A Multi-Institutional Medical Educational Collaborative: Advocacy Training in California Pediatric Residency Programs
Chamberlain, Lisa J. MD, MPH; Wu, Susan MD; Lewis, Gena MD; Graff, Nancy MD; Javier, Joyce R. MD, MPH; Park, Joseph S.R.; Johnson, Christine L. MD, Capt, MC, USN; Woods, Steven D. MD, MSPH; Patel, Mona MD; Wong, Daphne MD; Blaschke, Gregory S. MD, MPH; Lerner, Marc MD; Kuo, Anda K. MD, MPH
Dr. Chamberlain is assistant professor, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
Dr. Wu is assistant professor of clinical pediatrics, Department of Pediatrics, University of Southern California Keck School of Medicine and Children’s Hospital Los Angeles, Los Angeles, California. She also codirects a community pediatrics and advocacy rotation for her institution’s pediatric residents.
Dr. Lewis is program director, Community Primary Care and Advocacy Rotation, Children’s Hospital and Research Center Oakland, Oakland, California.
Dr. Graff is clinical professor, Department of Pediatrics, University of California, San Diego, and Rady Children’s Hospital, San Diego, California.
Dr. Javier is assistant professor of clinical pediatrics, Department of Pediatrics, University of Southern California Keck School of Medicine, and Children’s Hospital Los Angeles, Los Angeles, California.
Mr. Park is research associate, Prevention Research Center, Berkeley, California.
Dr. Johnson is specialty leader, Navy Pediatrics, and former program director, Department of Pediatrics, Naval Medical Center, San Diego, California.
Dr. Woods is assistant clinical professor of pediatrics, Department of Pediatrics, University of California, Los Angeles, and director of pediatric residency training, Kaiser Los Angeles Medical Center, Los Angeles, California.
Dr. Patel is assistant professor of clinical pediatrics, Department of Pediatrics, University of Southern California Keck School of Medicine and Children’s Hospital Los Angeles, Los Angeles, California. She also codirects a community pediatrics and advocacy rotation for her institution’s pediatric residents.
Dr. Wong is assistant program director, Children’s Hospital Orange County, Orange, California.
Dr. Blaschke is division head, General Pediatrics, Oregon Health and Sciences University, Portland, Oregon; during the collaboration period, he was faculty in the Department of Pediatrics, Naval Medical Center, San Diego, California.
Dr. Lerner is medical officer, Orange County Department of Education, Orange, California; during the collaboration period, he was clinical professor of pediatrics, Department of Pediatrics, University of California, Irvine, Irvine, California, and Children’s Hospital Orange County, Orange, California.
Dr. Kuo is program director, Pediatric Leadership for the Underserved, Department of Pediatrics, University of California, San Francisco, San Francisco, California.
Correspondence should be addressed to Dr. Chamberlain, Stanford University School of Medicine, 770 Welch Rd., #100, Palo Alto, CA 94304; e-mail: email@example.com.
Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents’ training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.
The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration (“the Collaborative”) to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative’s activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative’s impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.
Medical educators must keep pace with rapid growth of curricular content in an era of restricted resources. One approach to mitigating this challenge is through educational collaboratives. Such collaboratives, where educational entities work together sharing resources and infrastructure, have been employed in health care to improve quality of care,1–4 in interprofessional education,5–8 as consortia in graduate medical education,9–12 and to address specific issues (such as abortion care13 and research methods).14 Although some curriculum and learner evaluations have been described,13–15 there has been no systematic assessment of the benefits and impact of educational collaborations.
