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Building a Generation of Physician Advocates: The Case for Including Mandatory Training in Advocacy in Canadian Medical School Curricula

Bhate, Tahara D. MD; Loh, Lawrence C. MD, MPH

doi: 10.1097/ACM.0000000000000841
Perspectives
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There is an increasing focus on the social accountability of physicians as individuals, and of medicine itself. This has led to increasing emphasis on physician advocacy from a wide variety of institutions. The physician advocacy concept is now part of the Health Advocacy competency mandated by the Royal College of Physicians and Surgeons of Canada. Despite its growing prominence, physician advocacy remains poorly integrated into current medical undergraduate curricula. The authors recommend how and why curricular reform should proceed; they focus on Canadian medical education, although they hope their views will be useful in other countries as well.

The authors discuss conflicting definitions of physician advocacy, which have previously hampered curriculum development efforts, and suggest a way of reconciling the conflicts. They review current gaps in advocacy-related curricula, suggest that these can be addressed by incorporating practice-based and skills acquisition elements into current didactic teaching, and offer several strategies by which an advocacy curriculum could be implemented, ranging from small modifications to current curriculum to developing new competencies in medical education nationally.

The authors present a case for making an advocacy curriculum mandatory for every Canadian medical trainee; they argue that teaching trainees how to fulfill their professional responsibility to advocate may also help them meet the social accountability mandate of medical school education. Finally, the authors explain why making the development and implementation of a mandatory, skill-based curriculum in advocacy should be a priority.

T.D. Bhate is a graduate student, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.

L.C. Loh is public health physician, Public Health Ontario, Toronto, Ontario, Canada, and adjunct lecturer, Dalla Lana Faculty of Public Health, University of Toronto, Toronto, Ontario, Canada.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed are those of the authors and should not be construed to represent the positions of any of the institutions listed in this article.

Correspondence should be addressed to Lawrence C. Loh, University of Toronto, Dalla Lana School of Public Health, 155 College St., Sixth Floor, Toronto, ON, Canada M5T 3M7; telephone: (647) 281-5971; e-mail: lloh@jhsph.edu.

Over 150 years ago, Rudolph Virchow asserted that “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”1 Today, Virchow’s notion of the physician advocate is regaining its primacy within the professional conceptualization of medicine. Suggestions that physicians should limit their spheres of influence solely to clinical medicine2 have been met with vociferous opposition,3–11 and recent academic and nonacademic discussions have identified advocacy as an essential skill for today’s physicians.12–14

During his recent term as president of the Canadian Medical Association (CMA), Dr. Louis Francescutti impressed upon Canadian physicians the importance of establishing health advocacy as a cornerstone of medical practice.15 Similar calls to engage in health advocacy have increasingly proliferated in professional codes and charters across North America, most notably those created by the Accreditation Council for Graduate Medical Education,16 the Canadian College of Family Physicians (CFPC),17 and the Royal College of Physicians and Surgeons of Canada (RCPSC).18 These aren’t simply token calls; the RCPSC, for example, lists the role of Health Advocate as one of six core competencies essential to the modern physician,18 whereas the CFPC states that “family physicians have the responsibility to advocate public policy that promotes their patients’ health” within one of their four principles of family medicine.17

The newly defined social accountability mandate for medical undergraduate programs, first articulated by the World Health Organization,19 has given advocacy a new prominence in medical education as a potential means to help meet that mandate. In Canada, major stakeholders such as Health Canada20 and the Association of the Faculties of Medicine in Canada21 envision a future where medical education is grounded in social accountability and trains physicians to be leaders in addressing the health needs of individuals and their communities. These professional bodies hope that embedding advocacy in the skill sets of future generations of physicians will encourage them to employ their scientific and clinical expertise in influencing the overarching determinants that shape their patients’ health. At present, medical students and young physicians in Canada and elsewhere striving to meet this modern vision are challenged by an absence of opportunities to acquire relevant knowledge and skills. To overcome these barriers, we maintain that theoretical and practical advocacy training must be incorporated into the curriculum plans of medical students in Canada and potentially elsewhere. We hope the case we make for advocacy training may be useful for medical schools in other countries also, especially those where training and accreditation standards are similar to Canada’s.

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Defining the Spectrum of Advocacy: Beyond Just Political

Unlike other competencies outlined for Canadian physicians, there have been notable challenges in integrating advocacy into current pedagogical models.22,23 One of these is agreement on a comprehensive definition of physician advocacy itself.24,25 Earnest et al24 define physician advocacy as

action by a physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.

Furrow26 suggests that advocacy occurs on a spectrum that includes legislative, administrative, clinical, and patient-centered endeavors.

The emphasis on political advocacy has often presented a barrier to acceptance of advocacy training2; it is thus important to recognize that political involvement is a permissible but not required avenue of physician advocacy.21 In its most basic form, we believe that physician advocacy involves the pursuit of strategies outside the provision of medical care to effect a desired positive change in the health of individuals or communities. This complements what Croft et al13 offer as the purpose of advocacy training: offering a set of

experiences that improve a physician’s ability to advocate along a continuum, from issues arising for individual patients to those affecting health care policy.

