Oandasan, Ivy F.
One cannot teach something that is not well-defined. Herein lays the problem related to teaching the role of the physician as health advocate. There are many interpretations of the meaning of advocacy. For many physicians, advocacy resonates most closely with the values of “helping.” The root of the word advocacy can be traced to the Greek term parakletos describing one who is “called alongside to help or support someone in need.”1 Many physicians would claim that being a doctor makes them an advocate, for they help patients on a daily basis.
The Webster’s New World Dictionary states that an advocate is one who “pleads another’s cause.”2 This definition describes the notion of speaking on behalf of someone when someone is unable to act on his or her own behalf. Kohnke3 has described a different role of the advocate. She states that an advocate is one who “informs and supports whatever decision is made” by a patient. She argues that most patients have a voice and are not silent, and that most are competent and able to make informed decisions and voice their decisions. Hence, a true advocate supports the decision of the patient regardless of whether they agree.
Ezell4 describes yet another definition of advocacy as a practice or an action that one does rather than a set of thoughts, feelings, or attitudes. He emphasizes that advocacy “consists of purposive efforts to change specific existing or proposed policies or practices on behalf of or with a specific client or group of clients.”4, p. 23 To this end, individuals involved in advocacy are involved in deliberate efforts that entail studying, planning, taking action and evaluating actions taken.
The definitions identified thus far illustrate the diversity of concepts related to advocacy including the act of helping, speaking for those who are powerless to speak, and standing with those who make decisions for themselves. From Ezell, the notion of advocacy as “purposive efforts” to make change happen is also described. When definitions adopted by the medical profession and accreditation bodies are examined, the role of health advocate takes on yet a different interpretation. The Royal College of Physicians and Surgeons of Canada (RCPSC) defines a health advocate as someone who “is able to identify the determinants of health that effect a patient, so as to be able to effectively contribute to improving individual and societal health in Canada.”5
For advocacy to be taught to physicians (and in fact all health professionals), there is a need to develop an operational definition of health advocacy. At a time when educational accreditation bodies like the RCPSC mandate the teaching of health advocacy within its residency programs, it is especially important to have a clear definition to assist in building curricula and assessment methodologies. In creating an integrated understanding of health advocacy, medicine can avoid dichotomous thinking that advocacy is either: (1) something that physicians do on a daily basis just because they are working in a “helping field,” or (2) advocacy is something physicians do “beyond the call of duty” and is left to a few exceptional individuals.
This article is the second article published describing the findings of a qualitative study to discover what exemplary community-responsive family physicians do, and what they have in common.6 Teaching how family physicians respond to the needs of the community is an accreditation requirement mandated by the College of Family Physicians of Canada.7 It was the intent of the author to assist in developing an understanding of community responsiveness to enhance pedagogy within this domain. A relationship between community responsiveness and health advocacy was found from the qualitative study and a literature review that was conducted based on the themes that emerged. This article attempts to bring clarity to educators about the notion of health advocacy through the voices of community-responsive family physicians engaged in health advocacy activities.
As noted earlier, this article builds upon a previous article that described the common characteristics of community-responsive physicians.6 A detailed description of the methodology used can be found in that article. A summary is hence described for this article. Case study methodology8 was chosen for this study to understand the nature of “community responsiveness” among physicians who seemed to practice this skill. Because community responsiveness occurs in a social context, five communities were chosen to reflect the diversity of locations and populations in which Ontario family physicians work. Each case study illuminated different dimensions of what the physician participants were doing in responding to the needs of the communities in which they worked.
Although it was the intention of the author to recruit one physician from each of the five communities, eight physicians were recruited in total. Exemplary community-responsive family physicians were recruited by speaking with management personnel from social service and health-based community agencies. The personnel were asked to identify names of primary care physicians who were exemplary in responding to the needs of their respective communities. The physician who was consistently named the most for each community was invited to participate in the study. In some communities two physicians emerged as being community responsive and hence both were asked to participate in the study. This accounts for the eight physicians recruited from five communities.
Following informed consent, the physicians participated in two 90-minute audio-recorded interviews using a semistructured interview guide with field notes taken. After the first interview with each of the eight physicians, the researcher contacted and interviewed medical colleagues, community members, and patients who worked with the physicians. The present data set is informed by information gathered from all of these interviews. A total of 43 interviews were conducted. The data were collected and analyzed in an iterative fashion. All documents and transcripts were read by the author. Through a constant comparison analysis method,9 themes were developed and discrepancies carefully discussed with expert qualitative research advisors for whom the author requested supervision for this study. This allowed for increased assurance of validity and accuracy.10 The computer software program NVivo was used to support nonnumerical unstructured data indexing.11
Community-responsive physicians were found to engage in advocacy activities. It is not the intent of this article to equate advocacy as the only means by which physicians respond to the needs of the community. However, in this study, the physicians’ community-responsive actions fit most closely with a spectrum of health advocacy definitions, particularly Ezell’s definition of purposive efforts to effect change.