An area where educational collaboration could produce significant benefits is in community health and advocacy training. The Accreditation Council for Graduate Medical Education (ACGME) incorporated advocacy principles into the Common Program Requirements,16 and the Physician Charter of the American Board of Internal Medicine reaffirmed this commitment, stating that physicians as individuals and as a profession have a responsibility to improve the health care system and reduce health inequities, through “promotion of public health and preventive medicine, as well as public advocacy.”17 In response, medical schools, residency programs, and academic health centers are increasingly incorporating experiential service–learning curricula that include social determinants of health,18–20 community-based education,21,22 and political action.23
However, interprogram variability of faculty preparedness, curricular depth, and resident experiences persist.22,24,25 A survey of pediatricians found high interest in advocacy but declining actual rates of advocacy activity.26 Respondents cited inadequate skills in public speaking, health policy, and knowledge of population-level health issues as reasons for not participating, and a majority said that they would participate more if they had more training.
With these needs in mind, in 2007, the California Collaborative in Community Pediatrics and Legislative Advocacy Training (hereafter, “the Collaborative”) was founded with the goal to unite 13 pediatric training programs (see Table 1) to rapidly strengthen participants’ curricula in community pediatrics and legislative advocacy training. Supported with a year of planning funding (2007) and then two years’ funding (2008–2010) from the California Endowment,27 the Collaborative used a social network site and twice-yearly faculty development sessions to develop and disseminate educational resources. As will be described, although the official Collaborative lasted only through the period of funding, it informally continues.
In this article, we describe (1) the impact of the Collaborative on advocacy training in participating residency programs, and (2) the benefits, barriers, and impact of participating in this multi-institutional medical education collaborative experienced by the faculty and their institutions.
Developing curriculum in pediatric advocacy training is a challenge because most faculty do not receive formal advocacy training themselves, given its relatively recent emergence. Furthermore, community pediatrics and advocacy training programs struggle to find faculty and trainee time, corresponding financial resources, and best practices for developing and implementing curricula. These issues are even more pronounced as institutions make difficult economic decisions and programs face reductions in resident duty hours. To address these issues, the founding members of the Collaborative (L.C., A.K., G.L.), who were faculty in three California pediatric residency programs, believed that an educational collaborative was needed, and in 2007 they contacted the remaining 14 pediatric residency programs in California via e-mail and/or by phone. These efforts eventually resulted in the participation of 10 additional programs, bringing the total to 13.
History and process
The founding members of the Collaborative received one year of funding (January 2007 to December 2007) from the California Endowment, a large conversion foundation focused on improving the health of Californians, to explore the possibility of building a statewide coalition dedicated to improving the health of California’s children. These faculty, from three California pediatric residency programs, surveyed the remaining 14 such programs during the planning year to explore those programs’ assets, needs, and goals. The implementation grant mentioned earlier was subsequently obtained that allowed the creation of the Collaborative. Between 2008 and 2010 (the two years the entire Collaborative was funded), faculty time was protected to develop and disseminate educational resources in advocacy via a social networking platform to build faculty capacity in the total of 13 programs (including the original 3) that were interested in being part of the Collaborative. Collaborative members joined one of three workgroups (legislative training, community pediatrics training, or evaluation) that were responsible for presentations at in-person meetings, collecting and disseminating educational tools, and structuring an evaluation of the Collaborative. Through workshops, semiannual meetings, and an online community, the Collaborative facilitated communication, sharing of resources, and evaluation of educational interventions.
Training in advocacy was identified by Collaborative members as an area of weakness in residents’ education, prompting the establishment of a legislative advocacy work group. The group met monthly via conference calls in addition to the face-to-face semiannual meetings where they worked together during designated breakout sessions. To address this barrier, the work group designed a tool to facilitate meetings with institutional government and media relations leadership. In January 2009, the work group led a half-day faculty development session on legislative advocacy. The session included developing goals and objectives, a tutorial for working with institutional leadership, and learning modules for various legislative advocacy skills.
The Collaborative used conference calls, in-person meetings, and social networking to communicate. The frequency of calls varied depending on need, and in-person meetings occurred twice a year, in alternating regions of the state. In February 2009, the Collaborative developed a system that paired experienced programs with programs developing training modules for the first time. Each mentor from an experienced program assisted the members of his or her “mentee program” with making contact with institutional government relations staff, developing goals and objectives, and curricular module design.
