Health disparities based on race, ethnicity, income, and insurance status are pervasive in the United States and worldwide.1,2 Physicians have a unique vantage point from which they can observe the ways social, economic, and political factors impact health outcomes. The perspective they gain from this vantage point, combined with scientific, clinical, and public health knowledge, can equip physicians to be effective advocates for systemic changes that enhance health outcomes and health equity.3 Medical educators and medical professional organizations increasingly view such advocacy as a matter of ethical and professional responsibility.4
Medical education has the potential to reinforce the values that inspired students to choose careers in medicine and to play a critical part in preparing physicians for advocacy roles.5 Prior studies have shown a precipitous decline in idealism and interest in social issues during medical training.6 Although thoughtful educational programming that expands knowledge about the social determinants of health while developing health advocacy skills has the potential to mitigate this decline, social medicine and health advocacy curricula are uncommon in postgraduate medical education.
To address this need, we designed and implemented a novel, in-depth social medicine and research-based health advocacy curriculum that has become a centerpiece of the internal medicine residency program at the Cambridge Health Alliance (CHA), an integrated safety-net health care system in Massachusetts. The intent of this paper is to describe the curriculum’s structure, goals, and content, as well as our preliminary experience with and evaluations of the program.
CHA’s internal medicine residency program is a Harvard Medical School–affiliated training program in a safety-net health care system comprising 2 academic community hospitals and 12 community health centers. CHA provides care primarily for a disadvantaged and racially and ethnically diverse population of patients. The residency program is a three-year program, with 8 resident slots per year (24 residents per year in total).
From academic year (AY) 2006 to AY 2011, nearly half of all residents participated in a popular one-month elective in health disparities and research-based health advocacy. Program leadership recognized that by transforming this elective into a required curriculum, CHA could meaningfully contribute to building a health care workforce with the capacity to improve health equity. Thus, in AY 2012, we transformed the health advocacy curriculum into a centerpiece of our residency program. In its new form, the course has three major innovations: (1) it has a yearlong longitudinal curriculum, (2) it is required for all residents, and (3) all residents complete a group research-based health advocacy project within the curricular year. Exposure to role model health advocates and personal mentorship also play important roles in the course.
Residents participate in the social medicine and research-based health advocacy course within their ambulatory clinical cohort, a group of eight first-, second-, and third-year residents. Each cohort takes part in the course during one year of their three-year residency training. Because each cohort has residents from all three years, the year in which a resident participates in the course is arbitrary. Over the course of the year, residents take part in over 100 hours of curricular instruction, organized within two 2-week immersion blocks and an additional 18 hours of didactic sessions (see Figure 1 for details on the course structure). During the immersion block weeks, the curriculum is delivered through small-group sessions (made up of lectures and group discussions), field trips, and research and advocacy skill workshops. Project time is built into the curriculum for a group research-based health advocacy project; however, over the year residents may also spend about 10 to 50 hours of elective time on the project if they are interested. Two course directors (D.M., G.B.) organize the course in conjunction with additional CHA and non-CHA faculty who lead small-group sessions within the course.
The goals of the course are:
- To clarify and further develop the values that brought residents to train in a residency program committed to the care of underserved populations;
- To explore the role physicians can play in addressing systemic health inequities;
- To improve knowledge of topics in health equity, social determinants of health, and health policy;
- To develop skills in research methodology, leadership, and health advocacy; and
- To provide mentorship and role modeling to support career development that incorporates health advocacy.
The curriculum covers three major domains: (1) health equity, social determinants of health, and health policy; (2) health services research methods; and (3) social change, leadership, and advocacy. Table 1 lists course topics explored within these domains. In addition to the three major domains, another major part of the course is the group research-based health advocacy project.
Learners prepare for each small-group session with assigned readings and participate in discussions. We also dedicate a number of small-group sessions to reflective practice, during which we ask residents to reflect on their professional values and explore what physician advocacy means to them. Viewpoints from all value systems and across the political spectrum are honored and made integral to these sessions.
Health equity, social determinants of health, and health policy.
The study of health equity, social determinants of health, and health policy is the basis of our curriculum. Certain core topics are taught every year. The course also incorporates topics of interest to each new cohort; these topics change from year to year to meet the learning needs and interests of the residents.
Health services research methods.
Additionally, the course is rooted in a research-based health advocacy model which highlights the value of using evidence to promote policy change. Therefore, the course covers core topics which provide introductory training in basic health services research. This training is further developed through the conception and execution of a group research project (described below). Additional topics in this domain vary year to year according to the research project(s) chosen by the residents.
Social change, leadership, and advocacy.
The course also places a strong emphasis on translating research into action, with residents participating in numerous field trips and research and advocacy skill workshops to learn how health professionals, policy makers, and community organizers use advocacy skills to make change. Field trips have included visits to government officials, health advocacy organizations, and media outlets. We also conduct advocacy skill workshops on topics such as public speaking, writing opinion editorials, and community organizing.
Research-based health advocacy project.
A focal point of the course is the group research-based health advocacy project. As a group, residents develop a research project that examines a problem they have observed clinically, in which social or systemic factors pose a barrier to health equity or optimal health outcomes. With the support of experienced health services researchers, the residents conduct a study using primary data collection methods or secondary data from large, national health care databases. Faculty mentors help residents use appropriate research methodology to analyze the data and interpret the results. This rigorous scholarly process challenges residents to design and execute an institutional review board–approved research proposal and teaches them how to critique research, emphasizing the importance of bias, validity, and precision in evaluating data.
