Secondary Logo

Journal Logo

Research Reports

Prevalence and Characteristics of Advocacy Curricula in U.S. Medical Schools

Brender, Teva D.1; Plinke, Wesley MPH2; Arora, Vineet M. MD, MAPP3; Zhu, Jane M. MD, MPP, MSHP4

Author Information
doi: 10.1097/ACM.0000000000004173

Abstract

Physician advocacy, defined as “action … to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that [a physician] identifies through … professional work and expertise,” 1 has long been recognized by national organizations as a core tenet of professionalism in medicine. The American Medical Association (AMA), for instance, includes advocacy in its “Declaration of Professional Responsibility,” 2 and the American Board of Internal Medicine calls for a “commitment to … public advocacy on the part of each physician.” 3 While some physicians believe that advocacy remains outside the scope of their obligations, 4 a number of major professional medical organizations recognize advocacy as a fundamental component of a physician’s duties and responsibilities. 5 Consistent with these positions, many professional medical organizations now provide advocacy training programs and resources, 6,7 and a number of these groups, including the American College of Physicians (ACP) and the American Academy of Pediatrics, have released public statements in response to recent national sociopolitical events. 8,9

Formal medical training may present an ideal opportunity to shape future physicians’ understanding of their professional responsibilities and teach them the skills necessary to fulfill these obligations. For example, the Accreditation Council for Graduate Medical Education (ACGME) lists “advocating for quality patient care and optimal patient care systems” as a core objective for residents across all subspecialties. 10 Proponents point to a number of benefits of introducing advocacy training early in medical education. For example, trainees who have attended institutions that emphasized population and community-based advocacy have reported greater advocacy skills and more civic engagement 5 years into their careers than their peers who attended schools that did not have such foci. 11 Others have suggested that the length and challenges of medical training irreparably alienate trainees from their communities. 1 Advocacy activities may improve psychological well-being by cultivating social connections at a critical juncture of professional development, and, further, these activities can empower individuals by fostering a sense of competence. 12 Studies also suggest that advocacy training promotes proficiencies and skills to address problems in the health care system, which may be an effective tool to ameliorate physician burnout. 13–15

Despite these potential benefits, challenges remain in how physicians can be trained in advocacy skills and competencies. Critics suggest that emphasizing social issues may come at the expense of developing clinical competencies. 16 Surveys have also consistently shown that physicians are more likely to support advocacy efforts than to personally participate in them, due in part to long clinical hours and competing career demands. 17–19 Trainees, in particular, often express a strong interest in advocacy. Specifically, large numbers of medical students self-identify as advocates, 20 yet they report low confidence in both their knowledge of health care advocacy and their ability to practice it. 21 Within this context, few standards are available to guide the integration of advocacy training into existing coursework. Whereas individual medical schools have incorporated advocacy into their undergraduate medical education (UME) curricula, the Liaison Committee on Medical Education (LCME), the body that writes the accreditation standards for all U.S. MD-granting medical schools, does not list advocacy as a requirement for UME programs. 22

While prior studies have assessed different models of advocacy curricula and the integration of such coursework into graduate medical education (GME), 23–26 we are aware of no comprehensive analyses of advocacy instruction for medical students to date. We, therefore, conducted content analyses of the online course catalogues of MD-granting medical schools in the United States to describe the structure and topics covered in both required and elective advocacy courses. Understanding both the extent to which physician advocacy is being taught in medical schools and the nature of this instruction is needed to help define expectations of advocacy training in medical education.

Method

Using the member school directory provided by the Association of American Medical Colleges (AAMC), we compiled a list of 154 MD-granting medical schools in the United States. We used a number of search strategies to identify online course catalogues, applying predetermined search terms (i.e., course, course description, curriculum, course catalogue, syllabus, required, elective, clinical, pre-clinical, and foundations) to query each school’s curriculum website, specifically its Office of the Registrar, medical student handbook, and medical program handbook webpages. To capture courses that may have contained elements of trainee or physician advocacy content, we then performed manual searches of all available course catalogues using the following search terms: advocacy, policy, equity, social determinants of health, and variations of these terms (e.g., social, SDOH). Data collection and analysis took place from July 2019 through May 2020. We transferred the course descriptions that we identified into NVivo (Version 12, QSR International, Melbourne, Australia) for data management and analysis.

