontario, Canada. Queen's University has approximately 280 residents training in 33 residency programs accredited by the RCPSC and the CFPC. The study received approval from the Research Ethics Board of Queen's University.
We set up four focus groups, two of attending faculty and two of residents from a cross section of specialties. Participants were asked standardized questions based on the two identified tasks: What is a health care advocate as understood and reported by teachers and residents?, and What are the reported barriers and enhancers to teaching and evaluating the role of residents as health care advocates? In addition, we asked the residents and faculty about teaching in health advocacy as preparation to deal with difficult issues in patient encounters such as health care promotion and disease prevention; poverty; inability to pay for health care services or medications; interactions with employers, schools, and third-party insurers; caregiver burden; living situation; and policy changes that affect patient care and patient care support systems.
To recruit focus-group participants, we extended an open invitation sent via e-mail to all faculty and residents using current, complete university list services from the dean's office. The research associate for the study sent all approximately 280 faculty and 280 residents an invitation via e-mail to “Dinner and a Focus Group.” We accepted all positive responses until the four groups were full (seven to ten persons per group). Participation was determined based on availability on the night in question planned for the focus group. We did not preselect or invite individuals, nor did we influence the composition of the groups in any way. Two of us (SV and LF) participated in each of three focus-group sessions, and SV, the principal investigator, moderated one focus group alone. All participants signed an informed consent.
We developed a series of key questions prior to the focus groups to give a structure to the discussion and to ensure that we covered important details (see Table 1).5 We outlined in advance the five key categories for investigation: definition, barriers to teaching and learning, barriers to evaluation, issues of social responsibility, and ideas for curriculum content. These categories were defined following deliberations with colleagues and a hospital patient advocate. We tape recorded the proceedings and took notes as backup. We analyzed the transcripts using the framework technique that has been developed in Great Britain specifically for applied or policy-relevant qualitative research, in which the objectives of the investigation can be set in advance and a more structured approach is taken to qualitative data collection.6 The framework approach uses five stages of data analysis: familiarization, identifying a thematic framework, indexing the data in textual form, charting the data according to the thematic framework, and mapping and interpretation. The process is influenced by the original research objectives as well as by the themes that emerge during the focus groups and subsequent review of the data. We chose this approach as an alternative to using computer software for two reasons: firstly, the development of health advocacy in medical education has significant policy implications for which the framework approach is an effective tool, and secondly, the approach would help us with subsequent stages of the research project, namely using an expert panel to develop cases, implementing a formal curriculum for postgraduate trainees in our academic core days, and a faculty-development workshop.
We outlined five main categories of investigation and divided each category into subcategories (see Table 2). Each comment made was allocated to one of the subcategories. We repeated the charting for each focus group using the same subcategories. The interview technique was standardized and was iterative after the first focus group. Faculty were asked to comment on residents’ perceptions and vice versa. We did not, however, modify the questions for any of the groups, and we posed them as shown Table 1. We intended to allow for consistent time allotment for each topic.
Table 3 shows the characteristics of focus-group participants. Twenty-nine residents and faculty participated in the four focus groups: 14 of 280 faculty and 15 of 285 residents and all who volunteered were put into a focus group.
We compared our individual analysis of the focus-group comments and found that our analyses agreed. We will give the results using the five categories of the framework technique: roles and objectives, barriers to teaching and evaluating, barriers to learning, social responsibility, and curriculum content.
Understanding the roles and the RCPSC objectives for health advocate
All four focus groups required information about the RCPSC's definition of the role of health advocate. Although members of the groups were aware of the health advocate role and objectives, none knew the RCPSC's definition. The family doctors who participated in the two faculty groups had background knowledge about the history of the CanMEDS roles and that they evolved from the Educating Future Physicians for Ontario (EFPO) project. None of the residents knew the health advocate role or its expectations of learners. Thus, following our initial discussions in the first focus group, we provided the RCPSC definition as a handout to all participants for the discussion period in each focus group.
Members of all focus groups, particularly the faculty groups, felt that the definition of a health advocate required clarity. The participants posed questions about the role of a health advocate and the CanMEDS definition, and the issue of patient advocacy versus health advocacy on a broader level, and grappled with the complexity of advocacy at three levels: individual, community, and society at large. The resident groups had problems with delineating the boundaries and limits of the health advocacy role, as the following residents’ comments show:
I didn't really know the Royal College guidelines. ... So I think being a good patient advocate means the patient's health care needs are your foremost priority.
