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

Integration of behavioral, social, and humanities sciences into healthcare and education and their alignment with medical education programs

There has been an increasing acknowledgment of the intricacies inherent in health and healthcare processes, leading to a shift in medical education. This change underscores multidimensional, thorough, reflective, and contextual approaches characterized by mutual interaction and change. The perception of health/well-being and illness is transitioning toward acknowledging them as outcomes arising from the complex interplay of individual, social, and environmental/ecosystemic factors. This includes biological, genetic, behavioral, sociocultural, and environmental influences. In line with this changing perspective, the purpose of this article is to provide a general framework for the integration of behavioral, social, and human sciences into Medical Education Programs in Healthcare and Training Processes. The framework presented is based on the following three conceptual and theoretical basis: (1) Complex systems thinking and reflective, contextual healthcare and education practices, (2) Health systems and socio-economic-political framework, (3) Ecosystem framework in health and disease. Our aim in this article is to provide a guide for the integration of Behavioral, Social, and Humanity Sciences into medical education programs and to present examples from around the world.

The next viral pandemic-where do we stand?

The world is presently undergoing a recovery phase following the unexpected challenges posed by the coronavirus disease 2019 (COVID-19) pandemic. The loss of lives and the economic setbacks experienced by the global population will require considerable time to address. It is clear that future outbreaks, epidemics, or even pandemic caused by unknown bacterial, fungal, or viral pathogens are inevitable. In this context, public health front-liners will be essential in minimizing the impact of such incidents. This mini-review briefly discusses sociocultural issues, diagnostic capacities, surveillance, and screening strategies for potential future viral pandemic - referred to as Pandemic X. Additionally, it addresses treatment responses, vaccine development efforts, scientific advancements, policy considerations, and prospects for science communication related to forthcoming viral pandemics. While this review does not encompass all scientific approaches available on these topics, it aims to serve as a guideline for informing public health sectors about appropriate measures that should be undertaken.

How Are We Teaching Advocacy? A National Survey of Internal Medicine Residency Program Directors

BACKGROUND

Although internal medicine (IM) physicians accept public advocacy as a professional responsibility, there is little evidence that IM training programs teach advocacy skills. The prevalence and characteristics of public advocacy curricula in US IM residency programs are unknown.

OBJECTIVES

To describe the prevalence and characteristics of curricula in US IM residencies addressing public advocacy for communities and populations; to describe barriers to the provision of such curricula.

DESIGN

Nationally representative, web-based, cross-sectional survey of IM residency program directors with membership in an academic professional association.

PARTICIPANTS

A total of 276 IM residency program directors (61%) responded between August and December 2022.

MAIN MEASUREMENTS

Percentage of US IM residency programs that teach advocacy curricula; characteristics of advocacy curricula; perceptions of barriers to teaching advocacy.

KEY RESULTS

More than half of respondents reported that their programs offer no advocacy curricula (148/276, 53.6%). Ninety-five programs (95/276, 34.4%) reported required advocacy curricula; 33 programs (33/276, 12%) provided curricula as elective only. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous; experiential learning in required curricula was low (23/95, 24.2%) compared to that in elective curricula (51/65, 78.5%). The most highly reported barriers to implementing or improving upon advocacy curricula (multiple responses allowed) were lack of faculty expertise in advocacy (200/276, 72%), inadequate faculty time (190/276, 69%), and limited curricular flexibility (148/276, 54%).

CONCLUSION

Over half of US IM residency programs offer no formal training in public advocacy skills and many reported lack of faculty expertise in public advocacy as a barrier. These findings suggest many IM residents are not taught how to advocate for communities and populations. Further, less than one-quarter of required curricula in public advocacy involves experiential learning.

The courage to advocate: How two professions approach public advocacy work

BACKGROUND

While health advocacy is an established physician role, most of the educational attention to advocacy has been at the individual patient level. Public advocacy-efforts to effect change at the level of communities, populations or society-remains a poorly defined concept whose educational foundation is underdeveloped. To enrich our understanding of public advocacy, we explored how professionals in two disciplines-medicine and law-have approached its tasks and experienced its challenges.

