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The Health Advocate Role: Preparing Future Physicians for Socially Responsive Practice Dharamsi, S. 2010

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 THE HEALTH ADVOCATE ROLE: PREPARING FUTURE PHYSICIANS FOR SOCIALLY RESPONSIVE PRACTICE SHAFIK DHARAMSI JO-ANN OSEI-TWUM FARAH SHROFF LISA MU ROBERT WOOLLARD  2010 Executive Summary Health advocacy represents an opportunity for physicians and physicians-in-training to respond appro- priately to the social determinants of health, health care inequities, and the needs of underserved popula- tions. To better prepare physicians-in-training, there is a need to identify tangible ways of incorporating health advocacy into medical curriculum. The purpose of this e-booklet is to:  Highlight the activities of health advocate ‘champions’,  Vanessa Brcic,  Jocelyn Chase, Healthy Young Minds, Tracy Monk, Davedeep Sohi, and Brian Westerberg,  Discuss the social determinants of health and provide case examples on health advocacy,  Identify relevant literature on health advocacy, teaching approaches, and existing programs. This e-booklet is intended for medical educators, physicians, physicians-in-training, medical students, and other health care professionals interested in health advocacy. Ultimately, this e-booklet seeks to in- form and be informed by the health advocacy activities of readers. Suggestions are encouraged and gladly welcomed. 
 T h e  H e a l t h  A d v o c a t e  R o l e E x e c u t i v e  S u m m a r y i Table of Contents ............................................................................................................................................................Preface
 iii ....................................................................................................................................................Introduction
 1 Commentary, Dr. ............................................................................................................... Jeffrey Turnbull
 3 ................................................................................................................CanMEDS Health Advocate Role
 4 ..........................................................................................................................Inspiring Health Advocacy
 5 .....................................................................................................Health Advocate Physician Champions
 6 .......................Vanessa Brcic, R3 Clinical Investigator, UBC Department of Family Practice
 6 .............................................Jocelyn Chase, Chief Medical Resident, UBC Internal Medicine
 8 .......................Healthy Young Minds: Mental Health Promotion for Students by Students
 10 .........................................................................Davedeep Sohi, PGY2 UBC Internal Medicine
 12 ....................................Tracy Monk, Clinical Assistant Professor of Family Medicine, UBC
 14 ....................Brian Westerberg, Clinical Associate Professor, Department of Surgery, UBC
 15 ..............................................................................................................................Why Health Advocacy? 
 16 ..............................................................................Teaching Health Advocacy: Starting Points
 17 ......................................................................................................Problem-Based Case Studies 
 18 ....................................................................................................................................................Conclusion
 21 .....................................................................................................................................Acknowledgements
 22 ..........................................................................................................................Supplementary Resources
 23 ..................................................................................................................Curriculum Resources
 23 ......................................................................................Canadian Physician Health Advocates
 24 ..........................................................................................................Community Organizations
 26 ...................................................................................................................Intellectual Resources
 27 .....................................................................................................................................................References
 31 
 T h e  H e a l t h  A d v o c a t e  R o l e Ta b l e  o f  C o n t e n t s i i 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 re- veals a more comprehensive concept. From the educational point of view, health advocacy comprises all of the activities that physi- cians do to advance the health and well being of individual pa- tients, communities, and populations.1 A large part of health advo- cacy 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 ad- vocacy. 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 practic- ing health advocacy. We believe that for those residents who are involved in health advocacy, the experi- ence 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 
 T h e  H e a l t h  A d v o c a t e  R o l e P r e f a c e i i i ! Introduction The CanMEDS Health Advocate (HA) role relates to the physician’s responsibility to identify and re- spond appropriately to the social determinants of health,2 healthcare disparities, and the needs of vulner- able 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 jus- tice, autonomy, integrity and idealism.”3 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 ex- amples of how the concept can be better integrated into medical curricula and subsequent clinical prac- tice, and evaluated. It is a complex and multi-faceted concept. Some physicians consider HA a central as- pect 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 de- terminants 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, vio- lence 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 suc- cessful 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 Vancou- ver 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 politi- cians.  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 pre- 
 T h e  H e a l t h  A d v o c a t e  R o l e I n t r o d u c t i o n 1 eminent medical educator Ernest Boyer puts our responsibilities in perspective: “The crisis of our time re- lates 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 part- nership 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 or- ganizations, health professionals, and the public.’4 Thus, embedded in this definition are the partners we must seek in setting our personal and institutional priorities. Cultivating relationships with relevant profession- als, 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 profes- sional 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 
 T h e  H e a l t h  A d v o c a t e  R o l e I n t r o d u c t i o n 2 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 reflec- tions 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 com- munities, 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 responsi- bility 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 impor- tant. 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. 
 T h e  H e a l t h  A d v o c a t e  R o l e C o m m e n t a r y,  D r.  J e f f r e y  Tu r n b u l l 3 CanMEDS Health Advocate Role Definition:5 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 navi- gating the healthcare system and accessing the appropriate health resources in a timely manner.  Com- munities 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 spe- cific 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... 1. Respond to individual patient health needs and issues as part of patient care 1.1. Identify the health needs of an individual patient 1.2. Identify opportunities for advocacy, health promotion and disease prevention with individu- als to whom they provide care 2. Respond to the health needs of the communities that they serve 2.1. Describe the practice communities that they serve 2.2. Identify opportunities for advocacy, health promotion and disease prevention in the commu- nities that they serve, and respond appropriately 2.3. Appreciate the possibility of competing interests between the communities served and other populations 3. Identify the determinants of health for the populations that they serve 3.1. Identify the determinants of health of the populations,  including barriers to access to care and resources 3.2. Identify vulnerable or marginalized populations within those served and respond appropri- ately 4. Promote the health of individual patients, communities, and populations 4.1. Describe an approach to implementing a change in a determinant of health of the populations they serve 4.2. Describe how public policy impacts on the health of the populations served 4.3. Identify points of influence in the healthcare system and its structure 4.4. Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism 4.5. Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper 4.6. Describe the role of the medical profession in advocating collectively for health and patient safety 
 T h e  H e a l t h  A d v o c a t e  R o l e C a n M E D S  H e a l t h  A d v o c a t e  R o l e 4 Inspiring Health Advocacy In response to increasing calls for post-graduate medical education to advance HA in medicine, we un- dertook 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 educa- tors 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 moti- vations 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 motiva- tors 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 commu- nity 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 sys- tem framework becomes conducive to HA by physicians for their patients. The following section highlights the HA activities of a number of ‘champions’, Vanessa Brcic, Jocelyn Chase, Healthy Young Minds, Tracy Monk, Davedeep Sohi, and Brian Westerberg. 
