Rationale for Advocacy Training in Undergraduate Medical Education

Abstract

Advocacy is the outspoken support of a cause or group of people. Within the context of medicine, it includes any individual or organized effort that strives to improve health outcomes, expand the inclusivity of the field or promote awareness of a systemic problem that can be ameliorated through legislative efforts. Examples of advocacy in medicine range from fighting for a patient’s costly prescription drug to be covered by insurance, to ensuring that historically underrepresented groups are given the opportunity to achieve a presence in a certain specialty, to contacting legislators to fund efforts to decrease the overcrowding of emergency rooms in public hospitals.  Thus, advocacy is crucial across all specialties in the medical field. We believe increasing the exposure of medical students to advocacy training is imperative and will provide them with the necessary tools to beneficially influence the field during their careers. The American Medical Association (AMA) states that physicians must “advocate for the social, economic, educational and political changes that ameliorate suffering and contribute to human well-being” in its Declaration of Professional Responsibility, and other physician and specialty organizations urge such important professional activity as well.^1-7

Undergraduate Medical Education (UGME) refers to the instruction received during medical school by students when pursuing an M.D. or D.O. degree. Graduate Medical Education (GME), on the other hand, refers to any type of education after completing an M.D. or D.O. degree, which usually includes residency or fellowship training. Both the United States and Canada recognize the importance of training physicians in advocacy at the GME level, however, advocacy training at the UGME level is less cohesive.^8,9 In addition, even at the GME level, though some specialties such as pediatrics do have a requirement for advocacy training, there are no standardized curricula or standards across specialties.^10,11

UGME currently lacks compulsory advocacy training integration into the medical school curriculum, although The American Council for Graduate Medical Education (ACGME) in the USA and the Royal College of Physicians and Surgeons (RCPS) in Canada recognize training in advocacy as an objective of GME.¹² This could explain the gap between the AMA’s vision of professional responsibility and medical students’ perception of their duties as future physicians. In a 2014 survey, McCrea and Murdoch-Eaton found that medical students “expressed limited appreciation of the concept of social accountability and acknowledged little explicit teaching around underpinning core concepts such as awareness of local health needs, advocacy and nurturing of altruism.”¹³ They did, however, recognize “the importance of qualities such as advocacy in their future professional careers.” In order to close this gap, UGME should ensure curricular components that foster the nurturing of advocacy are included from an early stage in the instruction of medicine. This will help prevent negative ramifications such as the decline in interest for social issues during medical training, which Bhate et al. describe.¹⁴ Bhate also notes that training in advocacy has been shown to change physician’s attitudes towards its practice. Additionally, Press et al. argues that “exposing all medical students to advocacy within medicine may help shape and define their perceived professional role.”¹⁵ As advocacy in healthcare can contribute to the enactment of regulations and standards that ultimately improve the public’s health, students should be exposed to formal training that equips them with the necessary tools to engage in effective advocacy and understand their responsibility for engagement. UGME should, therefore, have a requisite to offer advocacy training that is evidence-based, influenced by clinical expertise and contextualized to account for social, economic and political realities.

Lastly, these advocacy-driven initiatives are likely to lead to an improvement in patient-centered measures such as patient satisfaction. Feuerwerker et al. argue that the creation of a position called "Patient Advocate" by a medical student in pre-clinical years would make patients feel more satisfied with their care in the ED and teach students to actively solve patient's frustrations.¹⁶ In a similar project, Ward et al. show through their “Patient Advocate Project” that outpatient satisfaction survey data from pre-, peri-, and post-provider (patient advocate) periods demonstrate the implementation of a Patient Advocate Project improved overall satisfaction scores in the ED during the peri-intervention period.¹⁷ Knowing that advocacy training can positively impact the quality of care as judged from a patient’s perspective should stand out as a driving force to implement these changes at a formative time in the careers of medical professionals: during UGME training.