The Collaborative’s adoption of online social networking facilitated curriculum sharing and development, supported decision making, provided a shared calendar, and helped set the agenda of the Collaborative. All information resources were housed on the shared social networking site. Some examples of content shared via the social networking site in the “advocacy file cabinet” included presentations on election updates, resources from national pediatric organizations on child health advocacy, worksheets on how to track a bill, guides to regulatory advocacy, and overviews of the budget process.
In 2009–2010, an evaluation of the Collaborative was undertaken to learn (1) whether it had changed the number of advocacy curricular components in the member programs and (2) whether it had increased the strength of the advocacy activities of the programs. To assess programs’ curricular components, the principal investigator (PI) at each of the 13 participating programs completed a survey at the beginning and the conclusion of the grant-funded Collaborative. The items, presented in Table 2, were drawn from ACGME program requirements16 and were supplemented by items developed by the lead faculty member for evaluation (A.K.) working with Collaborative members on the evaluation committee. Descriptive statistics were used to describe Collaborative members’ program components pre- and post curricular change. A second survey contained seven items assessing the strength of program activities using a continuous rating scale (1 for low to 5 for high; see Table 3). Results from the two anonymous Web-based surveys, administered pre- and post intervention by a research assistant (J.P.), were downloaded from SurveyMonkey (Palo Alto, California) into Excel files that were imported into SPSS (IBM, Chicago, Illinois). Chi-squared analysis was used to test whether responses to the pre–post questions differed.
To understand the impact of the educational collaborative, the faculty leadership at each site participated in a semistructured 45-minute interview that covered four domains: (1) impact on individual career development, (2) impact on curricular development, (3) impact on the program, and 4) future directions. Interviews were conducted by a research assistant via Skype Internet phone calls. Calls were recorded and transcribed. A subset of faculty reviewed relevant sections for theme identification using grounded theory. A codebook was created through the process of identifying, organizing, and reconciling themes independently and then as a group. Two research assistants with no direct involvement with the project coded the transcripts using Nvivo 8 software (QSR, Victoria, Australia) untilno additional themes were identified.
All 13 sites obtained their institutions’ IRBs’ approval, and verbal consent for audio taping interviews was received from all participating faculty.
The 13 institutions (see Table 1) completed the program survey between October 2009 and March 2010. Results indicated that the Collaborative increased the number of programs adopting components of an advocacy curriculum (69% precollaborative to 92% postcollaborative; see Table 2). Advocacy training activities most commonly reported to increase were letter-writing campaigns (7–11 programs, 54%–85%), advocacy contacts with legislative officials (6–10 programs, 46%–77%), and bringing expert speakers to the program (5–10 programs, 38%–77%). Participation in the Collaborative strengthened advocacy training activities across six of seven program activities measured (see Table 3), with the largest impact achieved in “Meet with/make calls to elected officials (state and federal),” ranked as “strong” by 0 programs beforeand 8 programs after (0%–62%; P < .0001), and “Add advocacy topics and activities to morning reports and/or grand rounds,” ranked as “strong” by 1 program before and 6 programs after (8%–46%; P < .0001).
The two research assistants interviewed the 13 PIs, one from each of the participating programs, to assess the impact of the Collaborative, focusing on four domains: (1) faculty career development, (2) program curricular development, (3) residency program change, and (4) future directions needed. If the PI was not directly involved in resident training, one additional faculty member from that institution was also interviewed (a total of four). Themes identified are presented by domain in Table 4.
Impact on individual career development.
A recurring theme of faculty isolation in doing advocacy work emerged. This appears to have been mitigated through Collaborative participation, as educators in the various content domains met others facing similar challenges, leading to a sense of being part of a larger movement, which some members described as “validating” their work. Many interviewees expressed “being inspired” by their newfound colleagues and by the curricula that many programs had developed. Furthermore, participation in the Collaborative strengthened the academic developmentof some Collaborative participants.