 T h e  H e a l t h  A d v o c a t e  R o l e I n s p i r i n g  H e a l t h  A d v o c a c y 5 Vanessa Brcic Clinical Scholar Program, UBC Department of Family Practice How did you get started? Working briefly for CIDA, I saw the prevalence of unmet health needs at the heart of many grass- roots community initiatives, and began to under- stand the connection between physical and social environments and health. I was initially attracted to medicine with an interest in advocating for healthy community development and bringing an interest in determinants of health to clinical prac- tice.  From the first weeks of medical school I found space for these interests, campaigning against an expressway that now runs through what was Canada’s largest undeveloped urban green space, within metres of several elementary schools and through one of the poorest neigh- bourhoods in Canada. The health issues sur- rounding this project seemed clear, as did the im- portance of my engagement as a future physician. Primary care seemed like a fundamental place to learn how to address population health chal- lenges at the heart of a community's health. What is satisfying about this work for you as a physician? I see health advocacy as a satis- fying as well as an imperative part of my practice. Imagining how to improve my practice environment and work towards a more equitable primary health care system is a great motivational force. Sharing these ideas with col- leagues and patients amplifies this effect enor- mously, particularly within the UBC Department of Family Practice. I don’t see myself as a champion by any means; I am an exponent of health advocacy at most, someone who seeks out opportunities to partici- pate in her community. Those of us who under- stand our roles as advocates need to walk with other health providers, seeking to engage more deeply with col- leagues, patients and communi- ties on how to improve popula- tion health. What pearls of wisdom would you like to share with medical colleagues about this work? As an educated and privileged member of society, I feel a certain civic duty to be engaged in com- munity processes and policy. This can be as sim- ple as voting, or in my professional life,  taking a few minutes to read the news and discuss 
 T h e  H e a l t h  A d v o c a t e  R o l e Va n e s s a  B r c i c 6 “I
am
an
exponent
of
health
 advocacy...someone
who
 seeks
out
opportunities
to
 participate
in
her
community” ! "#$%&&#'()*)+,-#*./)0-! ! important issues with colleagues;  take the time to learn something about my practice population and the communities in which they live. These are basic levels of engagement but can foster future action on issues that are important to the health care needs of people who are most vulnerable. How do you think more physicians can be en- gaged in HA? I believe advocacy is more about perspective and openness. I don’t believe perspective is difficult to achieve, it is simply an approach to practice. It is about more sincere contemplation, productive conversations, and direction towards action. It is about shedding the cloak of disempowerment placed on our shoulders by heavy workloads and an often inefficient system, to think of how we might run things differently and optimally. Advo- cacy is simply the refusal to slouch under the weight of disempowerment and complaining about a system we are doing nothing to change. 
 T h e  H e a l t h  A d v o c a t e  R o l e Va n e s s a  B r c i c 7 Unnatural Causes…Is Inequality Making Us Sick? Source: PBS (California Newsreel) http://www.pbs.org/unnaturalcauses/ This series investigates why some Americans experience illness more often and die sooner than others. Unnatural Causes considers the root causes of illness, where well-being is not merely a result of genetic make up, behaviour choices or medical care. The social, economic, and physi- cal environments, in which individuals are born, live and work, affect their health. Jocelyn Chase Chief Medical Resident, PGY3 UBC Internal Medicine Future UBC Geriatrics Fellow How did you get started?   Like most people I was involved in health advo- cacy as a medical student. Then I had the freedom and time to do it.  Once residency came along, it became difficult to find the time and energy to continue community involvement; a barrier many residents experience, particularly in our first year. It’s a challenge to stay on top of our clinical duties or take time on weekends and evenings to engage in health advocacy. My current involvement in health advocacy stems from the UBC Internal Medicine Residency Pro- gram, which is really encouraging residents to be involved in the community. As the profession of medicine evolves and changes, the public and training bodies are looking to residents to make health advocacy an integral part of their practice. There is a paradigm shift to encourage doctors to engage in health advocacy as a normal part of their work, rather than something that is viewed as an optional add-on. With the support from my training program, I was able to help start the UBC Internal Medicine Health Ad- vocacy Program, in 2007-2008. The aim of our group is to help residents participate in community activities that resonate with their own inter- ests and goals. Further, we try to find opportunities that are conducive with residents’ busy schedules so either short evening/weekend activities or activities that take place during sanc- tioned teaching time. The largest project we’ve organized to date, in- volves a network of residents who give health promotion talks in the community (i.e. smoking cessation, cardiovascular risk reduction, diabetes care, additions etc.). We have gone all over, from Chinatown, to churches and community centers to the Downtown Eastside. Reviews from the community have been great and residents really feel inspired by these connections. We have also organized visits to the Downtown Eastside for residents to learn about the local re- sources available to patients once discharged from hospital. Every year we also participate in a dementia awareness program in Chinatown with sen- iors,  checking their blood pressure and encouraging them to be screened for cognitive impairment by their family physician if they have symptoms. What is satisfying about this work for you as a physician?   I get really energized seeing people in the com- munity who are interested in preserving their health and finding ways to prevent illness. If all we see are ill patients in our practices and in the hospital,  I think our view of health and illness on a community and population basis gets skewed 
 T h e  H e a l t h  A d v o c a t e  R o l e J o c e l y n  C h a s e 8 “The
best
thing
we
can
do
 for
any
person
is
to
find
a
 way
to
keep
them
healthy
in
 the
first
place
and
optimize
 their
quality
of
life.” jmchase@shaw.ca
 toward the pessimistic. People in the community are seeking health information; they look for wellness and prevention, rather than illness.    I have especially enjoyed my time in Chinatown and I am trying my best to learn a few phrases. What pearls of wisdom would you like to share with medical colleagues about this work? The profession as a whole should be proud of the many amazing technologies we’ve developed to treat and sometimes cure disease.   However, we also need to look further than the philosophy of our Western based practice, which largely deals with disease palliation rather than prevention. The best thing we can do for any person is to find a way to keep them healthy in the first place and optimize their quality of life.  To me, this repre- sents the core principle of health advocacy and will hopefully be something I can draw from in my future as a Geriatrician. How do you think more physicians can be en- gaged in HA? Each physician needs to examine their interests and current scope of practice to find their niche. This might be through holding a talk in the com- munity about a special topic,  participating in a local Health Fair or addressing prevention issues during office visits.   The best way to start is to connect with already established activities, since this is much less daunting and time consuming than starting from scratch.  Small contributions add up over time and no one should feel that even an hour spent here and there is too little. From there, anything is possible! 