METHODS

Using constructivist grounded theory, we interviewed 18 professionals (nine physicians, eight lawyers and one qualified in both disciplines) who engage in public advocacy. We used constant comparison throughout an iterative process of data collection and analysis to develop an understanding of what it means to be a professional in the public domain.

RESULTS

Public advocacy work occurs at the intersection of personal and professional identities. Lawyers perceived public advocacy as an embedded element of their professional identity, while physicians more often viewed it as outside their core professional scope. Nonetheless, professional identity influenced how both groups conducted their work. Physicians were more likely to draw on professional attitudes (e.g. their orientation towards evidence and their trusted social position), while lawyers were more likely to draw on professional skills (e.g. building an argument and litigating test cases). The work requires courage and often demands that individuals tolerate personal and professional risk.

CONCLUSION

While medicine has enshrined advocacy in its competency frameworks, it is the legal profession whose practitioners more fully embrace advocacy as intrinsic to professional identity, suggesting that roles are difficult to engineer or impose. Collaboration across public-facing professions like medicine and law creates opportunities to reimagine public advocacy, to identify the skills required to do it well and to refresh educational strategies.

Conceptualization and teaching health advocacy in undergraduate medical education: a document analysis

BACKGROUND

Health advocacy is considered to be a core competence for physicians, but it remains unclear how the health advocacy role, despite being described in overarching competency frameworks, is operationalized in undergraduate medical education (UME). This study aimed to identify how health advocacy is conceptualized and taught in undergraduate medical curricula.

METHODS

We performed a qualitative analysis of curriculum documents from all eight medical schools in the Netherlands, all of which offered competency-based UME. Thematic analysis was used to code all the documents and generate themes on health advocacy conceptualization and teaching. To categorize the emerging themes, we used the framework of Van Melle et al. for evaluating the implementation of competency-based medical educational programs.

RESULTS

Health advocacy was mostly conceptualized in mission statements about social responsibility of future physicians, related to prevention and promoting health. We found key concepts of health advocacy to be taught mainly in public health and social medicine courses in the bachelor stage and in community-based clerkships in the master stage. Specific knowledge, skills and attitudes related to health advocacy were taught mostly in distinct longitudinal learning pathways in three curricula.

CONCLUSION

Health advocacy is conceptualized mostly as related to social responsibility for future physicians. Its teaching is mostly embedded in public health and social medicine courses and community-based settings. A wider implementation is warranted, extending its teaching to the full width of medical teaching, with longitudinal learning pathways providing a promising route for more integrative health advocacy teaching.

An Op-Ed Writing Curriculum for Medical Students to Engage in Advocacy Through Public Writing

BACKGROUND

Op-ed writing can be a powerful and accessible advocacy tool for physicians, but training is lacking in undergraduate medical education.

AIM

To train and engage first-year medical students in op-ed writing.

SETTING

Midwestern research-intensive medical school.

PARTICIPANTS

All students in a required first-year health policy course in 2021 and 2022.

PROGRAM DESCRIPTION

For their health policy course's final assignment, students could opt to write an op-ed on a healthcare issue of their choice. All students received written instruction on op-ed writing. Additionally, they could access a seminar, coaching and editing by peers and faculty, and publication guidance.

PROGRAM EVALUATION

Of 179 students over 2 years, 105 chose to write op-eds. Fifty-one attended the seminar, 35 attended peer coaching sessions, 33 accessed structured peer editing, and 23 received faculty assistance. Thirty-eight students submitted a total of 42 op-eds for publication. Twenty-two pieces were published in major outlets and 17 in the university's health policy review. Of the 22 in major outlets, 21 received editing from either peers or faculty.

DISCUSSION

An op-ed writing curriculum can be integrated into an existing medical school health policy course, resulting in a high level of engagement and in published op-eds by medical students.

Charting the Advocacy Landscape: A Qualitative Content Analysis of Syllabi in Public Health Graduate Education

CONTEXT

Addressing public health challenges necessitates policy approaches, but concerns persist about public health graduates' preparedness to advocate.