Using an iterative process, we generated a preliminary coding schema after reviewing an initial selection of course descriptions. Three research team members (T.D.B., W.P., and J.M.Z.) coded an overlapping sample of 30 schools’ course descriptions and syllabi (approximately 50 courses), meeting to discuss codes and resolve any discrepancies through consensus. After ensuring sufficient interrater reliability (kappa statistic 80%) for each code category, 2 team members (T.D.B. and W.P.) coded the remainder of course descriptions and syllabi independently. All authors met periodically to discuss codebook revisions and general patterns and trends that emerged.

Results

We identified 100 medical schools that had posted information on both required (“core”) and elective courses on their publicly available websites, 22 schools that posted only required course descriptions on publicly available sites, 12 schools that posted only elective course descriptions on public-facing websites, and 20 schools that had no publicly available course descriptions online. In total, we identified advocacy curricula in 114 required courses and 238 elective courses. Of the 134 U.S. MD-granting medical schools with mandatory and/or elective courses listed publicly online, 103 (76.9%) offered at least 1 advocacy course, 17 (12.7%) offered no advocacy courses, and the remaining 14 (10.4%) had no advocacy courses among the subset of elective or required courses that were listed online (these 14 are a subset of the 34 schools that listed only required or only elective courses online). Of the 122 schools that published their required course descriptions, slightly more than half had a required course that covered elements of advocacy (n = 64 [52.5%]). Of the 112 schools that published their elective course descriptions online, two-thirds (n = 75 [67.0%]) offered elective courses on advocacy. On average, schools offered 0.93 required and 2.13 elective courses on various advocacy topics in their UME curricula.

Table 1 compares the schools in our sample that offered any advocacy course (n = 103) with the schools that offered none (i.e., 17 schools that had publicly available catalogues for both required and elective courses, but did not list any advocacy courses among these). Schools with advocacy courses were, compared with those without, more likely to be private schools (56.3% vs 76.5%), more likely to be affiliated with a teaching hospital (82.5% vs 70.6%), less likely to be in rural areas (30.1% vs 41.2%), less likely to have class sizes of at least 150 students (48.5% vs 58.8%), and more likely to have majority non-White student bodies (43.7% vs 41.2%). Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B124 shows the availability of medical school advocacy course offerings by state.

Table 1
Table 1:
Characteristics of U.S. Schools With and Without Advocacy Courses, According to a 2019–2020 Search of AAMC Member U.S. Medical Schools’ Websitesa

Advocacy topics were taught in 2 overarching ways: as part of general studies courses and in courses specifically focused on advocacy content and skills development. General studies courses tended to cover physician advocacy topics as a subtopic within broad overviews of health care delivery and finance, health care law, humanities, bioethics, community and population health, epidemiology, and evidenced-based medicine. Many of the descriptions for these broader, more general courses emphasized the conceptual importance of physician advocacy on behalf of patients. For example, the Johns Hopkins University School of Medicine’s “Foundations in Public Health: Epidemiology, Ethics and Health Care Systems,” a required course for first-year students taught by multidisciplinary faculty, aimed “to stimulate interest in being an effective advocate for improving health and health care for … populations of patients.” Only 5 (4.4%) of 114 required courses included the term “advocacy” in their course titles.

In comparison, elective advocacy courses were more likely to have advocacy as a central point of the class, and 48 (20.2%) of 238 elective courses used the term “advocacy” in their title (Table 2). These advocacy-specific courses featured skills-building content, and specific learning objectives included writing opinion-editorial pieces, testifying before a legislative committee, and/or planning an advocacy campaign. In addition, while 13 (11.4%) of required advocacy courses and 31 (13.0%) of elective courses included community service components, elective courses offered a more diverse set of field experiences. These experiential learning opportunities included the following:

Table 2
Table 2:
Elements of Advocacy Curriculum, by Required Versus Elective Courses, According to a 2019–2020 Search of AAMC Member U.S. Medical Schools’ Websites
  • clinical advocacy (i.e., helping patients to navigate the health system) alongside social workers or nurses;
  • work with interest or patient advocacy groups, legislators, professional medical organizations, public health departments, and/or other governmental agencies; and
  • guided observation of the criminal justice system.

For example, the University of Illinois College of Medicine offered a course called “Legislative Education & Advocacy Development,” through which medical students, paired with resident physicians and public health graduate students, worked to prepare a policy analysis on a particular public health concern. Students then participated in mock briefings and, as a capstone, traveled to the state capital to deliver their policy brief to a state legislator during the Illinois legislative session.