 T h e  H e a l t h  A d v o c a t e  R o l e J o c e l y n  C h a s e 9 The Red Book Online is a web-based database that provides access to detailed descriptions of over 4,500 agencies offering a variety of services (counselling, health, housing, educational, fi- nancial etc.) in the Vancouver Lower Mainland. Access The Red Book Online Healthy Young Minds: Mental Health Promotion by Students for Students UBC Vancouver Fraser Medical Program 2013 How did HYM get started? The Healthy Young Minds Project is the brain- child of five first year medical students at the University of British Columbia who believe that health advocacy should start before illnesses arise. The dynamics of child and youth mental health is poorly understood, yet is an integral part of community wellness. Youth mental health (MH) is an area that has recently been identified as a priority health concern by the Mental Health Commission of Canada and other health promo- tion entities, due to a num- ber of indicators, including: • The estimated preva- lence of child and youth MH disorders in British Columbia is 15%.6 • The importance of early intervention in pro- moting mental well-being:  for more than 70% of Canadian adults living with a mental ill- ness, onset occurred before 18 years of age. • Less than 1/3 of children under age 18,  who have a serious mental health problem access any mental health services. • Youth are poorly equipped to recognize MH disorders,  yet are most likely to seek help from peers.7 HYM student leaders came together as a result of a common passion for reducing these disparities and providing young people with the tools to not only access mental health resources, but also to emphasize the importance of addressing mental health in self-care practices. Our mission state- ment is "to establish a sustainable framework for engaging youth in the discussion of mental health with the aims of reducing stigma and facilitating access to mental health care" through the creation and delivery of mental health workshops.  Impor- tant secondary goals include engaging youth in all phases of development and delivery of these workshops as well as identifying and tracking outcomes for evidence based evo- lution of this project. What is satisfying about this work for HYM as physicians-in-training? This work allows us to connect with the commu- nity in a number of ways while also providing us with the experience of acting as health advocates and experts.    HYM has gathered together many experts in the field, who are active in the commu- nity, to mentor and inform the project.    At the same time, the project gives us, 
 T h e  H e a l t h  A d v o c a t e  R o l e H e a l t h y  Yo u n g  M i n d s 1 0 (Left to Right) Kristy Williams, Taylor Swanson, Maryam Dosani, Disha Mehta and Alex Butskiy. “…came
together
as
a
result
of
 a
common
passion
for
reducing
 disparities…” physicians-in-training, the opportunity to interact directly with a vulnerable population as health experts and positive role models.  What pearls of wisdom would HYM like to share with medical colleagues about this work? HYM is only just getting its feet wet in the world of youth mental health and hopes to learn more as the project progresses.    Thus far, we have bene- fited immensely from doing background research before setting out to accomplish our goals.    Re- cently, a number of outreach programs and re- sources have been developed, which complement the HYM project. These include the Canadian Mental Health Association’s Mental Health & High School Curriculum Guide, British Columbia Medical Association’s Practice Support Program and their East Vancouver Youth Mental Health Pilot project, and Simon Fraser University’s Stu- dents for Mental Wellness.  HYM team leaders are already integrating these projects and their asso- ciated expert knowledge into the development of this project. In this way, HYM is integrating exist- ing expert knowledge into a deliverable project. How does HYM think more physicians can be engaged in HA? There are many community projects that could benefit from continued input from health profes- sionals,  especially in poorly researched areas such as youth mental health.    Physicians can provide both their medical expertise and experience with specific populations. HYM encourages health pro- fessionals at all stages of their careers to join us in the development, delivery; and evaluation of our youth workshops and training of our volunteers. 
 T h e  H e a l t h  A d v o c a t e  R o l e H e a l t h y  Yo u n g  M i n d s 11 Davedeep Sohi PGY2 UBC Internal Medicinesohi@interchange.ubc.ca What kind of advocacy activities are you in- volved in? I am primarily involved in health advocacy at the community level. The foundation for these activi- ties is community networking with local organi- zations such as community centres, outreach groups, residential facilities or shelters,  and cul- tural groups. This allows our advocacy team to reach a large portion of the population and focus on at-risk groups that are particularly in need of health information and education. This past year we have been focusing on providing public educa- tion on Internal Medicine topics. The response has been remarkable. So far this year our team has held community-based seminars on addiction, smoking cessation, heart disease, and cancer. Through the dedication of numerous Internal Medicine residents we have reached literally hundreds of people. We have worked in a variety of locations from Vancouver’s Downtown East- side to suburbs such as Langley and Richmond. Our advocacy program, focused on educational seminars, has provided the community with ac- curate and accessible healthcare information while giving residents an opportunity to get prac- tical health advocacy experience. How did you get started? The Internal Medicine residency program al- ready had an advocacy group, where like-minded residents could get in- volved.  With this support in place, I reached out to various community groups and advertised our team’s expertise and availability. In particular, the Healthy Living Program team at Vancouver Coastal Health was incredibly supportive and helpful in getting our name into the community. We immediately had a huge response from com- munity groups requesting health promotion seminars and have been busy ever since. What is satisfying about this work for you as a physician? For me, this work is an extension of what it means to be a physician and is satisfy- ing in many of the same ways. For starters, I have the oppor- tunity to meet a lot of incredible people. Listening to concerns from the community and re- sponding to questions also gives me a slightly different perspective on how the community views health, disease, and disability. Undoubtedly, I think this makes me a better physician. On top of this, there is always the immediate gratification of being able to teach people about their illness or help them learn about illnesses affecting loved ones. I really believe that this kind of education helps empower people to live healthier lives and manage their illnesses proactively. What pearls of wisdom would you like to share with medical colleagues about this work? I am still at the early stages of my career but after experienc- ing health advocacy first hand, I can say that it is definitely re- warding and not as time con- suming as one might think. How do you think more physi- cians can be engaged in HA? 
 T h e  H e a l t h  A d v o c a t e  R o l e D a v e d e e p  S o h i 1 2 “…education
helps
empower
peo‐ ple
to
live
healthier
lives
and
man‐ age
their
illness
proactively.” “…it
is
definitely
rewarding
and
not
 as
time
consuming
as
one
might
 think
–
so
give
it
a
try.” I think the major barrier to physicians being more involved in health advocacy is time. From a resi- dent’s point of view, it would be great to see ad- vocacy incorporated as an integral part of the training program given that it is a CanMEDS re- quirement. While dedicating time may be difficult during work hours, streamlining the logistics so that residents have to dedicate only one or two hours to conduct a health promotion seminar in the community is a great first step. 
 T h e  H e a l t h  A d v o c a t e  R o l e D a v e d e e p  S o h i 1 3 Healthiest Nation in One Generation Source: American Public Health Association (YouTube) http://www.youtube.com/watch?v=DuBggj7Zd3A&feature=player_embedded Despite affluence, technological advances and universal health care in America and Canada respec- tively, there are still communities that receive inadequate health care. The “Healthiest Nation in One Generation” illustrates how health promotion can theoretically alter the health of a nation in one generation. A similar transformation is needed to ensure health equity in Canada. Tracy Monk Clinical Assistant Professor of Family Medicine, UBC Head of the Department of General Practice, Royal Columbian Hospital, New Westminster How did you get started? I saw some teenagers on TV doing advocacy work about something I cared about and decided to dig into the data to learn more about the issue. I spoke to a lobbyist who explained that research- ing the facts and compiling a bulletproof presen- tation of the evidence on why something needed to be done, and then presenting the information in a short simple form was key in achieving suc- cess. Health advocates need a one pager and a one- minute elevator speech pre- pared. You need to know your subject inside out and know what 1-3 key points you are trying to make when talking to media. What is satisfying about this work for you as a physician? It is deeply meaningful to try to make a differ- ence, and the information I present is always a morale booster for physicians who might be tired in their day-to-day work and forget about the big picture. And if they are teaching – it reminds them of the difference they can make. What pearls of wisdom would you like to share with medical colleagues about this work? The literature supports what we all know in our hearts: making a commitment to patients over time, improves health outcomes, reduces costs and is deeply meaningful for both patients and doctors. How do you think more physi- cians can be engaged in HA? Understand what the word "ad- vocacy" means for starters . . . I am ashamed to say that in spite of being a mildly intelligent person, I did not even know what the meaning of the word “advocacy” was until I was 40 and got a bee in my bonnet about a particular issue. We need greater advocacy about how important health advocacy is,  and to connect with your community and a larger purpose… It might be a secret to physician happiness… Dr Tracy Monk is the co-coordinator of the UBC Centre for Relationship-Based Care. 