Advocates for patients or patient advocacy, which is a component of health advocacy?... but I think I have a much broader idea of what health advocacy is. Do we mean advocates for health care or, do we mean advocates for patients? I need help with that definition first.
Barriers to teaching and evaluating health advocacy
The faculty groups reported that teaching and evaluating the role of health advocate was a challenge. They learned about health advocacy by experience, as did the residents. Faculty indicated that there was no distinct curriculum for teaching advocacy or any parameters for assessing residents’ competency. Participants learned from role models, from their innate sense of values brought into medicine from the outset, or from their parents. Residents reported that the interest and personal skills of faculty determined whether advocacy was taught and evaluated. Residents and faculty felt that most people did not have the time to teach or to assess advocacy and were also constrained by resources and the need to get “everything else done.”
As some participants noted, particularly faculty, the conflict between advocate and manager roles was a key barrier, particularly where health care resources were strained:
To make you evaluate something you have to know what the gold standard is. What are the effective characteristics of an effective advocate?
The majority of attendings that we work with and work under are not qualified to evaluate us as health advocates because we are better than they are in a lot of instances. That's not because we have learned it better, it's because we are at a stage where we think about it more.
Barriers to learning about health advocacy
Consistently, the groups of residents and faculty both complained about the perception of advocacy as charity (unpaid) work and the gradual loss of altruism as learners went through their paces in medical school and post-MD training. Most faculty members felt unsure about their roles in teaching advocacy, having never learned it in their own training, and most residents agreed that they only acquired the skills either through forced personal experience or through rare role modeling, but indicated that role modeling alone was not enough. The residents indicated that they viewed good teaching and learning as dependent on the personal characteristics of their teachers, as these comments demonstrate:
At best that's poorly taught in residency and certainly not formally taught. Its poorly taught by experience, by exposure and perhaps by one's own sense of politic or sense of personal values ... just by the nature of the training we don't get that exposure.
I think that a lot of advocacy is done very poorly right now and all the people think you are doing advocacy through shouting and intimidation....
Even then, many faculty only dealt with health advocacy on one level—the individual patient and occasionally, if at all, on the other levels (community and society).
Constraints on time, lack of remuneration, and a feeling of being overwhelmed and beleaguered by too many learning expectations were common among all focus-group participants. One participant noted:
I think the Royal College has developed objectives that are quite frankly beyond some faculty's scope of practice. They are talking about the key issues under debate regarding changes in the Canadian health care system. That's a moving target: vital health outcomes and advocating to decrease the burden of illness at a societal level.
Issues regarding physicians’ social responsibility
The participants acknowledged an understanding that the role of the health advocate encompasses physicians’ responsibility to go beyond the care of an individual patient into their communities and into society at large. Participants were reluctant to take on this role and many felt that it raised expectations beyond their capacity. Their unease waned somewhat as they began to understand that health advocacy could be seen on a graduated basis or on a sliding scale that not everyone should have to do everything, all the time. Participants also had some difficulty with drawing the line between the expectations of physicians as health advocates and what most would normally see as their job. Two participants commented:
The Royal College has separated this concept of advocacy as somehow being distinctly different from just doing our jobs ... these roles are requiring us to dissect out specific aspects of our jobs.
I think people who start off during residency or acting as societal advocates in high school or in university, it is something in their gene pool that makes them.
Ideas on curricular content
Participants agreed that it is important to define the role of the health advocate and to expose residents to the various levels of advocacy, and to teach about the determinants of health including population based issues. The faculty had the most comfort with a graduated approach with objectives that are real and can be role modeled. The role of the health advocate could be integrated into all aspects of the curriculum, like the teaching of biomedical ethics. Both residents and faculty encouraged the use of language to highlight a clinical situation, a real case, an essay or a core presentation that demonstrated the role to the learners and the attending staff. All focus-group members agreed that faculty development on teaching and evaluating this role was needed, as one participant noted:
This idea of three levels of advocacy [should be] promoted. The way I see it, as individuals we advocate for individuals. When we are advocating for groups we often do better in groups and when we are advocating for society we have to take a bigger group ... and I don't see why we can't teach that hierarchy.
In our study, we used a focus-group format to examine the self-reported definitions of physician educators and residents as health advocates and to identify the barriers for educators to teaching and evaluating advocacy. Little has been written about how to teach and evaluate the CanMEDS role of the health advocate and faculty have expressed concern that this role is difficult to address in the curriculum, and guidance is needed on how to approach it.