Once the research is complete, residents use their findings to develop suggested policy interventions to improve the problem they have identified. They then design and carry out a plan to disseminate their findings and advocate for the policy solutions they have developed.
This research project meets the Accreditation Council for Graduate Medical Education (ACGME) requirements for scholarly work.7 Residents are expected to present an academic poster on their completed project within 12 months of completing the course at a regional and/or national Society of General Internal Medicine conference. Some motivated residents have developed manuscripts based on their projects for submission to academic journals. Additionally, the residency program will fund first and second authors to present their findings at a national Society of General Internal Medicine conference.
On end-of-year course evaluations over the last four years (AYs 2012–2015), the aggregate mean score on the overall quality of the course has been rated as 5.2 (standard deviation = 0.64 on a scale of 1–6, where 1 = inadequate and 6 = outstanding, by 17 out of 32 residents [response rate: 53%]). These data and qualitative comments suggest that residents largely regard this course as one of the major strengths of their residency experience. For example, one resident described the course as “CHA at its best.” Another said, “I really feel incredibly fortunate to have the time and space to think so critically about pressing issues in our [health care] system.”
The most tangible outcomes of the course are the scholarly products from the group research-based health advocacy projects (Table 2). In each year since the new course has been implemented (AYs 2012–2015), all of the scholarly work from the course has been accepted for presentation at regional and/or national Society of General Internal Medicine conferences. One of these projects was chosen as a finalist for the society’s Mack Lipkin Award, given to the three best scientific presentations by trainees. As of the end of AY 2015, 31 residents have been involved as presenters and/or coauthors at these conferences.
CHA’s internal medicine residency program has allocated substantial time and resources to a course that we believe is underrepresented in postgraduate medical education. This social medicine and research-based health advocacy course has become a centerpiece of our residency program. By making an institutional commitment to health advocacy as a core component of being a physician, our residency program aims to reframe the responsibilities of medical practice and further shape professional identity and goals.
The course has been championed by our institution’s academic leaders because we believe it reinforces the value of training in a safety-net health system and attracts high-caliber residents to our training program and, in turn, well-trained physicians to our faculty.
We designed our course to help residents clarify and further develop the values that motivated them to pursue careers in medicine and to choose a residency program committed to caring for underserved patients, whose lives are often devastated by poverty and injustice. We believe that connection to these values is vital to a resident’s evolving self-perception and formation of their professional identity.8
The yearlong longitudinal design of the course seems to reinforce acquisition of knowledge and skills through didactics, discussions, field trips, and research and advocacy skill workshops. Experiential learning through the group research-based health advocacy projects appears to stimulate further synthesis of knowledge and skills and to provide residents with a firsthand experience of serving in the role of health advocate. It also delivers a valued product: a presentation at a regional and/or national conference. The emphasis on scholarship is meant to support development of research, leadership, and presentation skills.
Gaufberg et al9 define the hidden curriculum as “learning that occurs by means of informal interactions among students, faculty, and others and/or learning that occurs through organizational, structural, and cultural influences intrinsic to training institutions.” The hidden curriculum in this new course has exposed residents to inspiring role model physician advocates, which is essential to the development of their identity as physician advocates. Personal mentorship further provides residents with resources to support their career development as physician advocates.
We are currently collecting and analyzing extensive qualitative and quantitative data on the impact of the course that will allow us to determine whether we are achieving our course goals.
We intend to use our findings to advocate for a national health advocacy competency framework in the United States, perhaps modeled after CanMEDS.10 Such a framework could meaningfully support U.S. medical institutions in developing physician advocacy curricula. We believe the ACGME should include required advocacy curricula as a part of their systems-based practice initiative, and the American Board of Internal Medicine examination should assess physicians’ competencies in this domain.
Generalizability, limitations, and barriers
We recognize that the uniqueness of our institutional context and of our resident cohorts may limit the applicability of replicating our course in other institutions. While we believe in the importance of robust health advocacy training in medical education, we also understand that for some institutions it may be prudent to initiate a curriculum that requires fewer institutional resources. Other formats for such curricula may include a lunchtime lecture series, elective courses, field trips to local health care institutions, or research-based health advocacy project options for interested residents. Identifying a committed faculty to mentor residents and coordinate programming is the most important element in the development of a health advocacy curriculum.
At our institution, the required health advocacy course has cut down on elective time, which we considered to be an acceptable trade-off. Our faculty is currently exploring funding sources to sustain support for course development and evaluation. Both of the course directors invest approximately 10% of their full-time equivalent on this course and receive some financial support from the Department of Medicine. Guest lecturers donate their time. Otherwise, the course has negligible costs.
Residency training is a formative time during which the values that inspired a commitment to service through medicine should be honored and nurtured. Residency curricula can support young physicians in developing the knowledge, skills, and careers that enable them to serve in the role of health advocate. We believe our social medicine and research-based health advocacy course enriches our residents’ sense of medical professionalism, better prepares them to face the complexities of our modern health care delivery systems, and ultimately contributes to a workforce that better serves the public and improves health equity.
Acknowledgments: The authors wish to thank the following people for their intellectual contributions to the educational theory of the curriculum: David Hirsh, MD, Cambridge Health Alliance, Harvard Medical School; Jeffrey Linder, MD, MPH, Brigham and Women’s Hospital, Harvard Medical School; David Sloane, MD, EdM, Brigham and Women’s Hospital, Harvard Medical School; Kathryn Butler, MD, Massachusetts General Hospital, Harvard Medical School; and Lisa Thompson, DMD, Harvard School of Dental Medicine.
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