 T h e  H e a l t h  A d v o c a t e  R o l e Tr a c y  M o n k 1 4 “…how
good
it
feels
to
do
ad‐ vocacy
and
to
connect
with
your
 community
and
a
larger
pur‐ pose…It
might
be
a
secret
to
 physician
happiness…” Be
a
Health
ActivistSource:
The
View
From
the
Bay
(YouTube)http://www.youtube.com/watch?v=Ymqic2f1uVI Brian Westerberg Clinical Associate Professor, Department of Surgery, UBC Otolaryngologist, St Paul’s Hospital, Vancouver Approximately 30 million North Americans have speech- frequency hearing loss, and its prevalence among young adults is growing. Noise induced hearing loss (NIHL) educational pro- grams targeting elementary school children, as at that age they become exposed to noise during recreational activities such as the use of portable and personal music devices, toys, gunfire, firecrackers, lawnmowers, power tools, dance clubs, rock con- certs, and musical instruments. We assessed the short- and long- term efficacy of a hearing conservation program in changing the hearing loss prevention behaviours in elementary school chil- dren. Our study used Sound Sense, an educational program cre- ated by The Hearing Foundation of Canada, as an intervention. Sixteen Vancouver School Board schools volunteered to partici- pate in the study. The schools were randomized to either an in- tervention or a control group. A total of 846 grade six students (ages 9-13) were recruited to participate in the study, with 451 students in the control group and 395 students in the intervention group. The Hearing Foundation of Canada’s Sound Sense youth NIHL prevention program showed significant short- and long-term efficacy in changing the hearing loss prevention behaviours in elementary school children. Noise-induced hearing loss is a disabling, incurable condition that presents years after noise exposure. With evidence to show it is occurring at a younger age possibly due to increased noise expo- sure in youth, appropriate educational programs with established efficacy that not only improve attitudes towards using ear protection but also result in behavioural modification in youths are required. The clinical significance of our work is obvious when compared to another widely accepted educational intervention, smoking cessation counselling by a physician.  Physician advice on smoking cessation re- sults in unassisted quitting rates at 6 months of 2-3%, which is accepted to be clinically significant. Sound SenseTM resulted in rates of improvement of 1-6% at 2 weeks and 1-3% in 6 months in earplug use in grade six students during activities with different degrees of noise exposure, which is indeed similar to the improvement in quitting rates of smoking following physician advice. The development, implementation and evaluation of a community-based health promotion project around hearing loss can serve as a tremendous opportunity for otolaryngology residents to develop their knowledge and skills around the CanMEDS Health Advocate Role. 
 T h e  H e a l t h  A d v o c a t e  R o l e B r i a n  We s t e r b e r g 1 5 Why Health Advocacy? The Romanow Report proposes “sweeping changes” to make the healthcare system “more responsive and efficient as well as more accountable to Canadians.”8 This has raised important questions concerning the education of health professionals,9,10,11 particularly within the context of recent discussions in Canada around primary care renewal and ensuring the provision of necessary services to disadvantaged populations.12,13 ,14,15 In Canada, approximately 1.6 million individuals live in poverty;16 and child poverty is highest in BC, with nearly one in four children living below the poverty line.17 Chronic poverty has harmful effects on children’s health,18 with socioeconomic status being a key determinant of health out- comes and of the appropriate use of health services.19,20 ,21,22 ,23 ,24,25  In their detailed examination of the in- equities in health and healthcare experiences among disadvantaged or vulnerable populations, Shi and Stevens26 broadly define vulnerability to include various social, economic, political, environmental, and biological conditions that prevent people from protecting their own needs and interests.  Vulnerable popu- lations experience worse health outcomes, higher rates of morbidity, and barriers to care; inappropriately use health services; and have little control over the conditions that contribute to their circumstances.27 Healthcare practices and policies that fail to consider ways of addressing disparities and the healthcare needs of marginalized populations are unlikely to have the desired impact on health outcomes.28 Reduc- ing health disparities and promoting equity for vulnerable populations in Canada is thus an essential im- perative underlying the Canada Health Act.29 Yet,  inequities continue to influence and plague the health of Canadians and the Canadian healthcare system.30 A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health indicates that, although improving socio- economic conditions is essential, health services can play a key part.31 Understanding social inequity and maldistribution of wealth are thus two vital aspects of understanding ill health and disease. Most of the resources we have provided here are an attempt to do this. In order to act within the capacity of health advocate, physicians and physicians-in-training need to ac- knowledge and appreciate the role of the social determinants of health. As educators we must also take the time to critically evaluate our own experiences and understanding of social determinants and how it impacts health status. Below we offer problem-based case studies and resources to aid medical educators better integrate the concept of health advocacy into the curriculum. 
