Best practices in teaching/learning health advocacy  in medical schools

– a systematic review  

Dr Indira Samarawickrema Australian National University

A/Prof Christine Phillips Australian National University

Prof Donna Mak University of Notre Dame

Introduction

• Conventionally focused on individual patient care, access to care and direct socio-economic influences1.

• Greater engagement in improving the health of populations and systems of care2.

• Health advocate – Australia3, USA, Canada4

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Knowledge and skills required for a generalist medical graduate

• “innovative, collaborative, participatory and transformative approaches”5,6,7

– Identify, define, strategic partners, a strategic action plan, an effective message”5

• Need reasoning and communication skills4.

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Aims and objectives

• To systematically review publications on teaching/learning advocacy in medical schools – Identify best practice methods in developing

skills in health advocacy among medical students.

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Research question

• What are the best practice methods in developing skills in health advocacy among medical students?

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PICOS

• Participants- medical students• Intervention: health advocacy modules

with hands-on experience• Comparisons: health advocacy modules

without hands-on experience• Outcomes: Skills in advocacy as evident

with evaluations• Study design: experimental and/or

evaluation6

Methods

• We carried out a systematic review of publications

• Database: PubMed, ERIC via NLM• Search terms: “advocacy” and “medic*” in

the article• Time period: 1st Jan 2011 to 14 Sept 2014

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N=31

N=26

Initial screeningN=1300

Duplicates = 96

N=1204Does not mention medical students

=1173

Not in English = 3

N=4

Commentaries = 2

Does not address teaching/learning in curriculum; exclude

electives

Results

• Four from medical schools in North America– Three from USA– One from Canada

• None from Australia

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Table 1: Summary of included studies

Intervention

Comparison

Outcomes

Study design

Findings

Belkowitz, et al 2013(University ofMiami Miller)8

Y1&2 community health advocacy training in regional campus (RCM)

Main campus (MC)

Attitudes, self-reportedand objective knowledge, and skills

Cross-sectional

RCM higher scores>MC (p<0.01)Mean knowledge - community health needs

(35 vs 31)- About CBOs (3 vs 2.7)- Community resources

(5 vs 2)Mean skill scores- 13 vs 11Attitudes - Female>male

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Table 1: Summary of included studies (contd.)

Intervention

Comparison

Outcomes

Study design

Findings

Gill & Gill 2011(University ofAlberta and University of Calgary)9

Political Action Day with Members of Legislative Assembly (2-days)

None Attitudes, self-reportedknowledge, and skills

Pre- and post- survey

Improved skills- Advocacy concepts- How to efficiently organize a meetingwith an elected official- How to approach lobbying an issueat a population level

Require- More in-depthTeaching

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Table 1: Summary of included studies (contd.)

Intervention

Comparison

Outcomes

Study design

Findings

Huntoon et al 2012(AMSA at National Advocacy day)10

½ day advocacy experience at Capitol Hill

None Knowledge, skills and attitudes towards legislative advocacy

Pre- and post- survey

- Contact their legislators (p = 0.03)

- Meet in person (p<0.01),

- Advocate for populationhealth needs (p = 0.04).- Role of a physician

advocate (p = 0.03). - Formal curricula

insufficient- Plan to engage inlegislative advocacy activities in the future (p<0.01)

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Table 1: Summary of included studies (contd.)

Intervention

Comparison

Outcomes

Study design

Findings

Long et al 2011(University of Colorado Denver)11

Leadership Education AdvocacyDevelopment Scholarship program

None Knowledge, skills and attitudes towards legislative advocacy

Pre- and post- summer internship

Empowerment, improved self-efficacy, and increasedlikelihood of future engagement in leadership and healthAdvocacy (p<0.05)

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Discussion

• In-class + hands-on modules. • Diverse experiential learning

– Advocacy projects/internships with CBOs– Legislative advocacy

• Evaluation of hands-on modules– Improved skills– Empowerment– Likelihood of future engagement– Self-efficacy– Rated highly by students.

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Discussion

• Small scale initiatives not integrated into the broader population health curricula.

• Lacks a more robust positioning of advocacy within the curriculum.

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AMC new medical graduate outcomes and advocacy3

• One of the four domains• Two of the first three outcome standards in

that domain• How to advocate for others (not only about

populations and inequality)• Knowledge, some exposure to the

concepts and a public health responsibility

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Challenges of teaching specialised skills to generalist medical graduates• How a generalist could apply it in their

normal daily practice.• Ethics of advocacy

– Potential to cause harm to people and communities 

• Adaptability of focused skills • No evidence that the education translated

into better medical practice?

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Limitations

• Grey literature not included• Unpublished • Teaching to the interested only• Self-education

 

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Conclusions

• Hands-on teaching/learning activities improved skills in advocacy among medical students in North America.

• More work is required to assess the breadth and effectiveness of medical school health advocacy teaching programs in Australia.

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References1. Gruen RL, Pearson SD, Brennan TA. Physician-citizens-public roles and professional obligations. JAMA. 2004

Jan 7;291(1):94-8.

2. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923-58.

3. Medical Board of Australia. Accreditation standards for primary medical education providers and their program of study and graduate outcome statements. Canberra: Medical Board of Australia 2012.

4. Frank JR, editor. The CanMEDS 2005 physician competency framework. Ottawa: Office of Education, The Royal College of Physicians and Surgeons of Canada; 2005. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it. Acad Med. 2010 Jan;85(1):63-7.

5. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it. Acad Med. 2010 Jan;85(1):63-7.

6. Martin D, Hum S, Han M, Whitehead. Laying the foundation: teaching policy and advocacy to medical students. Med Teach. 2013 May;35:352-8.

7. Dharamsi S, Ho A, Spadafora SM, Woolard R. The physician as health advocate: translating the quest for social responsibility in medical education and practice. Acad Med. 2011 Sep;86(9):1108-13.

8. Belkovitz J, SandersLM, Zhang C, Agarwal G, etal. Teaching health advocacy to medical students: a comparison study. J Public Health Manag Prac. 2013 Dec 6 (Epub ahead of print)

9. Huntoon KM, McCluney CJ, Wiley EA, Scannell CA, Bruno R, Stull MJ. Self-reported evaluation of competencies and attitudes by physicians-in-training before and after a single day legislative advocacy experience. BMC Med Educ. 2012 Jun 22;12-47.

10. Gill PJ, Gill HS. Health advocaccy training: why are physicians withholding life saving care: Med Teach. 2011;33(8):677-9.

11. Long JA, Lee RS, Federico S, Battaglia C, Wong S, Earnest M. Developing leadership and advocacy skills in medical students through service learning. J Public Health Manag Pract. 2011 Jul-Aug: 17(4); 369-72.

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