By: Megan Rich, MD, Associate Professor of Family & Community Medicine, University of Cincinnati; and Manasa Irwin, MD, Faculty, Forbes Family Medicine Residency
Reprinted from the spring 2020 Issue of The Ohio Family Physician.
There is increasing evidence that the social and structural determinants of health (SDoH) have a greater impact on health outcomes than clinical care provided within the health system.1 Physicians may write prescriptions, order tests, and perform procedures, yet still lose the battle against the SDoH. So what is the physician’s response when SDoH are encountered in clinical practice? It is advocacy. Physician advocacy can take one of two forms: agency and activism. Agency is when a physician “works the system” for a single patient, such as by completing prior authorization paperwork, calling a specialist to move up an appointment date, or connecting the patient to community resources.2 Activism occurs when a physician tries to “change the system” to improve the health of entire communities.2 Each form of advocacy is important for patient care, and medical students and residents need training in both to successfully care for patients throughout their careers. However, there is no standardized advocacy curriculum for family medicine training.2
In a Canadian study of internal medicine residents, the authors designed questionnaires to discern attitudes around the role of advocacy in medical training and professional practice. The 76 residents taking the survey overwhelmingly supported advocacy as a role for the physician, both in caring for individuals and communities.3 Moreover, resident self-assessment of their abilities to identify SDoH was quite high. Interestingly, three-quarters of respondents reported not participating in advocacy-related activities, and only one-third had considered incorporating such activities into future careers. Residents reported limited time, high stress levels, and a need to protect work-home boundaries as reasons for their lack of engagement.3 The discordance between residents reportedly supporting advocacy as an important skill, but avoiding advocacy activities may be related to feelings of low self-efficacy. Therefore, residents value being an advocate, but don’t know how to live out that value on a daily basis. In addition, they may not recognize physician agency activities as a type of advocacy, and thus underrate their engagement.
Despite the lack of standardized curriculum, many family physicians have developed expertise in advocacy and have applied it routinely in their practices. How did they learn to do this? In a qualitative study of expert health advocates, several themes arose. All participants noted a strong motivation to seek out advocacy activities due to fundamental beliefs about social justice and commitments to vulnerable populations. Most noted that informal mentoring, as well as formative experiences outside of traditional training, helped bolster skills.4 In another study, advocacy experts labeled their everyday activities of educating patients, trainees, and communities, and quality improvement work as advocacy-related.2 Implementing advocacy efforts can begin at a clinic and community level with screening for SDoH and linking patients to appropriate resources.
Currently, there is much interest in developing advocacy competencies and curricula. The pediatric residency program at Cincinnati Children’s Hospital teaches advocacy through a required rotation that incorporates both lectures and experiential learning; the residents visit community resources and apply what they learn while working at an underserved community clinic.5 A Boston pediatric program uses a longitudinal approach, where residents are exposed to topics such as community health and health policy, and complete a project related to health advocacy.6 Whatever the methodology, Hubinette, et al., propose a standardized framework for teaching advocacy.7 They argue that to become advocates, trainees must first understand health inequities and the systems that create them. Once that foundational knowledge is in place, trainees can learn to engage and empower communities, aid patients in navigating the healthcare system, and improve their inter-professional and communication skills.7
Despite the emerging interest in teaching advocacy, there is still much that is unknown. A number of studies have evaluated advocacy curricula based on knowledge gains or self-assessed skill improvement, but sustained behaviors are rarely assessed.7 Additionally, the best time for advocacy training remains unknown. Some have argued that it is a skill set best learned as an attending.8 Regardless, it seems likely that important seeds are planted during medical school and residency.9 Thus, it is incumbent on attending family physicians to role model advocacy, clearly labeling their work of physician agency and office process improvement as advocacy-related. After all, education is a part of our advocacy repertoire.
References are available on the OAFP website.