 T h e  H e a l t h  A d v o c a t e  R o l e W h y  H e a l t h  A d v o c a c y ? 1 6 But Why? Adapted from the Determinants of Health, Public Health Agency of Canada “Jason is in the hospital. But why is Jason in the hospital? Because he has a bad infection in his leg. But why does he have an infection? Because he has a cut on his leg and it got infected. But why does he have a cut on his leg? Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on. But why was he playing in a junk yard? Because his neighbourhood is kind of run down. A lot of kids play there. But why can't his parents move? Because his Dad is unemployed and his Mom is sick. But why...?” Teaching Health Advocacy: Starting Points In our experience, teaching and learning about HA is most successful using a participatory approach, that is, by working closely with our communities, medical residents and students in developing key learning objectives and outcomes. The aim is to create educational opportunities that will enhance the learners’ knowledge and skills around the social determinants of health, health promotion,  principles of social jus- tice and advocacy,  and effective community engagement strategies. The intent is to nurture a sense of so- cial responsibility and social accountability for responding to the inequities in healthcare and the needs of those people in society who are rendered vulnerable because of various social, economic, political,  en- vironmental, and biological influences that prevent them from protecting their own needs and interests. Using a participatory and inclusive process, begin with opportunities for dialogue and discussion. Create several opportunities for residents to discuss HA initiatives and how the curriculum can best foster op- portunities for social awareness and responsibility. Convene faculty,  residents, staff, and clinicians to col- lectively examine issues, conduct literature searches and environmental scans, develop priorities, explore partnerships with community-based organizations, and consult with health authorities. The first session may begin with a small group of faculty and residents identifying HA related issues within your discipline,  what existing initiatives are underway at the local and national levels, and how to get involved. For instance, there are several opportunities and efforts underway in the areas of maternal and child health, inner city health,  mental health,  child rights, men’s health, access to care, trauma, home- lessness, adverse outcomes, and medical errors - these are just a few examples. Health
Promotion:
"the
process
of
enabling
people
to
in‐ crease
control
over
their
health
and
its
determinants,
and
 thereby
improve
their
health" 
 T h e  H e a l t h  A d v o c a t e  R o l e Te a c h i n g  H e a l t h  A d v o c a c y :  S t a r t i n g  P o i n t s 1 7 Charity vs. Social Justice approaches to HA Explore the differences between charity conceptions of HA with one based in social justice. Many HA ef- forts tend to take an almost exclusively charity based approach – providing services or relief to people who are in desperate need. Charity based HA activities tend primarily to be based on the “good Samari- tan” concept – providing resources, time, knowledge, and clinical service to vulnerable people. A charity based approach is not only difficult to sustain, it creates a dependency relationship. Charity approaches can be seen simply as band-aid solutions that do not address the root problem of health disparities. A so- cial justice approach, on the other hand, requires residents to focus their efforts on understanding and working to change the structural or institutional factors that contribute to inequitable conditions. HA within a social justice framework enables an equal and collaborative partnership with communities; de- velop mutual capacity to address the root causes of systemic social inequity and disparity; and focuses on building social capital. Problem-Based Case Studies Case Example 1 Mr. Dalek Novak immigrated to Vancouver from the Czech Republic in 1994. He initially was employed in the building industry and eventually was able to sponsor his wife and four children to join him in Sep- tember 1999. Adjusting to life in Vancouver proved difficult for the rest of his family, particularly his wife Anicka,  who spoke little English. She spent most of her time at home, occasionally heading out to the lo- cal park. By September 2000, Anicka no longer left the house and had very little contact with people out- side of her immediate family. Things become more difficult for the family as Dalek lost his job in 2002, and he was repeatedly between jobs for the next five years. The family struggled to make ends meet. On December 29th, 2008 Anicka was found alone,  disoriented in the local park, and inappropriately dressed for the cold weather. In the emergency room, the attending physician, resident, and nurse became concerned when they found that there was no history of Anicka accessing the medical system in Canada, and to make matters worse, they were unable to contact her family. Questions 1. How would the competencies listed under the CanMEDS Health Advocate Role help physicians re- spond effectively to this case (at the individual level, community level, and population level)? 2. What actions should be taken to address Anicka’s current situation? a. What should be done on December 29th, during the following week and in the months to come? b. What physician will follow up in the New Year?  Why? How? 3. What social support systems are available to help the Novak family? 4. What is the role of (lost) relationships in bringing forth and treating Anika’s disease? 
 T h e  H e a l t h  A d v o c a t e  R o l e Te a c h i n g  H e a l t h  A d v o c a c y :  P r o b l e m - B a s e d  C a s e  S t u d i e s 1 8 Case Example 2 Two generations of the Radcliffe family have worked in the automobile industry of southern Ontario. Scott and Debbie Radcliffe joined the General Motors plant in Oshawa, Ontario straight out of high school in 1986. Working with General Motors ensured that both Scott and Debbie received full health insurance, retiree medical coverage, and pensions. In late 2006, the Number 1 plant in Oshawa was cancelled resulting in the loss of 1,000 jobs; amongst those newly unemployed were Scott and Debbie Radcliffe.  The effects of unemployment were devastat- ing; there were limited job opportunities for the couple. Debbie finally secured a job at the local grocery store,  and Scott remains unemployed. He and his unemployed work buddies get together almost every day drinking and lamenting about the circumstances they find themselves in. Scott is admitted to emergency one afternoon complaining of chest pain. Scott is overweight, borderline alcoholic, and has started smoking again. Questions 1. How would the competencies listed under the CanMEDS Health Advocate Role help physicians respond effectively to this case (at the individual level, community level, and population level)? 2. Identify the stressors in Scott’s life, consider environmental, psychological, and economic. What is the root cause/s of these stressors? 3. The government of Ontario recognizes the potential increase in healthcare costs due to the recent plant closures; you are invited to provide your informed opinion to the Keep Ontario Healthy task force.  What recommendations would you make to this task force?  Consider education and re- training opportunities, financial assistance programs etc.  What recommendations would you make about having the Task Force engage Scott and his buddies directly in their deliberations? Consider the direct health benefits on all cause mortality of patients having a sense of agency.  What resources would you access to ensure your opinion was evidence-based?  What actions would you take once you returned to your practice? Case Examples 3 Take a moment to read the Code Red Series that appeared in The Hamilton Spectator, by Steve Buist. The series reflects over three years of research carried out jointly between the Spectator and researchers affili- ated with McMaster University.  The series offers several real case studies that you can use to think about your role as health advocate.  We have adapted one of the sections in the series and included it here to give you an introduction. Health disparities by neighbourhoods Two neighbourhoods, separated by just five kilometers: they might as well be worlds apart. Between these Hamilton neighbourhoods, representing two ends of the spectrum, there's a difference of 21 years in average age at death. If it were a country, one of the neighbourhoods would rank 165th in the world for life expectancy, tied with Nepal, just ahead of Pakistan and worse than India, Mongolia and Turkmeni- stan. The huge gap in life expectancies across the city is one important piece of a much larger story con- cerning the health of Hamilton's neighbourhoods. It reflects the great divide between the poor and the prosperous. 
 T h e  H e a l t h  A d v o c a t e  R o l e Te a c h i n g  H e a l t h  A d v o c a c y :  P r o b l e m - B a s e d  C a s e  S t u d i e s 1 9 Read the rest of CodeRED (Copy and paste http://www.thespec.com/news/article/251417--worlds-apart). 1. How would the competencies listed under the CanMEDS Health Advocate Role help physicians respond effectively to this case (at the individual level, community level and population level)? 2. Consider the following quotes from Rudolph Virchow, arguable the 19th century father of cellular pathology:  “Medicine
is
a
social
science,
and
politics
 is
nothing
 else
but
medicine
on
a
 large
 scale.
 Medicine, 
as
a
social
science,
as
the
science
of
human
beings,
has
the
obligation
to
point
out
problems
 and
 to
attempt
 their
theoretical
 solution:
the
 politician,
 the
 practical
 anthropologist,
must
find
the
 means
 for
their
 actual
 solution.”
 “The
 physicians
 are
 the
 natural
 attorneys
 of
 the
 poor,
 and
social
 problems
fall
to
a
large
extent
within
 their
jurisdiction.”
“It
is
the
curse
of
 humanity
that
it
learns
to
 tolerate
even
the
most
horrible
situations
by
habituation.