More than a quarter of all 352 advocacy courses (n = 93, 26.4%) focused their curricula on a specific community or population. Among courses with an explicit population focus, children were the most common (n = 32), followed by courses focusing on global health populations (n = 15) and people with low socioeconomic status (n = 13) (Table 3). Examples of UME curricula in these areas included general pediatrics advocacy courses and courses on advocacy for victims of child abuse, clinical rotations in developing countries or in rural and underresourced settings, and course credit for providing service in student-run free health clinics in underserved communities. Women (n = 10), racial/ethnic minorities (n = 8), immigrants/refugees (n = 6), and rural communities (n = 3) were other populations recurring in course descriptions. One course focused on lesbian, gay, transgender, bisexual, and queer (LGBTQ) persons. Examples of curricula focusing on these groups include training in family planning/reproductive rights and domestic violence, information on immigrant/refugee health and comprehensive social services, coursework on African American and Native American health disparities, and a primary care clerkship caring for LGBTQ patients.

Table 3
Table 3:
Focus of Advocacy Courses Among Courses on Specific Populations, According to a 2019–2020 Search of AAMC Member U.S. Medical Schools’ Websitesa

Discussion

Our findings suggest that most U.S. medical schools now offer at least 1 advocacy course, although the majority of advocacy offerings are elective rather than required. Required courses typically cover advocacy as a subtopic within broader health policy, population health, or public health courses, whereas elective courses are more likely to feature advocacy skills-building content and experiential learning and to focus on specific populations.

Our analysis not only demonstrates heterogeneity in the availability of and instruction used in advocacy curricula but also offers several curricular models for educators looking to further integrate advocacy coursework into UME curricula. Evidence suggests that simply teaching students about the social determinants of health is insufficient to change health outcomes. 27 Instead, educational research has shown that allowing students to apply classroom knowledge to an authentic, real-world setting reinforces concepts, stimulates greater engagement, promotes systems-level thinking, and provides context that further enhances conceptual learning. 28,29 In our sample of medical schools with curricula publicly available online, elective courses were more likely to incorporate such educational elements, offering students advocacy-focused, skills-building content and experiential learning opportunities. These findings indicate that medical schools may be able to design a range of courses that cover advocacy topics, balancing content knowledge with skills-based learning and practice.

Given the absence of guidance on designing and integrating advocacy curricula into UME, there may be a role for more coordination and communication across different levels of medical training. In a systematic review of advocacy curricula in GME, Howell and colleagues found that pediatric advocacy training programs were overrepresented among medical specialties. 30 They attribute this observation, in part, to the ACGME’s explicit advocacy requirements, which require pediatric residency programs to allocate educational time to elements of community pediatrics and child advocacy. The authors found that a majority of the programs with child advocacy curricula cited these ACGME requirements as the motivation for developing and implementing the content. 30 Likewise, in our analyses, child advocacy courses were overrepresented in UME curricula, suggesting that even though the LCME does not include advocacy in its accreditation standards, medical schools may have identified a need to prepare students for the competencies that will be expected of them in their GME programs. Educators have been calling for more coordination across undergraduate, graduate, and continuing medical education for years, 31 but structural barriers continue to impede continuity across these different stages of medical training. Guidelines and support from GME programs and from leading medical/professional organizations may help to promote the development and uptake of integrated advocacy education earlier in training.

Questions about the extent to which advocacy content should be a required element of medical education remain. As training evolves to keep up with the changing health needs and societal priorities of the United States, medical schools face the daunting task of incorporating an ever-expanding set of new, important educational topics while preserving a fundamental basic science and clinical curriculum. To support curricular flexibility, the LCME’s current accreditation standards are centered around general competencies rather than specific requirements, allowing each medical school to establish a curriculum tailored to its mission and educational objectives. 22 Given that schools must weigh competing curricular priorities in the context of finite time and resources, more research is needed to understand the effectiveness of different educational approaches and the potential effects of advocacy learning on both short- and long-term educational and professional outcomes. 32 Evidence will help schools evaluate the relative benefits and tradeoffs of including advocacy curricula as part of a core competency or as an elective offering—and how best to do so. In addition, shared learning objectives and data collection across licensing, accrediting, and certifying bodies may help support higher-quality courses and improve tracking and assessment of instructional outcomes over time. For example, the AAMC and the American Association of Colleges of Osteopathic Medicine (AACOM) recently announced plans for a shared Curriculum Inventory, starting August 2021, to benchmark and report on medical school curricula. 33 Including advocacy coursework in this joint venture and others like it may help to inform and strengthen the content, structure, and timing of future instruction.