We believe the focus-group format worked effectively as a research tool in our study for several reasons. It is well-known that focus groups are unique in their explicit use of group interaction to produce data.7 Using focus groups as a method is based on two fundamental assumptions. The first is that individuals can provide a rich source of information about a topic. The second is that the collective and individual responses encouraged by the focus-group setting will generate material that differs from material generated by other methods.8 As Krueger and Casey9 note, the purpose of focus groups is to promote a comfortable atmosphere of disclosure in which people can share their ideas, experiences, and attitudes about a topic. Participants “influence and are influenced,” while researchers play various roles, including that of moderator, listener, observer, and, eventually, inductive analyst. The framework technique was especially useful for us in this case.10 In addition to the unique advantages of the focus-group format, we studied the faculty and resident groups separately, as well as compared the two groups, to gain novel insights about perceptions around health advocacy.
We found a surprising consensus between faculty and residents on the key issues. The definition of the health advocate and the expectations at each level of training require clarity and direction from the RCPSC. Academic programs would benefit from clear, explicit objectives. The majority of participants were not familiar with the RCPSC's definition of the role and were very keen to receive further guidance on teaching tools and methods of evaluation. The one glaring exception to the consensus between residents and faculty was the disconnect between the faculty members’ belief that advocacy is an aspect of their daily work and the residents’ apparent lack of awareness of this behavior in their preceptors. This important finding shows that modeling, the mode of teaching most commonly used for the role of health advocate, is not sufficient as a sole means for teaching the importance of advocacy.
Participants identified several barriers to teaching the health advocate role and ultimately to evaluating it in postgraduate training, in particular ill-defined objectives and a lack of a sound curriculum. Participants also ascribed low value to the role of health advocate relative to the other CanMEDS roles. Finally participants also perceived a conflict between the health advocate role and other roles such as manager and collaborator. For example, on one hand the physician must advocate for their patients as caregivers and on the other hand as a manager of limited resources, such as urgent needs for hospital beds.
An unanticipated finding was that both groups perceived advocacy as charity work, and as such, not valued. Moreover, the residents believed that they were the only ones advocating for the patients and that the faculty had given up on advocacy. They did not appreciate that the faculty prided themselves on advocating for their patients and viewed it as an essential aspect of their work. The residents’ view was in stark contrast to the comments many faculty made stating that advocacy and altruism were prime motivators in their decisions to select medicine as a career. These views taken together would suggest that many faculty members lacked skills in teaching advocacy and making their advocacy clear to the residents.
Despite these problems, physician–educators and residents recognized that physicians are expected to actively demonstrate social responsibility and provide leadership in this forum. The expectation ranges from guiding and advising an individual patient in one's office to delineating a path through complex institutional and bureaucratic systems in order to gain access to health care. The role of health advocate can mean speaking out on a higher level in committees or to members of Parliament about a problem in the community, or advocating at an advanced stage of social activism. All these activities translate into valuable public service and the health care system reaps the benefits of the character and courage of those who step into the role of health advocate. This view, however, raised serious concerns about the physician's ability to meet these expectations, concerns that were lessened, however, when participants agreed that “not everyone must do everything.”
Our study involved residents and faculty from a broad representation of disciplines across the university (see Table 3). Nonetheless, our study was limited by the small number of participants, all of whom volunteered to join the focus groups. Thus we may have only heard from those who were already passionate about advocacy. If so, this would suggest an even greater need for education in this area.
Several important concepts emerged from focus-group discussions on methods for teaching and evaluating the role of health advocate. There was broad consensus that faculty development was sorely needed. Participants also agreed that role modeling, although invaluable, is alone not sufficient and that a graduated curriculum and sharing of resources across schools would optimize the acquisition of skills and knowledge about health advocacy in postgraduate training. Hence, although the CanMEDS roles and the four principles of family medicine are ostensibly well ensconced in our postgraduate training programs, the results of our study verify that continued work is necessary to fully integrate these roles, in particular that of health advocate, into our educational programs.
The authors wish to acknowledge the grant provided by the Royal College of Physicians and Surgeons of Canada/Associated Medical Services CanMEDS Research and Development Fund, and especially the assistance of Mrs. Donna Ware with the project and with finalizing the manuscript.