Physicians
are
 the
natural
 attorneys
of
the
 poor,
and
the
social
problems
should
largely
be
solved
by
them.”
How does this help inform your obligations and work in this regard? 3. What responsibilities do physicians have to engage in the political process on behalf of their pa- tients? 
 T h e  H e a l t h  A d v o c a t e  R o l e Te a c h i n g  H e a l t h  A d v o c a c y :  P r o b l e m - B a s e d  C a s e  S t u d i e s 2 0 Conclusion With this e-booklet we have sought to introduce medical educators to the concept of health advocacy and how it might be integrated into medical education and both postgraduate and undergraduate levels.  We have reviewed HA literature, profiled Canadian physicians engaged in health advocacy, provide peda- gogical approaches and external resources as a means of encouraging further activity in this area. This e- booklet is by no means exhaustive and it is our hope that it will serve as a platform for dialogue and a space where physicians, teachers, learners and policy makers can share their experiences. Beyond its immediate purpose to serve the teaching needs of medical educators, we envision that this e- booklet could be an educational tool for medical institutions, community based organizations and patient support groups. We invite readers to share it far and wide and only ask that you cite it as our work. We invite your comments, stories, and reflections. Dr. Shafik Dharamsi Department of Family Practice, UBC shafik.dharamsi@familymed.ubc.ca 604-827-4397 
 T h e  H e a l t h  A d v o c a t e  R o l e C o n c l u s i o n 2 1 Acknowledgements We would like to thank the following reviewers for taking the time to critically review this e-booklet and providing valuable suggestions for improvement. Reviewers: John Blatherwick CM, OBC, CD, FRCP(C) Vancouver ‘s Chief Medical Health Officer (Former) M. Peter Granger MD Clinical Associate Professor, Department of Family Practice, UBC Director, Division of Inner City Medicine Medical Coordinator, Three Bridges Community Health Centre Charles P Larson MD, FRCP(C) Clinical Professor, Department of Pediatrics University of British Columbia Director, Centre for International Child Health, BC Children's Hospital Rena C Tabata MSc Manager, Community Liaison for Integrating Study and Service, Department of Family Practice University of British Columbia Helen Weiss MD Vancouver Native Health Clinic Roger Wong BMSc, MD, FRCPC, FACP Clinical Professor, Department of Medicine, UBC Assistant Dean, Faculty Development Associate Program Director, Postgraduate Medical Education Photographer: Emily Ko Funding: 1. The Faculty Development Initiatives Grant, Faculty of Medicine at the University of British Co- lumbia, funded the development of this e-booklet. 2. Teaching and Academic Growth (TAG) and the Faculty of Cohort on Global Citizenship at the University of British Columbia, provided funding for various aspects of this e-booklet’s produc- tion. 3. The Royal College of Physicians and Surgeons funded a larger health advocacy research project Preparing Medical Students for the CanMEDS Health Advocate Role. 
 T h e  H e a l t h  A d v o c a t e  R o l e A c k n o w l e d g e m e n t s 2 2 Community Resources Advocating for Health Academic Institution: Tulane University “Advocating for Health” is an elective course of- fered by the Office of Global Health at Tulane University. Students interact with local and na- tional health sciences professionals who are also practiced health advocates. This course empha- sizes the importance of addressing underlying social, political and economic factors that influ- ence health. Emergency Physician as a Health Advocate Academic Institution: University of Alberta Emergency Medicine at the University of Alberta has developed a summary document on incorpo- rating health advocacy within a residency cur- riculum. A definition of health advocacy is pro- posed and worksheets provided to identify health advocate activities already being conducted. Readers may find this document useful when considering the inclusion of health advocacy in medical education. Graduate Studies in Health Advocacy Academic Institution: Sarah Lawrence College www.slc.edu/graduate/programs/health-advoca cy/ The master’s program in Health Advocacy at Sarah Lawrence College is currently the only graduate studies program dedicated to this spe- cific area. An interdisciplinary approach is taken to prepare students to influence health policy and serve individuals in need of advocacy. The Centre for Patient Partnerships Academic Institution: University of Wisconsin – Madison www.patientpartnerships.org/index.php Training is provided to graduate and professional students in patient advocacy. This program is fo- cused on advocacy at the patient level, equipping individuals make more informed medical deci- sions, navigate employment issues and build support systems. The Centre of Advocacy, Community Health, Education and Diversity Academic Institution: University of Rochester Medical Centre  The Centre for Advocacy, Community Health, Education and Diversity provides support for the broadening of topics in medical education. The Centre seeks to promote an understanding of health, cultural and educational experiences among physicians to create a profession that is cross-culturally competent. The Residency Program in Social Medicine Academic Institutions:  Montefoire Medical Centre and the Albert Einstein College of Medicine www.montefiore.org/prof/departments/family/ rpsm/ This Residency Program in Social Medicine trains primary care physicians for practice in un- derserved communities. 