OBJECTIVE

This qualitative study sought to assess advocacy content and skills taught to Master of Public Health students enrolled in US accredited schools and programs of public health (SPPHs) by analyzing 98 course syllabi submitted to the Council on Education for Public Health (CEPH) between 2019 and 2021. Syllabi were submitted by SPPHs during their (re)accreditation process to demonstrate compliance with CEPH's advocacy competency requirement.

DESIGN

Qualitative content analysis study. Syllabi were analyzed using MAXQDA Qualitative Data Analysis Software using a 2-coder approach.

SETTING

SPPHs accredited by CEPH.

PARTICIPANTS

Ninety-eight syllabi submitted to CEPH by 22 schools of public health and 54 programs of public health.

MAIN OUTCOME MEASURES

Exemplary language from advocacy courses and assignments and aggregate frequency of syllabi advocacy content and skills.

RESULTS

Most advocacy courses (61%) were survey, health policy, or health care delivery courses, covering policy (66%), policy communication (46%), coalition-building (45%), lobbying (36%), community organizing (33%), and media advocacy (24%) skills. Only 7% prioritized advocacy skill instruction, and 10% addressed how to advocate in an equitable way.

CONCLUSIONS

Defining public health advocacy and essential skills is crucial. Issuing competency guidelines, supporting advocacy faculty, offering standardized training, and expanding experiential learning are important first steps. More research is needed on how academic institutions are incorporating equity skill training into courses, whether separate from or combined with advocacy skills.

Advocacy Connection Team-Now educational program for headache fellows and patients/caregivers: Assessment of educational objectives

OBJECTIVE

To assess for improvement in comfort in participating in advocacy for migraine and headache disorders and knowledge needed for successful advocacy.

BACKGROUND

The Advocacy Connection Team (ACT)-Now program is an educational program offered through Miles for Migraine, a non-profit advocacy organization. It is designed to teach headache fellows and patients advocacy skills.

METHODS

In a cross-sectional pre-test-post-test design, the 2021 ACT-Now cohort of 98 participants were administered a set of 11 pre-course survey questions identifying their role (healthcare provider/headache fellow or patient/caregiver), baseline knowledge of migraine-related disability and stigma, and baseline engagement and comfort with advocating. The post-course survey questions were the same as the pre-course questions, with the addition of one question assessing knowledge of migraine-related disability, additional questions addressing comfort levels advocating with insurance and policymakers, as well as creating an advocacy plan.

RESULTS

For the pre-course survey, 69 participants responded and for the post-course survey, 40 participants responded. Compared to the pre-course survey, participants were able to correctly identify epidemiological data about migraine following the ACT-Now course (pre-course 46% correct, post-course 58% correct, p = 0.263). There was also an increase in the comfort level of participants in advocacy activities, including the creation of an advocacy action plan (pre-course 23% were "very comfortable" advocating, post-course 63%, p < 0.05).

CONCLUSION

These results demonstrate that ACT-Now is effective at improving advocacy skills in a mixed cohort of patients and headache fellows, giving them the skills to create advocacy plans and engage with other patients and physicians, payers, and policymakers to create a more understanding, equitable and compassionate world for persons with migraine and other headache diseases.

Advocacy for Health Justice: An Innovative Pilot Course for MD and Master of Public Policy Students