Finally, we found few advocacy courses focused on addressing health care inequities that specific populations (e.g., those in rural communities and racial and ethnic minorities) face. For example, despite awareness of the disproportionate impact that COVID-19 has had on minority communities and despite the renewed calls to address racial inequities within the health care system, U.S. medical schools do not appear be explicitly confronting issues of race, racism, injustice, and inequity in coursework. The reasons for this are unclear, but 1 possibility is that racial and ethnic minorities remain underrepresented in medicine, 34 including within the ranks of faculty who influence the design and adoption of course curricula. 35 Recent attention to racial injustice may inspire the development of curricular competencies and the reinforcement of skills that meet medical trainees’ growing desire to address racial disparities and biases. 36,37 More effort is needed to meet the increased calls for medical schools and health care institutions to equip trainees with the tools to recognize and confront racism and structural inequities in medicine. 38 More broadly, strengthening medical school outreach to underrepresented communities—through clinical placements within rural or underserved communities, Indian Health Service student rotations, and community health programs—may be a valuable means through which trainees can learn and engage more directly in advocacy skills building.

We note several limitations to our study. First, we relied on the availability of online course catalogues and a predetermined set of search criteria, and both of these approaches may have resulted in an underestimation of the number of advocacy courses offered across U.S. medical schools. For instance, additional broad search terms, such as justice and diversity, or specific terms such as firearm safety or gun violence, could have yielded more advocacy-relevant courses. Second, our content analysis was limited by the completeness of the course descriptions available online; thus, we may have missed course elements and topics that were not described but were taught. Third, our search was completed in late 2019, and in the interim, some schools may have added or amended their course offerings. Fourth, our analysis did not include the 37 currently accredited U.S. osteopathic schools, which may have varying approaches to and capacity for advocacy training. Finally, we were unable to assess the quality or educational benefits of the advocacy courses we identified, and examining these elements is important for future work. Nonetheless, this study, which provides an important and timely overview of advocacy curricula at U.S. MD-granting medical schools, establishes a foundation for further research focused on advocacy training and content in UME.

Conclusions

Recent attention to issues such as gun violence, the COVID-19 pandemic, and racial inequities has reignited interest in physicians’ professional obligations as advocates. We identified and characterized advocacy curricula across 134 MD-granting medical schools in the United States and found that 103 (76.9%) schools offered at least 1 advocacy course, and the majority of these were elective. Most required courses covered advocacy in the context of more general courses on health policy and public health and did not include content on advocacy skills building. Compared with required courses, elective courses on advocacy were far more likely to include field experiences and skills-building content, and they were more likely to focus on advocacy training on behalf of specific populations (e.g., children and those with low socioeconomic status). Few advocacy courses focused explicitly on the health inequities that racial and ethnic minorities face.

Taken together, our findings provide an overview of the landscape of advocacy education in UME, but more work is necessary to understand the quality of education and long-term effects of advocacy training on medical students’ attitudes and competencies.