Specific health advocate roles
There were two ways in which physicians were found to engage in health advocacy.
1. “Indirect change agents” as a resource providing necessary information to people in positions of power on behalf of or with patients/communities in order to effect change for health improvement.
2. “Change agents” initiating, mobilizing, and organizing activities on behalf of patients/communities to systematically effect a change for health improvement.
1. The health advocate as an indirect change agent
As an indirect change agent or resource of information, all the physicians were known for writing letters, signing forms, and conducting telephone calls providing information to decisionmakers who have the power to assist their patients and enhance their well-being. One physician described her advocacy interventions for a homeless youth in this manner:
I’ve made more phone calls. I’ve written more letters on his behalf then I think he’ll ever know, to get him things that would help him, like, social assistance, like drug cards, like a residence to stay in or detoxes to get him into.
Many community informants commented that the physicians were involved in informing the community, administration, and government with information related to the health of the community. One physician stated:
That’s part of “the advocate— information providing” is saying, “well, I know that nobody wears helmets here … or nobody uses seatbelts when they drive, and you may feel that’s fine that’s your right to do that, but, you know, three people have been killed in the last two years as a result … so it’s that sort of information that’s medical.
In the “informant” role, physicians were noted to be medical experts on whom communities could rely:
… you trust them [physicians] for being knowledgeable in … their fields and … kind of constantly keeping abreast of things and willing to take a risk to speak up on an issue.
While the communities expressed a reliability on physicians to “keep abreast of things,” the physicians used a profession-specific term, “being evidence driven” to describe this responsibility. One physician stated:
I think that the distinguishing characteristic for me … of responsible advocacy by a physician is that the physician remains evidence driven. As a physician, I obviously have a personal connection with a patient or with the community I’m working with. But I have a responsibility to actually bring a scientific view point, and to be able to say here’s what we know from the data.
Through the writing of letters, signing of forms, and speaking on the telephone, physicians were able to advocate on behalf of their patients to decisionmakers by informing them of the key issues that physicians have a unique opportunity to uncover.
2. The advocate as change agent
The second physician advocacy role that emerged in this study was that of a change agent. In acting as a change agent, physicians initiated, mobilized, and organized a response to an issue of concern within his or her community. Examples from the case studies of physicians who acted as change agents include a rural physician who succeeded in expanding rural medical education and improving recruitment and retention of physicians in rural Ontario; and an urban physician who improved health care to those with HIV, particularly those within a Southeast Asian community.
Key to the role of this expression of advocacy was the organization of advocacy activities that may have started with the physician as an informant but moved toward the physician initiating strategies to mobilize and organize individuals interested in addressing an issue. In keeping with Ezell’s definition of advocacy, the physicians were involved in planned efforts with a purpose to address health concerns by studying, planning, taking action, and evaluating what was done.
The two rural physicians in this study acted as informants to the community, notifying community members about the importance of bike helmets to children’s health and safety. They did not stop at informing the community; they instead organized the community to campaign for mandatory legislation requiring the use of bicycle helmets. One of the community members commented:
… they were seeing kids coming in [to the emergency department] with some, luckily not serious, head injuries but could have been, and just noticing also around the community a lot of children not wearing helmets, because it wasn’t the law at that time. But they viewed that as not a safe thing and so they took it upon themselves to really go after promoting that. And they raised quite a large profile about it.
Many of the physicians were known for the “art” of persuading and mobilizing people to work with them in their advocacy efforts. One community member commented on one physician’s ability to persuade in this way:
[h]e is able to summon support from all his friends, and his colleagues … he has a way of making people do things for him, willingly, voluntarily … he cooks up his solutions, his vision and then he puts it out to other people, he gets his support from everybody, and then everything comes out great in the end.
Hence there were two roles for which physicians were found to engage upon related to health advocacy: being a direct change agent and being an indirect change agent as a resource of information.
The purpose of this article is to provide an operational definition of advocacy which may aid in the teaching of this domain. In this study, the main forms of advocacy demonstrated by exemplary community-responsive physicians illustrated how they recognized and responded to issues they identified as negatively impacting the patients/communities with which they worked. Such issues included the determinants of health such as reduced access to health care (HIV care in the Asian community) and/or negative personal practices (bicycle helmet use). The physicians were able to mobilize others to work with them to enact change. They were “doing something,” which is different from “thinking about something,” as Ezell outlines in his definition of advocacy.4
It is of interest that the RCPSC uses the term health advocate to describe the advocate role.5 What is health, and how are medical educators defining it? The World Health Organization describes health as “more than a state of a person not suffering from disease. It is a way of being able to reach a state of complete physical, mental, and social well-being.”12 If it is believed that the definition of health is more than the absence of disease, then the role of the physician as the health advocate would be one who defends and promotes the right of individuals and communities to reach a healthy state of well-being. In this way, the actions conducted by the physicians in this study as indirect and direct change agents have more meaning when considering the definition of what health advocates do.