Problem: U.S. medical schools are searching for ways to address issues of health justice in undergraduate medical education. Physicians have not typically received training in how to be effective advocates for systemic change and individuals in policy fields are not usually equipped to understand the complex issues of health science and their intersection with the health system and society. To address this gap, medical school faculty partnered with school of public policy faculty on a collaborative learning model that engaged MD and Master of Public Policy students together to strengthen their collective knowledge of the healthcare landscape, and to build skills to work for health justice. Intervention: We hypothesized that pairing medical students with public policy students to learn about the intersections of health justice and advocacy could enhance the efficacy of each group and provide a new model of collaboration between medical and policy professionals. The students collaborated on a health justice advocacy project through which they provided consultation to an established community organization. Context: The 8-week course took place in the spring of 2021 in Los Angeles, California. Due to Covid-19 the course was taught online and included asynchronous learning modules and live Zoom sessions. The project also served as a pilot for the post-clerkship phase of a new longitudinal health justice curriculum for MD students that launched in August 2021. Impact: Analysis of student work products, course evaluations, partner interviews, and student focus groups showed that students valued learning through their interdisciplinary collaborative work which gave them new perspectives on health justice issues. The community partners indicated that the students consultative work products were useful for their initiatives, and that they found working with MD and MPP students to be a valuable way to think about how to build stronger and more inclusive coalitions to advocate for health justice. This project has the potential for national impact as it aligns with the Association of American Medical Colleges' renewed focus on the responsibility of academic medicine to partner with communities for health justice. The project also contributed to the national conversation on how to align health systems science education with the aims of health justice through our participation in the American Medical Association Accelerating Change in Medical Education Consortium. Lessons Learned: Leveraging faculty relationships with community partners was crucial for developing meaningful projects for students. Cultivating and expanding community partner networks is necessary to sustain and scale up this type of intervention. Centering the needs of communities and supporting their on-going work for health justice is essential for becoming an effective advocate. Learning communities that bring interdisciplinary students, healthcare providers, policy professionals, and community partners together to learn from one another can create key opportunities for ameliorating health inequities.

Awareness, Adjustment, Assistance, Alignment, and Advocacy: Operationalizing Social Determinants of Health Topics in Undergraduate Medical Education Curricula

Social and economic factors, such as those related to food, housing, and transportation, are major drivers of health and health inequities. Multiple national professional organizations have articulated roles for physicians in identifying and addressing social determinants of health (SDOH) and the need to include SDOH in all stages of physician education. Despite encouragement from these professional organizations, medical schools still do not routinely offer SDOH education alongside basic and clinical sciences curricula. A recent national expert consensus process identified priority SDOH knowledge domains and professional skills for medical students but lacked an organizing schema and specific pedagogical examples to help translate prioritized skills into routine pedagogical practice. One such schema is the 5As framework developed by the National Academies of Sciences, Engineering, and Medicine, which elaborates on 5 strategies to strengthen social care: awareness, adjustment, assistance, alignment, and advocacy. In this article, the authors highlight and provide examples of how mapping SDOH skills to the 5As framework can help educators meaningfully operationalize SDOH topics into specific curricular activities during the preclinical and clinical stages of undergraduate medical education. As a foundational first step in this direction, medical schools should conduct an internal curricular review of social care content (ideally mapped to the 5As framework) and identify opportunities to integrate these topics into existing courses when relevant (e.g., in social medicine, population health, and health systems science courses). Given that health and social care integration is highly context dependent, each medical school will likely need to tailor curricular changes based on their own institutional needs, mission, patient populations, and ties to the community. To increase interinstitutional alignment, medical schools might consider using or adapting peer-reviewed materials and assessments curated and centralized by the National Collaborative for Education to Address the Social Determinants of Health.

Nurse education about forced migrants with diverse sexual orientations, gender identities, and gender expressions: An exploratory focus group study

BACKGROUND

In many countries, forced migrants can seek asylum based on persecution and danger related to self-identifying as having diverse sexual orientations, gender identities, and gender expressions; herein defined as lesbian, gay, bisexual, transgender, queer, or other non-heterosexual orientations, non-cisgender identities, gender expressions and/or reproductive development considered beyond cultural, societal or physiological norms. Nurse education has a significant role in promoting cultural competence among future health professionals.

OBJECTIVES

To explore the experiences and views regarding education about forced migrants with diverse sexual orientations, gender identities, and gender expressions, among students and lecturers in nurse education.

DESIGN

Explorative qualitative study with focus group discussions.

SETTINGS

Swedish nursing programs.

PARTICIPANTS

Final-year nursing students and lecturers (n = 25 participants) at nursing programs were recruited with convenience and snowball sampling.

METHODS

Semi-structured digital focus group discussions (n = 9) were audio recorded and transcribed verbatim. Data were analyzed with inductive qualitative content analysis.