Impact on curricular development.
Nearly every program participating in the Collaborative developed an advocacy curriculum by July 2009. Participation in the Collaborative helped faculty members to identify their programs’ curricular deficiencies, learn from colleagues with more advocacy expertise, and develop new knowledge and resources for curricular approaches. In-person meetings were important for shared expertise and disseminating “curricular modules” that Collaborative members developed. Most faculty, because of sharing of the curricular modules, reported more structured curricula after participation. Having access to teaching modules via the Collaborative’s social networking Web site, Groupsite, allowed faculty to develop more robust curricula and clearer didactics. However, this led to a barrier that some members expressed: moving from a paper-based, in-house curriculum to a digital form. Although the Web site was an important source for curricular material sharing, some found transitioning to electronic versions cumbersome. Some caution is needed in interpreting the Collaborative’s impact. Each program had a unique curriculum, therefore making it difficult to evaluate the impact of specific aspects of the curriculum.
Impact on the programs.
Having a shared source of funding available to protect faculty time was a large and positive impact of the Collaborative. However, interviewees expressed that even with the funding provided by the Collaborative, faculty time was scarce. One approach to limited faculty time was to engage new faculty who had expressed interest in residents’ education but had not previously participated. The barrier of scant availability of residents’ time was mentioned by some faculty, and others found it difficult to fit new teaching materials into the rotations. Another theme that arose from the interviews was that faculty had differing abilities to implement changes based on their faculty rank and institutional culture.
Sustainability was the primary concern of faculty, and most interviewees reported that further funding would be important for continuing the Collaborative. Faculty needed more time to work on the curricula and to apply for grants. Conversely, some Collaborative participants stated that now that initial relationships and a collaborative structure had been established, the Collaborative was sustainable with minimal financial support. Several suggested that ongoing face-to-face meetings coupled with Groupsite would be enough to sustain the Collaborative. Many Collaborative faculty stated that one aspect of sustained impact was the curricular change they had made and that would remain. Interestingly, a few faculty expressed interest in expanding the Collaborative beyond California. Others described their support for strengthening and continuing the statewide linkages for policy engagement.
This multi-institutional, medical education collaborative amplified resources, rapidly disseminated faculty expertise, and increased advocacy training activities across California in an era when medical educators are challenged with declining resources and increasing educational demands. Our experience demonstrated the feasibility of developing and maintainingan educational collaborative despite the inherent difficulty of sustaining grant-funded endeavors. Even after funding stopped, the participating faculty have reported sustained impact through the curricular changes, and the Collaboratives’ members have continued to meet occasionally. (A subsequent grant was awarded to a Collaborative member[S.W.] to support improvingchild coverage in Southern California.)
The Collaborative provides a model for building capacity in emerging areas of curricular need such as quality improvement, disaster preparedness, and environmental health. The Collaborative achieved rapid change: In two years, legislative advocacy training was in place across 92% of training programs in California, contrasted to the 17 years often cited for innovation to translate into medical practice.28
Advocacy allows physicians to participate in improving the health of populations, effectively working beyond the walls of the clinical environment. Because advocacy is a relatively new content area in medical education, there are few evidence-based approaches and a paucity of trained faculty—challenges shared by other emerging fields. The knowledge and skills required to practice population-based medicine via community or legislative engagement are in increasing demand.29 Specific to pediatrics, there is a pressing need to engage in advocacy, as child health disparities are increasing, and many of the challenges facing the health and well-being of children, such as obesity and exposure to violence, are deeply rooted in social and environmental contexts.30 The Collaborative was able to overcome many of the barriers of novel curriculum introduction through mentorship and by providing program faculty access to educational and financial resources.