Based upon the findings of this study, it may be better to define advocacy based upon one’s level of participation in making change happen. Horton13 describes the role of physicians’ advocacy efforts as taking problems that one faces day-to-day and pursuing their resolution outside their usual place of presentation by writing a letter to newspaper, posting a comment on a Web site, or asking a question at a meeting. It is the premise of this author, that it is not enough to share information, but there needs to be a persistence on the part of the physician to be heard by decision-makers who can make change happen. If not heard and acted upon by these decisionmakers, physicians may need to consider whether they must become change agents themselves.
Advocacy is an activity that one does. It goes beyond thinking that something needs to be changed. It is about “doing something” to make change happen. It is further understood that the form of advocacy that is being described in this article includes leveraging physicians’ societal power in order to speak for individuals or communities who are not heard or who are silenced. Ideally, physicians will speak with or stand by individuals and communities who are able to assert their autonomy so that they may be heard, and can enact change themselves.
The “What” and “How” of Health Advocacy
If it is believed that health advocacy engages physicians to consider the factors that impact on the health and well-being of patients and communities, then the determinants of health are a good place to begin in providing the content for which learners must master.
The determinants of health answer the question of “what” must be addressed in health advocacy. Gruen and Brennen14 argue that physicians are best placed to identify, and have major impact on advocacy efforts that address the determinants of health related to accessing health services, and in issues like the environment and personal health practices. Broader global socioeconomic issues like inequitable education, literacy, and social justice are types of advocacy activities that all citizens can undertake, not only physicians. As medical experts knowledgeable in evidence-based medicine, physician trainees should be able to identify “the cause and effect” of the specific determinants of health (as Gruen and Brennen have described) and recognize how to address them as part of their physician duty or scope of practice. This brings up the question of considering which of the determinants of health are within the ethical duty of physicians to address and which may be considered duties that all citizens should assist in addressing. Educators must grapple with this question in considering the “what” and the “how” of teaching health advocacy.
It is this author’s assertion that what is missing both in the practice and teaching of health advocacy is the description of how the determinants of health can be addressed by physicians, not just what they are. The Ottawa Charter of Health Promotion12 provides a good starting point. The strategies in the charter include building health public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. The Ottawa Charter of Health Promotion provides the basis for the “how” to enact advocacy in an empowering way. Importantly it stresses the notion of working with others in doing health promotion and highlights the need for physicians to work collectively to accomplish successful health advocacy activities. Physicians should not feel alone in advocating for their patients, but must learn how to work with others collaboratively to enhance the health of individual patients and communities. By situating health advocacy with notions of interprofessional collaboration,15 medical education can also address another competency for which the RCPSC and the Institute of Medicine have been calling for; i.e., the “Physician as Collaborator.”16,17
In delineating an operational definition of health advocacy that can assist in the training of health professionals, this author suggests the following definition, which addresses the notion of health as a state of well-being and the role of physicians in enacting change. Health advocacy may be defined as:
Purposeful actions by health professionals to address determinants of health which negatively impact individuals or communities by either informing those who can enact change or by initiating, mobilizing, and organizing activities to make change happen, with or on behalf of the individuals or communities with whom health professionals work.
Health advocacy acts as a bridge between the determinants of health and health promotion. It is our responsibility as educators to find ways to teach this vital role to our medical trainees as they fulfill our collective quest to improve patient care, addressing issues of social accountability and heightening physicians’ own personal satisfaction by making a difference through purposeful efforts of change enhancing health and well-being.
I would like to thank a number of key individuals who assisted in this study: Professors Muzzin, Lingard, Regehr, and Weston for their advice on methodological design, literature to expand my understanding of this topic area, and mentorship related to my research endeavors; Keegan Barker for her qualitative research assistance and editorial skills; and the physicians whom I met during this study for their inspirational stories.
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12 World Health Organization. Ottawa Charter for Health Promotion: First International Conference on Health Promotion. Ottawa, ON: World Health Organization, 1986.
13 Horton R. The doctor’s role in advocacy. Lancet. 2002;359:9305.
14 Gruen RI, Brennen TA. Physician-citizens: public roles and professional obligations. JAMA. 2004;291:94-98.
15 D’Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof Care. 2005:19(1 suppl):S8–S20.
17 Greiner A. Health Professions Education: A Bridge to Quality. Washington DC: National Academies Press, 2003.
Moderator: Jennifer Doyle, MD
Discussant: Paul Mazmanian, PhD