Defining Health Advocacy in Medical Education

Shelly Chopra, John Peel

Health Advocate is one of six essential competencies of the Royal College of Physicians and Surgeons of Canada (RCPSC) that medical students should attain by the end of their training. The RCPSC explains that, as health advocates, physicians responsibly use their expertise and influence to advance the health and wellbeing of individual patients, communities, and populations.[1] This description emphasizes the purpose of health advocacy rather than the nature of activn fulfilling the competency. It might be vague definitions similar to the one from the RCPSC that have mities involved iade it difficult for educators and students in medical programs to appreciate the importance of health advocacy and the role of physicians beyond that of providers of clinicallyreasonable care.

After interviewing communityresponsive physicians, Ivy Oandasan proposed that health advocacy involves acting as both indirect and direct agents of change.[2] As indirect agents of change, physicians provide patients with appropriate information and resources to ensure that they feel supported in all aspects of their lives. Achieving this capacity requires a physician to understand the social determinants that contribute to a patients state of health as well as the services available to address concerns beyond the medical scope of practice. Physician activities that promote change indirectly include completing local and governmental agency forms and contacting community organizations for purposes of residence, counseling, and other social programs.[2] As direct agents of change, physicians develop and undertake actionoriented strategies to respond to a concern that is negatively affecting members of their community.[2] Such actions might include communicating directly with decisionmakers to discuss health system issues and conducting a campaign to garner support from fellow professionals and the general public.

In a more recent study, Hubinette et al. derived three conceptualizations of health advocacy from interviews with family physician preceptors: clinical advocacy, paraclinical advocacy, and supraclinical advocacy.[3] Clinical advocacy involves supporting patients by employing appropriate diagnosis and treatment approaches, providing diseaserelated information, and promoting lifestyle change. Similar to Oadansans definition of physicians as indirect agents of change, paraclinical advocacy focuses on provision of information and resources beyond the immediate clinical disease. Supraclinical advocacy parallels Oadansans description of physicians as direct agents of change, where the emphasis is on addressing populationlevel issues.

Thus, based on the work of Oadansan and of Hubinette et al., health advocacy involves both ensuring that patients have access to necessary services within and outside the health care system and leading strategic efforts to promote the clinical and social wellbeing of a community.

So how do medical students engage with the activities intrinsic to health advocacy? Students around Canada have been active participants in leading protests and in communicating directly with federal and provincial policymakers to advocate for patients. Last year, the Canadian Federation of Medical Students (CFMS) focused on lobbying for a national pharmacare program at National Lobby Day on Parliament Hill andmost recentlythrough an editorial in the The Toronto Star.[4,5] These efforts, however, highlight the motivation and action of only a select group of students in influencing systemlevel change on topical issues.

As part of its curriculum, the University of British Columbia MD program offers secondyear students a community service learning option (CSLO) in the Doctor, Patient and Society course.[6] In this option, students work directly with community organizations and targeted populations to understand and sometimes address the negative impact of social disparities on health.[6] Nevertheless, similar to the CFMS, it is typically students with a preexisting interest in social and community issues who elect to participate in the CSLO.

For most other students, health advocacy is less of a priority than learning the high volume of biomedical and clinical information tested by exams and attending physicians.[6] Although the RCPSC recognizes Health Advocate as a key competency, no MD program in Canada has developed an educational approach to ensure that all graduating students understand how to recognize and resolve gaps in a patients system of social care.[7] In contrast, several universities in the USA support advocacy training in their undergraduate and graduate medical curricula.[7,8] Boston University and Wright State University, for example, offer medical students comprehensive health advocacy and leadership programs that include field experience, casebased modules, an independent research project centered on the design and evaluation of advocacy tools, and facultyled mentorship.[7,9] Similarly focused training at the residency level of medical education has shown improvement in learner knowledge and leadership skills relevant to health advocacy.[8] Further research on the efficacy and longterm impact of different training methods at the undergraduate level will be invaluable in informing the development of advocacy education for Canadian medical students.[8]

The range of articles on health advocacy in this issue underscores the expanding interest of health care professionals, researchers, and community members in this field. Student authors have examined the impact of specific social determinants of health such as parental stress on childhood development (Kalil), the importance of physician leadership (Ip), and the role of physicians in the Canadian health care system (Jones). Our feature articles include an interview with Dr. Erica Frank, Canada Research Chair in Preventive Medicine and Population Health, and an opinion piece by Dr. Carolyn Bennett, Liberal Critic for Aboriginal Affairs and Chair-Liberal Womens Caucus.

While health advocacy training in medical education will evolve, it remains clear that physicians are essential players in addressing negative social determinants of patient health. Through collective action, health care professionals have the capacity to help patients access the resources they need for optimal wellbeing and to remove systemic barriers that impede patientsaright to health.

REFERENCES
  1. The CanMEDS framework [Internet] 2005 [cited 2015 Jan 5]. Available from: http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework
  2. Oandasan I. Health advocacy: bringing clarity to educators through the voices of physician health advocates. Acad Med. 2005;80(10):38-41.
  3. Hubinette MM, Ajjawi R, Dharamsi S. Family physician preceptorsconceptualizations of health advocacy: implications for medical education. Acad Med. 2014 Nov;89(11):1502-9.
  4. Lobby Day [Internet]. 2014 [cited 2015 Jan 5]. Available from: http://www.cfms.org/media-and-advocacy-3/lobby-day-new.html
  5. Canada needs a national pharmacare plan: editorial. The Toronto Star [Internet]. 2014 Nov 28 [cited 2015 Jan 5]. Available from: http://www.thestar.com/opinion/editorials/2014/11/28/canada_needs_a_national_pharmacare_plan_editorial.html
  6. Dharamsi S, Richards M, Louie D, et al. Enhancing medical studentsconceptions of the CanMEDS health advocate role through international servicelearning and critical reflection: a phenomenological study. Med Teach. 2010 Jan;32(12):977-82.
  7. Gill PJ, Gill HS. Health advocacy training: why are physicians withholding life-saving care? Med Teach. 2011 Jan;33(8):677-9.
  8. Croft D, Jay SJ, Meslin EM, Gaffney MM, Odell JD. Perspective: is it time for advocacy training in medical education? Acad Med. 2012 Sep;87(9):1165-70.
  9. Hopkins M. Training MED students to become patient advocates [Internet]. 2013 Jan 13 [cited 2015 Jan 12]. Available from: http://www.bu.edu/today/2013/training-med-students-to-become-patient-advocates/.