Preface
It is my true honour and pleasure to be invited to write the Preface to this electronic booklet on promoting health advocacy for post- graduate residents in the Faculty of Medicine at the University of British Columbia. Traditionally, physicians have always played the role of health advocates on behalf of their patients in the provision of health care. However, further reflection of health advocacy reveals a more comprehensive concept. From the educational point of view, health advocacy comprises all of the activities that physicians do to advance the health and well being of individual patients, communities, and populations. A large part of health advocacy involves health promotion, which in turn involves maintain- ing and improving not only the biological determinants of health, but also other psychological and social determinants.
We are pleased that the UBC Faculty of Medicine is playing a role in encouraging faculty members to expose residents to health advocacy. We understand that physicians already work very hard to keep up with their role as clinicians. We are therefore interested in identifying and creating synergies with existing clinical activities that already occur in the daily lives of our residents. We recommend an experiential approach to empower our residents in learning and practicing health advocacy. We believe that for those residents who are involved in health advocacy, the experience can be inspiring and rewarding.
Congratulations to the team who authored this electronic resource. We believe this will be an evolving piece that incorporates ongoing improvements in our endeavors to promote health advocacy among our postgraduate residents.
Roger Y.M. Wong, BMSc, MD, FRCPC, FACP
Clinical Professor, Department of Medicine
Assistant Dean, Faculty Development
Associate Program Director, Postgraduate Medical Education
Faculty of Medicine - University of British Columbia
Head, Geriatric Consultation Program - Vancouver General Hospital
Introduction
The CanMEDS Health Advocate (HA) role relates to the physician’s responsibility to identify and respond appropriately to the social determinants of health, healthcare disparities, and the needs of vulnerable or marginalized populations. In essence, in their role as health advocates, physicians are expected to attend to “the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism.”
HA is regarded as one of the more difficult Canmeds roles to integrate into medical education. We have prepared this e-booklet for medical educators and learners as a primer. It is meant to be a resource for students, residents, educators, and clinicians.
Teaching Health Advocacy
Teaching HA and its rigorous application in medicine can be a challenging task. We need illustrative examples of how the concept can be better integrated into medical curricula and subsequent clinical practice, and evaluated. It is a complex and multi-faceted concept. Some physicians consider HA a central aspect of their clinical practice. They interpret HA as “going to bat” for patients, particularly when they need specialized medical equipment or treatment. Others see HA within the broader context of social determinants of health. They are active in their communities, promoting health and well-being, and being part of efforts to eliminate poverty, unequal social status, environmental degradation, homelessness, violence and other such issues that loom large. HA reminds physicians of why they went into medicine in the first place—to help improve well-being and to make a difference in the lives of individuals, families, and communities.
In this e-booklet we have included a few comments from HA ‘champions’, who all draw on qualities that make for a successful change agent. Their stories are intended to provide examples and to inspire. For instance, we spoke with one of Canada’s pre-eminent health advocates, Dr. John Blatherwick, MD, FRCPC, LLD (Retired Medical Health Officer) who explained that:
Dr. Fred Bass, the medical guru of stopping smoking, has always pointed out that the number one influence on successful smoking cessation was physicians educating their patients to stop. All the gum, patches, pills, acupuncture, and hypnosis paled in comparison to the physician’s advocacy role at the patient level. At the macro level, health advocacy was getting the Vancouver City Council to adopt a non-smoking by-law in the face of heavy opposition from restaurants, bars and places of employment. Dr. Gerry Bonham, long time Medical Health Officer for Vancouver and Calgary, always said that for health advocacy to work, it had to be kept at for a long period of time. Going from wide open smoking to non-smoking in the workplace, bars and restaurants was a team effort by the Vancouver Health Department, involving all disciplines, over a period of 15 years. The battle continues to improve those by- laws. When the Medical Associations or specialists support macro level interventions, it is easier to convince politicians. Physicians carry a lot of weight in politics and the more united physicians are on a given issue, the easier it is to get a measure enacted.
This observation underscores the idea that physician advocates can, and must, intervene at various scales and in various ways in order to address the behavioural, social, economic, physical, and ecological factors that contribute to patient (“those who suffer”) welfare. This may seem an overwhelming suggestion for those who have the demand of staying clinically current in a rapidly changing world. However, the preeminent medical educator Ernest Boyer puts our responsibilities in perspective: “The crisis of our time relates not to technical competence, but to a loss of the social and historical perspective, to the disastrous divorce of competence from conscience.” However, we must keep in mind that we are not called upon to save the world by ourselves. As will be demonstrated below in some of our suggested readings and exercises, the physician advocate will be immeasurably aided by the relationships she/he forms and maintains with others. These “others” will be a fluid collection that varies over time, over issue and over the life cycle of physician practice. Without such relationships we are diminished as people and impotent as advocates. One useful ‘lens’ to look to the kind of support that will help us in the process of social change is the partnership pentagram developed by the WHO initiative Towards Unity of Health. This is under the rubric of the social accountability of medical schools. The latter is defined as ‘the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve. The priority health concerns are to be identified jointly by governments, healthcare organizations, health professionals, and the public.’ Thus, embedded in this definition are the partners we must seek in setting our personal and institutional priorities. Cultivating relationships with relevant professionals, policy makers, managers, academics and, above all, communities, offers our surest route to being effective health advocates. To do less than this is to fail to earn the considerable privileges that attends our professional status.
We invite your feedback and contributions to this e-booklet. It is our hope that it will be helpful in your efforts to motivate your residents to learn about and participate in health advocacy.