The expansion of educational collaboratives focused on training in pediatric advocacy could be transformative. To our knowledge, this article is the first to describe an educational collaborative across multiple medical institutions as a strategic instrument for policy change. The Collaborative mobilized faculty and residents to act with a unified voice, bringing evidence to the health policy discussion on state-level legislation such as the State Children’s Health Insurance Program31 and support for poison control centers.32 Some of the success of this collaborative may be due to the fact that California is large, allowing all 13 programs to focus on one state legislative agenda in child health, producing considerable cohesion. This cohesion may not emerge in regional collaborations, and thus it may be difficult to generalize this experience to smaller states.
Even so, we believe that regional or interprofessional collaboratives could be developed to address pressing state or regional child health issues in other states. Indeed, the Collaborative’s program leaders have been approached by pediatric training programs in New Jersey and Ohio, requesting assistance with developing similar statewide collaboratives.33 A second collaborative, funded in 2011 by the Josiah Macy Jr. Foundation, links five national “coaches” who have expertise in community pediatrics and advocacy training with 10 pediatric training programs that have strong interest but need additional support to further develop pediatric advocacy training programs. The aim is for each “trainee” site to then reach out to and partner with other programs in the programs’ state or region, in a train-the-trainer model, thus expanding the network of physicians and programs active in community and policy engagement. The coalescence of this and other existing training programs nationally, under the leadership of overarching national pediatric organizations, could provide a novel and coherent voice to speak in the interest of improved child health.
Multi-Institutional Educational Collaboratives Are Beneficial
Our experience suggests that multi-institutional educational collaborations can be beneficial to faculty and programs, creating a supportive network for faculty and enhancing each individual program’s curricula. Given the rapidly changing landscape of medical education and increasing demands on faculty, collaborations may offer an effective mechanism with which to cultivate innovation and efficiently disseminate novel curricula.
Acknowledgments: The authors wish to thank the members of the California Collaborative for Community Pediatrics and Legislative Advocacy Training: Alexandra Roche, MD; Maria Tupas, MD, Children’s Hospital Orange County; Kelly Clancy, Children’s Hospital Los Angeles; Diane Halberg, MD, Children’s Hospital and Research Center Oakland; Marti Baum, MD, Loma Linda University Medical Center; Grant Christman, MD; Julie Noble, MD, Harbor UC Los Angeles Medical Center; Elizabeth Baca, MD, MPA; Janine Bruce, MPH, Stanford University School of Medicine; Kathleen Heilpern, MPH, Navy Medical Center San Diego; Elizabeth Miller, MD, Children’s Hospital of Pittsburgh, formerly UC Davis; Elizabeth Sterba, MS, UC Davis; Katherine Wu, MD; Lynn Hunt, MD, UC Irvine; Alice Kuo, MD, PhD; Victor Perez, MD, MPH; Alma Guerrero, MD, UC Los Angeles; Frank Silva; Ashley Maier, MSW, UC San Diego; Amy Whittle, MD, UC San Francisco. The authors also wish to thank Alec Swinburne, Thomas Mullen-Hevey, Ashley Lau, and Garrick Lee, research assistants associated with this work. The authors appreciate the critical review of Sarah Horwitz. Finally, none of this would have been undertaken without the intellectual insights and tremendous foresight of Ignatius Bau, former program officer at the California Endowment.
Other disclosures: The program described in this article was funded by the California Endowment.
Ethical approval: IRB approval was obtained from all participating institutions of the California Collaborative for Community Pediatrics and Legislative Advocacy Training: Children’s Hospital Los Angeles; Children’s Hospital of Orange County; Children’s Hospital and Research Center at Oakland; Kaiser Los Angeles; Loma Linda University; Navy Medical Center San Diego; Lucile Packard Children’s Hospital (Stanford); University of California, Davis; University of California, Irvine; University of California, Los Angeles; University of California, San Diego; University of California, San Francisco. Also from University of California, San Diego (UCSD) which includes trainees at UCSD and Navy Medical Center San Diego.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government.
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