 T h e  H e a l t h  A d v o c a t e  R o l e C o m m u n i t y  R e s o u r c e s 2 3 Canadian Physician Health Advocates Canadian physicians are active in a number of health advocacy initiatives both locally and internationally. The list below is by no means complete and we strive to continually update it with your input. Anna Banerji, MD MPH FRCPC DTM&H St Michael’s Hospital anna.banerji@utoronto.ca Michaela Beder, MD Resident in Psychiatry, University of Toronto mbeder@gmail.com Access to healthcare for marginalized popula- tions Philip B. Berger, MD Medical Director, Inner City Health Program St. Michael's Hospital bergerp@smh.toronto.on.ca Human rights and torture, Methadone treat- ment, Homelessness John Blatherwick, MD FRCPC LLD fjblatherwick@shaw.ca Non-Smoking by-laws Gary Bloch MD CCFP St. Michael's Hospital gary.bloch@utoronto.ca Inner City Medicine, Poverty Reduction Jocelyn Chase MD Internal Medicine Residency Program, UBC jmchase@shaw.ca Smoking cessation, diabetes, heart disease, can- cer, geriatrics Jean Clinton MD clintonj@mcmaster.ca Early child development, Child Advocacy Peter Granger MD Director, Division of Inner City Medicine Peter.Granger@vch.ca Care of marginalized populations Erica Frank, MD MPH erica.frank@ubc.ca Preventive Medicine Tracy Monk MD Department of Family Practice, University of Brit- ish Columbia tlmonk@telus..net Andrew Pinto MD St. Michael's Hospital andrew.pinto@utoronto.ca Poverty in Canada, with Health Providers Against Poverty Malika Sharma MD PYG-3 Internal Medicine, malika.sharma@utoronto.ca Issues of poverty, Immigrant and refugee health Todd Sakkakibara Three Bridges Community Health Centre todd.sakakibara@vch.ca Inner city medicine, LGTB health, HIV/AIDS, Addictions Dave Sohi MD Internal Medicine Residency Program, UBC sohi@interchange.ubc.ca Smoking cessation, diabetes, heart disease, can- cer, community networking David Tu MD davidtu@telus.net Issues of inequity for Inner City Aboriginal peoplesRoger
Y
M
Wong
BMSc,
MD,
FRCPC,
FACPrymwong@interchange.ubc.ca
 Dementia
 syndromes,
 medical
 education
 on
 health
advocacy 
 T h e  H e a l t h  A d v o c a t e  R o l e C a n a d i a n  P h y s i c i a n  H e a l t h  A d v o c a t e s 2 4 CanMEDS Health Advocacy Working Group Sarita Verma, Faculty of Health Sciences, Queen’s University, Kingston (Chair) Glen Bandiera, Department of Emergency Medicine, St.Michael’s Hospital, Toronto Leslie Buckley, Department of Psychiatry, University of Toronto, Toronto Leslie Flynn, Department of Psychiatry, Postgraduate Medical Education, Queen’s University, Kingston Jeannine Banack, Assistant Professor, Dept of Health Policy, Management & Evaluation Jason R. Frank, Director of Education, Department of Emergency Medicine, University of Ottawa Jonathan Sherbino, Assistant Professor, Division of Emergency Medi- cine, Department of Medicine 
 T h e  H e a l t h  A d v o c a t e  R o l e C a n M E D S  H e a l t h  A d v o c a c y  Wo r k i n g  G r o u p 2 5 Community Organizations Alliance for People’s Health aphvan.wordpress.com/ A community based health advocacy group of health workers, grassroots organizers and people committed to the struggle for health for all BC 211 Community Connection Initiative www.communityinfo.bc.ca/211.html An initiative aimed at developing a province- wide, free, and confidential information and re- ferral service; 211 provides non-emergency serv- ices and support to communities Carnegie Community Centre Advocacy Re- sources www.carnegie.vcn.bc.ca/november_33_2005#idh V1G8Mx9MC7Gngk4K4omIw Organizations working on various advocacy is- sues in the Downtown Eastside, Vancouver Community Initiative for Health and Safety www.livingincommunity.ca/toolkit/ASWpage4. html Organizations working on the issues of equality and human rights of sex workers through sup- port and advocate Health Providers Against Poverty www.healthprovidersagainstpoverty.ca A group of physicians, nurses, nurse practitio- ners, dietitians, health promoters and other health providers committed to addressing poverty pri- marily in Toronto. People’s Health Movement www.phmovement.org/en A grassroots organization of individuals con- cerned with the growing inequities in health Physicians for Human Rights physiciansforhumanrights.org/ A non-profit, non-sectarian organization that ad- vances health, dignity and justice by investigating and responding to human rights violations Physicians for Social Responsibility www.psr.org/ A non-profit advocacy organization that advo- cates for policies that prevent nuclear war and stop or reverse global warming and toxic degra- dation of the environment QMUNITY www.qmunity.ca/ A resource centre offering community services and programs in support of healthy and active living for queer communities in British Columbia Rainbow Health Ontario www.rainbowhealthontario.ca This program is designed to improve access to health services and promote the health of On- tario’s lesbian, gay, bisexual, and transgender communities through education, research, outreach and public policy advocacy Red Book Online http://www.bc211.ca/redbook2.html A web-based database that provides access to detailed description of over 4,500 agencies in the Vancouver Lower Mainland Social Medicine Portal www.socialmedicine.org/ The Social Medicine Portal provides links to web- sites, documents and presentations related to so- cial medicine and health activism 
 T h e  H e a l t h  A d v o c a t e  R o l e C o m m u n i t y  O r g a n i z a t i o n s 2 6 Transgender Health Program transhealth.vch.ca A program that brings together transgender peo- ple, health care providers, health planners, and researchers to work to improve transgender health services in BC Vancouver Coastal Health Population Health Advocacy www.vch.ca/your_health/population_health/ad vocacy/advocacy This program focuses on a number of public and population health issues. Vancouver Coastal Health seeks to create positive change for people and their environments through advocacy. Audio and Visual Be a Health Activist Source: The View From the Bay (YouTube) www.youtube.com/watch?v=Ymqic2f1uVI Raymond Baxter,  Senior Vice President for Com- munity Benefit, Research and Health Policy Kai- ser Permanente, explains what a health activist is and why it is important for individuals to work together to change the health of their community. Healthiest Nation in One Generation Source: American Public Health Association (YouTube) www.youtube.com/watch?v=DuBggj7Zd3A&fea ture=player_embedded Despite affluence, technological advances and universal health care in America and Canada re- spectively, there are still communities that receive inadequate health care. The “Healthiest Nation in One Generation” illustrates how health promo- tion can theoretically alter the health of a nation in one generation. A similar transformation is needed to ensure health equity in Canada. Healthiest Nation – Move Source: Healthiest Nation (YouTube) http://www.youtube.com/watch?v=rIZ56OrLQ 5k&NR=1 Unnatural Causes…Is Inequality Making Us Sick? Source: PBS (California Newsreel) www.pbs.org/unnaturalcauses/ This series investigates why some Americans ex- perience illness more often and die sooner than others.  Unnatural Causes considers the root causes of illness, where well-being is not merely a result of genetic make up, behaviour choices or medical care. The social, economic, and physical environments, in which individuals are born, live and work, affect their health. Are you STRAIGHT? Source: (YouTube) www.youtube.com/watch?v=JQ1I_-MY_NY Four Feet Up Source: National Film Board of Canada Produc- tion films.nfb.ca/four-feet-up/ This film documents one Canadian family’s expe- rience with poverty. An Enemy of the People (play) Henrik Ibsen Poverty Advocacy, Dr. Gary Bloch Source: Ontario Coalition Against Poverty Radio www.radio4all.net/index.php/program/14251 Dr. Gary Bloch comments on the clear links be- tween poverty and health status and the role of health care professionals in the struggle to raise welfare and disability payments in Ontario. HIV Advocacy, Dr. Julio Montaner Source: CBC’s The Hour, December 2, 2009 www.cbc.ca/video/#/Shows/The_Hour/Guests /ID=1349548100 Dr. Julio Montaner,  President of the International AIDS Society,  discusses the current situation of HIV/AIDS in Canada and worldwide. He em- phasizes the need for political commitment at the federal level and individuals to speak out against policies that infringe on human rights. 