Shafik Dharamsi, PhD
Jo-Ann Osei-Twum, BSc
Farah Shroff, PhD
Lisa Mu, MD
Robert Woollard, MD
Commentary, Dr. Jeffrey Turnbull
President of the Canadian Medical Association
“…every community has their advocates…”
Dr. Jeffrey Turnbull
Dr. Jeffrey Turnbull, long time health advocate for the homeless in Ottawa, provided the following reflections on health advocacy:
Advocacy is extremely important and as physicians, we are uniquely positioned to engage in advocacy and should be engaging. Historically, physicians have been good advocates for their individual patients; however, in recent years, the public has called upon us to also advocate for the overall welfare of communities, for the healthcare system, and for an improvement in the social determinants of health. We must recognize that we will be less effective, if we merely seek to provide good healthcare and continue to disregard the underlying issues that have lead to our patients’ illness. We, physicians, have a responsibility to advocate. Yet, advocacy cannot be conceptualized as a “one size fits all” activity. Some may see their role at the patient level, while others will take on leadership roles within their group practice or at a local, regional, or national level. What is consistent with all advocacy activities is that physicians can have a significant impact - on the lives of their patients and on public health policy.
From my personal experience, advocacy has provided opportunities to work with individuals interested in homelessness but outside the healthcare field. We were all drawn together by a common initiative and through our efforts, our program has grown exponentially where now there is a systematic program for the delivery of health services for the homeless. What is evident is that success feeds success. Advocacy allows physicians to step outside what they normally do, to apply different skills, to interact further with their patients and view the experience through their eyes.
So, what would good health advocacy look like in practice and in education? Physicians would utilize evidence to guide decision-making in their own practice but also use this information to encourage others to develop policies around improving the health of our public. In order to achieve this, we will require the skills to extract, analyze, and apply information. An educational curriculum that supports advocacy at all levels, undergraduate, post-graduate and continuing professional education, will empower young physicians, residents, and medical students to pursue active engagement in issues that are socially important. They must understand that they too can make a difference. We all have a part to play, at the bare minimum; physicians have the responsibility to advocate for their patients.
CanMEDS Health Advocate Role
Definition: As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.
Description: Physicians recognize their duty and ability to improve the overall health of their patients and the society they serve. Doctors identify advocacy activities as important for the individual patient, for populations of patients and for communities. Individual patients need physicians to assist them in navigating the healthcare system and accessing the appropriate health resources in a timely manner. Communities and societies need physicians’ special expertise to identify and collaboratively address broad health issues and the determinants of health. At this level, health advocacy involves efforts to change specific practices or policies on behalf of those served. Framed in this multi-level way, health advocacy is an essential and fundamental component of health promotion. Health advocacy is appropriately expressed both by individual and collective actions of physicians in influencing public health and policy.
Enabling Competencies: Physicians are able to...
- Respond to individual patient health needs and issues as part of patient care
- Identify the health needs of an individual patient
- Identify opportunities for advocacy, health promotion and disease prevention with individuals to whom they provide care
- Respond to the health needs of the communities that they serve
- Describe the practice communities that they serve
- Identify opportunities for advocacy, health promotion and disease prevention in the communities that they serve, and respond appropriately
- Appreciate the possibility of competing interests between the communities served and other populations
- Identify the determinants of health for the populations that they serve
- Identify the determinants of health of the populations, including barriers to access to care and resources
- Identify vulnerable or marginalized populations within those served and respond appropriately
- Promote the health of individual patients, communities, and populations
- Describe an approach to implementing a change in a determinant of health of the populations they serve
- Describe how public policy impacts on the health of the populations served
- Identify points of influence in the healthcare system and its structure
- Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism
- Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper
- Describe the role of the medical profession in advocating collectively for health and patient safety.
Inspiring Health Advocacy
In response to increasing calls for post-graduate medical education to advance HA in medicine, we undertook a qualitative pilot study on what inspires family medicine residents, educators, and physicians to engage in HA and how to meaningfully incorporate HA into medical training.
We conducted semi-structured, in-depth interviews of health advocate residents, physicians, and educators within the University of British Columbia’s Department of Family Medicine. Four residents, three physicians, and two educators were interviewed. Participants were asked to reflect upon their own motivations for engaging in HA, the influence of their residency experiences upon their advocacy work, and how residency could be improved for those aspiring to do HA.
We found that early exposure to social injustice, parental influences, role modeling, and internal motivators were important inspirations for health advocacy. Residency appeared to be a challenging yet feasible opportunity to engage in HA, as the full demands of clinical practice were yet to set in.
A lack of formal incentives within the medical system discourages HA among residents and physicians. While institutions outside of the core medical system call for more sensitive, compassionate and community responsive physicians, the existing medical environment rewards the opposite. Small and meaning- ful steps are being taken to integrate HA within medical education such that the norm of the medical system framework becomes conducive to HA by physicians for their patients.
The following pages highlight the HA activities of a number of ‘champions’, Vanessa Brcic, Jocelyn Chase, Healthy Young Minds, Tracy Monk, Davedeep Sohi, and Brian Westerberg.
Vanessa Brcic
Clinical Scholar Program, UBC Department of Family Practice
Jocelyn Chase
Chief Medical Resident PGY3 UBC Internal Medicine, Future UBC Geriatrics Fellow
Healthy Young Minds
Mental Health Promotion by Students for Students, UBC Vancouver Fraser Medical Program 2013
Tracy Monk
Clinical Assistant Professor of Family Medicine, UBC
Head of the Department of General Practice, Royal Columbian Hospital, New Westminster
Davedeep Sohi
PGY2 UBC Internal Medicine
Brian Westerberg
Clinical Associate Professor, Department of Surgery, UBC
Otolaryngologist, St Paul’s Hospital, Vancouver
Why Health Advocacy?
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