It is absolutely essential that any advocacy curriculum be grounded in this broader understanding of physician advocacy, before making it mandatory can be considered or justified.

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Culture Building: The Case for Mandating Physician Advocacy Training

There are many diverse examples of present-day physician advocacy, from the family physician who advocates that his critically ill patient should be seen more quickly by a specialist, to the emergency physician who works to improve injury prevention programs, to the pediatrician who joins a community coalition to promote physical activity in schools.25 At present, an interested minority of medical students develop advocacy skills either on an ad hoc basis or through optional training experiences.27–30 However, greater practice complexity and growing health system pressures have recently highlighted opportunities for broader advocacy training in medical school curricula.6,13,31

These examples demonstrate physicians’ responses to advocacy needs, often without the benefit of formal training.25 The ease of finding this type of response3–11 seems to demonstrate that many physicians have an innate desire to advocate. It follows that this desire should be nurtured and supported by appropriate training around a basic “toolkit” of skills. However, all medical students, whether they are natural advocates or not, should receive such training. For if advocacy is to be accepted as an important component of Canadian physicians’ practice, as professional bodies have dictated it should, then all physicians upon graduation must possess the skills to engage in it competently. Mandating advocacy training would provide all Canadian medical school graduates an opportunity to develop those skills, which could be used in their future careers to address a societal or community problem, should the need arise.

Separate from providing students the means to meet professional obligations, mandatory advocacy training has several ancillary benefits. Besides evidence that highlights engagement in advocacy as a means to combat the seeming erosion of morale and empathy prevalent in medical trainees,32 such engagement might also foster students’ acceptance of advocacy into their professional identities. But reshaping professional identities alone may not be enough to secure the vision of medical practice articulated by the social accountability mandates of medical schools mentioned above. For example, the growing socioeconomic homogeneity amongst Canadian medical trainees33 has been identified as a potential barrier to advocacy work, especially on behalf of vulnerable populations34; compounding this, the literature notes that interest in social issues often declines during medical training.35,36

Potentially mitigating this, formal training in advocacy has been shown to reform attitudes toward its practice, even amongst physicians with no demonstrated preexisting interest.37 This parallels evidence that early exposure can lead to continued practice in other areas, such as global health,38 which has seen many high-profile physician advocates continue their involvement from an initial undergraduate experience. Many physicians who have been recognized for advocacy work later in their careers similarly detail their early exposure to advocacy activities.39 Mandatory exposure may thus represent an opportunity for physicians to recognize advocacy work as an important part of their professional identities, rather than a prescribed responsibility.

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A Curriculum for Advocacy: Overview and Implementation Strategies

As with any proposed curricular change, it is important to review existing curricular structures and identify gaps. Specific to advocacy, many medical schools provide lectures about theories of systems change and the social determinants of health, with occasional opportunities for service-based learning.40 For many students, particularly those who are interested in social issues, these sessions do not adequately prepare them to advocate, and do little to stem the rise in apathy toward social issues during medical training.36 In addition, the success of student-led practical programs—such as the Health Advocacy and Leadership program at the University of Alberta Faculty of Medicine and Dentistry—suggests that the ubiquitous curricular content focusing solely on teaching the social determinants of health is incomplete without the provision of tools for students to address those determinants.

The presentation of a fully elucidated, competency-based mandatory curriculum in advocacy is beyond the scope of this article, but essential components of a potential curriculum have been suggested elsewhere. These include understanding health care systems and financing, the provision of social services, familiarity with the process of policy development,14,28,41 and, although not essential, exposure to political advocacy.42 The literature highlights the importance of acquiring both transferable skills and practical knowledge in successfully carrying out advocacy activities.14,43 While there is emerging consensus around the broad content of an advocacy curriculum, there is little discussion on how to develop and integrate this new curricular content into the current educational framework.

Several different strategies could be employed in implementing a new advocacy curriculum. Given the already numerous competing demands for curricular time, the easiest solution would be to shift existing advocacy-related teaching from observation of physician advocacy efforts to contributing to actual advocacy efforts while in training. This shift could encompass both didactic content and practical experiences. The service-based learning opportunities already established around social determinants of health could similarly have their focus shifted by appending an advocacy project to them. This strategy is already in use in a small number of undergraduate and postgraduate training programs.44,45

This approach is similar to those recommended for clinical training: to introduce community practice experience early, as a replacement for or adjunct to existing lecture-based learning, in concert with a greater emphasis on active learning rather than passive observation.46 It would also allow educators to use the significant number of physicians who engage in advocacy work, both in academia and the community,47,48 to provide the mentored practice experiences necessary for students’ skills acquisition because social medicine courses often contain the necessary apparatus for service–learning opportunities under the mentorship model. With a curricular focus on skills acquisition, employing physicians in these mentorship roles could provide the practicality and global transferability essential for student buy-in, even if those physicians have no formal advocacy training themselves.