 T h e  H e a l t h  A d v o c a t e  R o l e C o m m u n i t y  O r g a n i z a t i o n s 2 7 Books A Fortunate Man John Berger The Citadel AJ Cronin Health and Social Justice: Politics, Ideology, and Inequality in the Distribution of Disease Richard Hofrichter Arrowsmith Sinclair Lewis Social Determinants of Health: Canadian Per- spectives Dennis Raphael Health, Luck, and Justice Shlomi Segall The Politics of Medical Encounters: How Pa- tients and Doctors Deal With Social Problems Howard Waitzkin Newspaper articles Public health advocacy — the role of doctors Joe Barry Irish Medical Times, March 2008. Justice is Good for Our Health How greater economic equality would promote public health Norman Daniels, Bruce Kennedy, & Ichiro Ka- wachi Boston Review, February/March 2000. Advocacy Training Can Give Students, Resi- dents Skills to Improve Community Health Barbara Bein American Academy of Family Physicians, Janu- ary 2010. CODE RED: Where you live affects your health Steve Buist, The Hamilton Spectator, April 10th -17th, 2010 CodeRed This is a case study of health inequities in Can- ada. The Hamilton Spectator and researchers af- filiated with McMaster University report on the health status of individuals living in the 130 neighbourhoods of Hamilton, Ontario. Caring Sisters in arms Kat Eschner Touch The University of Victoria Alumni Maga- zine, Autumn 2009. Cut and bruised: the recession threatens health of Toronto’s homeless John Rieti Networked Streets, April 2009. A sympathetic vision of public health: Incoming CMA president an opponent of two-tier care – but also of waste in the current system Michael Valpy The Globe and Mail, April 2009. Articles Bandiera, G.  (2003). Emergency medicine health advocacy: foundations for training and practice. Canadian Journal of Emergency Medicine, 5(5),  336- 42. Berman, S.   (1998). Training Pediatricians to Be- come Child Advocates. Pediatrics, 102(3), 632-5. Cené, C. W., Peek, M. E., Jacobs, E., & Horowitz, C. R. (2010). Community-based Teaching about Health Disparities: Combining Education,  Schol- arship, and Community Service. Journal of General Internal Medicine, 25(Suppl 2): 130-5. Cha, S. S., Ross, J. S., Lurie, P., & Sacaiiu, G. (2006). Description of a Research-Based Health Activism Curriculum for Medical Students. Jour- nal of General Internal Medicine, 21(12), 1325-28. 
 T h e  H e a l t h  A d v o c a t e  R o l e A r t i c l e s 2 8 Chamberlain, L. J., Sanders,  L. M., & Takayama, J. I.   (2005). Child Advocacy Training Curriculum Outcomes and Resident Satisfaction. Archives of Pediatrics & Adolescent Medicine, 159, 842-7. Dharamsi, S.,  Richards, M., Louie, D., Murray, D., Berland, A., Whitfield, M., & Scott I. (2010). En- hancing medical students’ conceptions of the CanMEDS Health Advocate Role through inter- national service-learning and critical reflection: A phenomenological study. Medical Teacher, 32, 1-6 (In Press). Dharamsi, S., Espinoza, N., Cramer, C., Amin,  M., Bainbridge, L., & Poole, G. (2010). Nurturing so- cial responsibility through community service- learning: Lessons learned from a pilot project. Medical Teacher, 32, 1-7 (In Press). Donohoe, M. T. Stories and Society: Using Litera- ture to Teach Medical Students about Public Health and Social Justice. The International Jour- nal of the Creative Arts in Interdisciplinary Prac- tice Issue 8. Earnest, M. A., Wong, S. L., & Federico, S. G. (2010). Perspective:  Physician Advocacy: What Is It and How Do We Do It? Academic Medicine, 85(1), 63-67. Flynn, L., & Verma, S. (2008). Fundamental com- ponents of a curriculum for residents in health advocacy. Medical Teacher, 30, e178-e183. Frank, J R. (Ed.). The Can MEDS 2005 Physician Competency Framework. Better standards. Better physicians. Better care. Ottawa: The Royal Col- lege of Physicians and Surgeons of Canada. Friedlaender, E & Winston, F. (2004). Evidence based advocacy. Injury Prevention, 10, 324-326. Gill, P. J., Gill, H. S., & Marrie,  T. J. (2010).  Health Advocacy Training: Now Is the Time to Develop Physician Leaders. Academic Medicine, 85(1), 5. Grant, N.,  Gibbs, T., Naseeb, T. A.,  & Al Garf,  A. (2007). Medical students as family-health advo- cates: Arabian Gulf University experience. Medi- cal Teacher, 29(5), e117-e121. Gregg, J.,  Solotaroff, R., Amann, T., Michael,  Y., & Bowen, J. (2008). Health and Disease in Context: A Community-Based Social Medicine Curricu- lum. Academic Medicine, 83(1), 1-9. Gruen, R. L.,  Pearson, S. D., & Brennan, T. A.   (2004). Physician-Citizens-Public Roles and Professional Obligations. Journal of the American Medical Association, 291(1), 94-8. Gruen, R. L., Campbell, E. G., & Blumenthal, D. (2006).  Public Roles of US Physicians. Journal of the American Medical Association, 296(20), 2467-75. Hurley, K. (2007).  Advocacy and activism in emergency medicine. Canadian Journal of Emer- gency Medicine, 9(4), 282-285. Lai, J.   (2009). Health advocacy in emergency medicine: a resident’s perspective. Canadian Jour- nal of Emergency Medicine, 11(1), 99-100. Leveridge, M., Beiko, D., Wilson, J. W. L., et al. (2007). Health advocacy training in urology: a Canadian survey on attitudes and experience in residency. Canadian Urological Association Journal, 1(4), 363-9. LGBT Health Matters: An Education & Training Resource for Health and Social Service Sectors, The Centre Lozano, P.,  Biggs,  V. M., Sibley, B. J., Smith, T. M., Marcuse, E. K., & Bergman, A. B.  (1994). Advo- cacy Training During Pediatric Residency. Pediat- rics, 94(4), 532-6. MacNeily, A. (2007). CanMEDS: time to teach the teachers. Canadian Urology Association Journal, 1(4), 370. 
 T h e  H e a l t h  A d v o c a t e  R o l e A r t i c l e s 2 9 Mikkonen, J., & Raphael, D. (2010). Social Deter- minants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. Morris, B. A. P., & Butler-Jones,  D. (1991). Com- munity advocacy and the MD: Physicians should stand up and stand out. Canadian Medical Associa- tion Journal, 144(10), 1316-17. Oandasan, I. F., & Barker, K. K. (2003). Educating for Advocacy: Exploring the Source and Sub- stance of Community-Responsive Physicians. Academic Medicine, 78(10), S16-9. Oandasan, I. F. (2005). Health Advocacy: Bringing Clarity to Educators through the Voices of Physi- cian Health Advocates. Academic Medicine, 80(10), S38-41. Smith, W. R., Betancourt, J.  R., Wynia, M. K., et al. (2007). Recommendations for teaching about ra- cial and ethnic disparities in health and health care. Vancouver Coastal Health. (2008). Immigrant Health In Vancouver Coastal Health. Verma, S.,  Flynn, L., & Seguin, R. (2005). Faculty’s and Residents’ Perceptions of Teaching and Evaluating the Role of Health Advocate: A Study at One Canadian University. Academic Medicine, 80(1), 103-8. Wear, D., & Kuczewski, M. G.   (2008). Medical Students’ Perceptions of the Poor: What Impact Can Medical Education Have? Academic Medicine, 83(7), 639-45. 
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