RESULTS

Promoting a broader understanding regarding societal structures and preparing students to provide culturally sensitive care were considered as essential components in nurse education. Challenges and problems involved a need for increased awareness, the associated topics and target populations seldom being addressed, and a need for improvements within clinical placements. Participants suggested the utilization of external resources, presented a range of different specific learning activities that would promote in-depth understanding, and articulated a need for overarching decisions and guidelines regarding mandatory inclusion in nurse education.

CONCLUSIONS

Students and lecturers describe several challenges and problems that need to be addressed in regard to forced migration, sexual health, and inclusion health. There seems to be a need for utilization of external competence in learning activities as well as establishing clearer guidelines, which may increase the quality of education and better prepare future nurses to support patients with diverse backgrounds and identities.

Incorporating Health Policy and Advocacy Curricula Into Undergraduate Medical Education in the United States

Physicians serve as crucial advocates for their patients. Undergraduate medical education (UME) must move beyond the biomedical model, built upon the perception that health is defined purely in the absence of illness, to also incorporate population health through health policy, advocacy, and community engagement to account for structural and social determinants of health. Currently, the US guidelines for UME lack structured training in health policy or advocacy, leaving trainees ill-equipped to assume their role as physician-advocates or to engage with communities. There is an undeniable need to educate future physicians on legislative advocacy toward improving the social determinants of health through the creation of evidence-based health policy, in addition to training in effective techniques to engage in partnership with the communities in which physicians serve. The authors of this article also present curricular case studies around two programs at their institution that could be used to implement similar programs at other US medical schools.

What are the attitudes of medical students and housestaff towards health advocacy? A physician-led voter registration initiative and health advocacy survey

Background

Compared to the general population, physicians have been shown to be less engaged in civic participation and less likely to vote. However, perspectives of current trainees on health advocacy remain under-explored.

Objective

To investigate perspectives on a physician led voter registration initiative and identify current beliefs of physicians in training and medical students regarding physician health advocacy.

Design

Cross sectional survey performed at a single urban academic center.

Participants

A total of 366 medical students, residents, and fellows voluntarily participated in the survey out of a total of 1,719 available (21% response rate).

Main Measures

We examined the current perceptions surrounding health advocacy among medical students and physicians in training and how this was impacted by the COVID-19 pandemic. Responses were analyzed using Chi-square analysis and logistic regression.

Key Results

The voter registration code was scanned 131 times prior to the 2020 Presidential elections. Barriers to hospital-based voter registration included lack of time, lack of fit into the workflow and forgetting to ask. Over half of internal medicine-based residents and fellows (51%) and medical students (63%) agreed that physicians should be involved in helping patients register to vote compared to 34% of surgical-based trainees. A large majority (87%) indicated that the COVID-19 pandemic made it more necessary for physicians to be involved in politics.

Conclusion

A high proportion of medical students and housestaff across specialties report an obligation to be involved in health advocacy, though there were differing views towards direct involvement in voter registration.

Implications of the Dobbs Decision for Medical Education: Inadequate Training and Moral Distress

This Viewpoint discusses how states’ restrictions on abortion will affect medical students’ training in providing reproductive health care and also create moral distress by being forced to provide care that may harm patients.

Prevalence and characteristics of advocacy curricula in Australian public health degrees

BACKGROUND

Public health advocacy is a fundamental part of health promotion practice. Advocacy efforts can lead to healthier public policies and positive impacts on society. Public health educators are responsible for equipping graduates with cross-cutting advocacy competencies to address current and future public health challenges.

PROBLEM

Knowledge of the extent to which students are taught public health advocacy is limited. To determine whether advocacy teaching within public health degrees matches industry needs, knowledge of pedagogical approaches to advocacy curricula is required. This study sought to understand the extent to which advocacy is taught and assessed within Australian public health degrees.

METHODOLOGY

Australian public health Bachelor's and Master's degrees were identified using the CRICOS database. Open-source online unit guides were reviewed to determine where and how advocacy was included within core and elective units (in title, unit description or learning outcomes). Degree directors and convenors of identified units were surveyed to further garner information about advocacy in the curriculum.