References

1. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med. 2010; 85:63–67
2. American Medical Association. A declaration of professional responsibility H-140.900. https://policysearch.ama-assn.org/policyfinder/detail/social%20responsibility?uri=%2FAMADoc%2FHOD.xml-0-431.xml. Modified 2017. Accessed April 30, 2021
3. ABIM Foundation. Medical professionalism in the new millennium: A physicians’ charter. Lancet. 2002; 359:520–522
4. Huddle TS. Perspective: Medical professionalism and medical education should not involve commitments to political advocacy. Acad Med. 2011; 86:378–383
5. American College of Surgeons Statements on Principles. Bull Am Coll Surg. 2016; 101:19–34
6. American College of Physicians. Advocacy in action. https://www.acponline.org/advocacy/advocacy-in-action. Published 2021. Accessed April 30, 2021
7. American Academy of Family Physicians. Advocacy. https://www.aafp.org/advocacy.html. Published 2021. Accessed April 30, 2021
8. Serchen J, Doherty R, Atiq O, Hilden D. Racism and health in the United States: A policy statement from the American College of Physicians. Ann Intern Med. 2020; 173:556–557
9. American Academy of Pediatrics. COVID-19 guidance for safe schools. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools. Published 2020. Accessed April 30, 2021
10. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Effective July 1, 2019. Accessed April 30, 2021
11. Minkovitz CS, Goldshore M, Solomon BS, Guyer B, Grason H; Community Pediatrics Training Initiative Workgroup. Five-year follow-up of Community Pediatrics Training Initiative. Pediatrics. 2014; 134:83–90
12. Gilster ME. Comparing neighborhood-focused activism and volunteerism: Psychological well-being and social connectedness. J Community Psychol. 2012; 40:769–784
13. Gazelle G, Liebschutz JM, Riess H. Physician burnout: Coaching a way out. J Gen Intern Med. 2015; 30:508–513
14. Berwick DM. Moral choices for today’s physician. JAMA. 2017; 318:2081–2082
15. Gruen RL, Pearson SD, Brennan TA. Physician-citizens—Public roles and professional obligations. JAMA. 2004; 291:94–98
16. Goldfarb S. Take two aspirin and call me by my pronouns. Wall Street Journal. https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291. Published September 12, 2019. Accessed April 30, 2021
17. Gruen RL, Campbell EG, Blumenthal D. Public roles of US physicians: Community participation, political involvement, and collective advocacy. JAMA. 2006; 296:2467–2475
18. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007; 147:795–802
19. Stafford S, Sedlak T, Fok MC, Wong RY. Evaluation of resident attitudes and self-reported competencies in health advocacy. BMC Med Educ. 2010; 10:82
20. Press VG, Fritz CD, Vela MB. First year medical student attitudes about advocacy in medicine across multiple fields of discipline: Analysis of reflective essays. J Racial Ethn Health Disparities. 2015; 2:556–564
21. Cole McGrew M, Wayne S, Solan B, Snyder T, Ferguson C, Kalishman S. Health policy and advocacy for New Mexico medical students in the Family Medicine Clerkship. Fam Med. 2015; 47:799–802
22. Liaison Committee on Medical Education. Functions and structure of a medical school: Standards for accreditation of medical education programs leading to the MD degree. http://lcme.org/publications. Published March 2019. Accessed April 30, 2021
23. Long T, Chaiyachati KH, Khan A, Siddharthan T, Meyer E, Brienza R. Expanding health policy and advocacy education for graduate trainees. J Grad Med Educ. 2014; 6:547–550
24. Ying Y, Seabrook C. Health advocacy competency: Integrating social outreach into surgical education. J Surg Educ. 2019; 76:756–761
25. Andrews J, Jones C, Tetrault J, Coontz K. Advocacy training for residents: Insights from Tulane’s Internal Medicine Residency Program. Acad Med. 2019; 94:204–207
26. Scott MD, McQueen S, Richardson L. Teaching health advocacy: A systematic review of educational interventions for postgraduate medical trainees. Acad Med. 2020; 95:644–656
27. Sharma M, Pinto AD, Kumagai AK. Teaching the social determinants of health: A path to equity or a road to nowhere? Acad Med. 2018; 93:25–30
28. Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-century health care system: An interdependent framework of basic, clinical, and systems sciences. Acad Med. 2017; 92:35–39
29. Gordon J. ABC of learning and teaching in medicine: One to one teaching and feedback. BMJ. 2003; 326:543–545
30. Howell BA, Kristal RB, Whitmire LR, Gentry M, Rabin TL, Rosenbaum J. A systematic review of advocacy curricula in graduate medical education. J Gen Intern Med. 2019; 34:2592–2601
31. Aschenbrener CA, Ast C, Kirch DG. Graduate medical education: Its role in achieving a true medical education continuum. Acad Med. 2015; 90:1203–1209
32. Croft D, Jay SJ, Meslin EM, Gaffney MM, Odell JD. Perspective: Is it time for advocacy training in medical education? Acad Med. 2012; 87:1165–1170
33. American Association of Colleges of Osteopathic Medicine. AACOM and AAMC joint announcement regarding shared services. https://www.aacom.org/news-and-events/news-detail/2020/07/09/aacom-and-aamc-joint-announcement-regarding-shared-services. Published July 8, 2020. Accessed April 30, 2021
34. Santhosh L, Babik JM. Trends in racial and ethnic diversity in internal medicine subspecialty fellowships from 2006 to 2018. JAMA Netw Open. 2020; 3:e1920482
35. Association of American Medical Colleges. Diversity in medicine: Facts and figures 2019. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019. Published 2021. Accessed April 30, 2021
36. Balch B. Medical students use momentum of anti-racism movement to advocate for change. Association of American Medical Colleges. https://www.aamc.org/news-insights/medical-students-use-momentum-anti-racism-movement-advocate-change. Published July 23, 2020. Accessed April 30, 2021
37. Reddy S, Starr S, Hayes S, et al. Implicit bias curricula in medical school: Student and faculty perspectives. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20200110.360375/full. Published January 15, 2020. Accessed April 30, 2021
38. Olayiwola JN, Joseph JJ, Glover AR, Paz HL, Gray DM II. Making anti-racism a core value in academic medicine. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20200820.931674/full. Published August 25, 2020. Accessed April 30, 2021

Supplemental Digital Content

Copyright © 2021 by the Association of American Medical Colleges