A potential barrier for using this model would be the difficulty in accumulating the necessary critical mass of faculty with the appropriate experience and willingness to provide practice opportunities. A generation of faculty will also need to adapt to the new curriculum and undergo advocacy training themselves, to ensure that they can support the new curricular requirement. Importantly, however, many service–learning opportunities already rely on professionals in other fields, even beyond the traditional allied-health fields. This multidisciplinary model could be adapted to provide educational experiences around advocacy, and could even enhance the depth of learning; similar models are already employed to great success in many undergraduate public health clerkship and elective rotations.

A more involved strategy involves creating a standardized, competency-based curriculum. Currently, service-based learning is a part of the accreditation standards for Canadian medical schools,49 but the emphasis is on knowledge acquisition as opposed to skills acquisition. One strategy may, therefore, involve revising accreditation standards to include a skills acquisition objective within service–learning placements. In addition, the 2015 revision of the Canadian Royal College CanMEDS competencies contains a more detailed set of competencies than previously described for the role of Health Advocate, as well as a new competency, Leadership.50 Of note, the competencies within the role of Health Advocate have been revised to explicitly require physicians to “respond to the needs of the community or population they serve, by advocating with them for system-level change,”50 both during their training and in practice. Strengthening the requirements to demonstrate practical experience in advocacy within the Health Advocate competency is another strategy that may foster the creation of skills acquisition opportunities in medical training for advocacy. Such a strategy would also be in keeping with the overall direction of the proposed 2015 revision,50 as the language, at least within the role of Health Advocate, has been significantly refocused from an emphasis on observation and understanding to one of action.

The final, most challenging strategy could involve the de novo development of competencies in physician advocacy to guide underlying and ongoing curriculum development. Important preliminary work using this strategy is already being done, as the CMA appears to be informally in the process of surveying medical students to gain their input on the development of advocacy competencies. Going directly to learners could also help foster a “culture of advocacy” in medical education and practice. Similar strategies oversaw previous cultural shifts toward patient-centered care51 and evidence-based medicine.52 This strategy would be the most resource intensive and involve the most stakeholders, but may be the best opportunity to ensure that a firm grounding of advocacy skills to support physician practice becomes second nature in medical education.

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Where to From Here?

Potentially significant changes lie ahead for the systems and concepts that govern medical practice and health care in Canada. Our professional and educational bodies have drawn up expectations that physicians will be at the forefront of this transformation, as advocates. As physicians consider the unique value they have to offer the health care system, the ability to draw on their clinical and scientific expertise to effect positive change is an essential component. Educators must recognize that a standardized, competency-based curriculum in advocacy, centered in both didactic teaching and skills development, is necessary to maintain this aspect of physicians’ unique value.

Appropriately incorporating advocacy education into medical training will be essential to allow members of the medical community to effectively respond to external challenges that affect their individual patients and their professional practices, such as changing models of health care, financial pressures on the health care system, the chronic disease burden, and the aging population. Because these external challenges are decidedly not apolitical, we recognize that any advocacy education will examine politicized topics and contexts.

In developing curriculum, care must be taken to ensure that physician trainees develop the ability to critically examine and discuss these kinds of topics and contexts. Lessons can be drawn from teaching about health care system models, which are arguably some of the most political topics in modern medicine; the aim should not be to instill a viewpoint but, instead, to foster critical thinking and equip students to tackle a controversial topic regardless of which side of the debate they stand on.

Although several challenges remain, the significant amount of research and discussion about advocacy education for medical students has made a mandatory curriculum in advocacy an achievable goal. Educators must first agree on what denotes competency in advocacy. That standardization will provide the necessary framework to support advocacy training and will hopefully facilitate the incorporation of an advocacy focus into existing curricular time already devoted to social aspects of medicine. This strategy is likely the most feasible model of implementation within the Canadian context, regardless of the process of national competency development. Doing so will allow a significant portion of educational time to be used to its maximum efficiency, which in turn will hopefully encourage faculty support of curricular reform. Faculty support is crucial so that the development of an advocacy curriculum will be a priority for them.

Canadian medical students are already seeking independent opportunities to meet their own educational goals in advocacy, making now the right time for faculties to engage in curricular redevelopment in concert with these student enterprises. Working collaboratively will allow educators to harness the preexisting student interest and experience in this area, while enhancing student engagement with the new curriculum. After almost a decade of discussion, the necessary components are in place to dramatically change the philosophy of social medicine education without requiring wholescale deconstruction of our current curricula. Everyone involved in Canadian medical education must give a high priority to bringing about this change. In this way, they will better equip the next generation of physicians to respond to emerging challenges in health care and to remain leaders in providing high-quality health care to individuals and their communities.

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