RESULTS

Of 65 identified degrees, 17 of 26 (65%) undergraduate degrees and 24 of 39 (62%) postgraduate degrees included advocacy within the core curriculum, while 6 of 26 (23%) undergraduate and 8 of 39 (21%) postgraduate offered no advocacy curriculum.

IMPLICATIONS

Australian and international public health competency frameworks indicate advocacy curriculum should be included in all degrees. This research suggests advocacy competencies are not ubiquitous within Australian public health curricula. The findings support the need to advance public health advocacy teaching efforts further.

Patient Advocacy Assessment in the Medicine Clerkship: A Qualitative Study of Definition, Context, and Impact

BACKGROUND

Advocacy is a core value of the medical profession. However, patient advocacy (advocacy) is not uniformly assessed and there are no studies of the behaviors clinical supervisors consider when assessing advocacy.

OBJECTIVE

To explore how medical students and supervisors characterize advocacy during an internal medicine clerkship, how assessment of advocacy impacted students and supervisors, and elements that support effective implementation of advocacy assessment.

DESIGN

A constructivist qualitative paradigm was used to understand advocacy assessment from the perspectives of students and supervisors.

PARTICIPANTS

Medical students who completed the internal medicine clerkship at UCSF during the 2018 and 2019 academic years and supervisors who evaluated students during this period.

APPROACH

Supervisor comments from an advocacy assessment item in the medicine clerkship and transcripts of focus groups were used to explore which behaviors students and supervisors deem to be advocacy. Separate focus groups with both students and supervisors examined the impact that advocacy assessment had on students' and supervisors' perceptions of advocacy and what additional context was necessary to effectively implement advocacy assessment.

KEY RESULTS

Students and supervisors define advocacy as identifying and addressing social determinants of health, recognizing and addressing patient wishes and concerns, navigating the health care system, conducting appropriate evaluation and treatment, and creating exceptional therapeutic alliances. Effective implementation of advocacy assessment requires the creation of non-hierarchical team environments, supervisor role modeling, and pairing assessment with teaching of advocacy skills. Inclusion of advocacy assessment reflects and dictates institutional priorities, shapes professional identity formation, and enhances advocacy skill development for students and their supervisors.

CONCLUSIONS

Students and supervisors consider advocacy to be a variety of behaviors beyond identifying and addressing social determinants of health. Effectively implementing advocacy assessment shapes students' professional identity formation, underscoring the critical importance of formally focusing on this competency in the health professions education.

Academic Careers in Advocacy: Aligning Institutional Values Through Use of an Advocacy Portfolio

Academic children's hospitals must embrace advocacy as a central component of their missions to discover new knowledge and improve the health of the communities and patients they serve. To do so, they must ensure faculty have both the tools and the opportunities to develop and articulate the work of advocacy as an academic endeavor. This can be accomplished by integrating the work of advocacy at the community and policy-change levels into the traditional value systems of academic medicine, especially the promotions process, to establish its legitimacy. Academic pediatric institutions can support this transformation through robust training and professional development programs and establishing opportunities, resources, and leadership positions in advocacy. The adoption of an advocacy portfolio can be used to align these activities and accomplishments to institutional values and promotion. This alignment is crucial to supporting the advocacy work of pediatricians at a time in which community engagement and systems and policy change must be added to professional activities to ensure optimal outcomes for all children.

The Role of Physician Advocacy in Achieving Health Equity: Where Is the Allergist-Immunologist?

As allergists and immunologists many of us have likely worked in the capacity of being an advocate for individual patients. However, how many of us are aware of our ability to be effective advocates who address root causes of health issues through policy changes? Physician advocacy is not a core competency medical specialty training (except pediatrics), yet physicians' clinical and research expertise and professional experience can be leveraged to shape policy. This rostrum describes the spectrum of activities for a physician advocate, barriers to physician advocacy, and actionable steps to encouraging the training and expansion of advocacy efforts by allergists and immunologists.