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Evaluation of resident attitudes and self-reported competencies in health advocacy Stafford, Sara; Sedlak, Tara; Fok, Mark C; Wong, Roger Y Nov 18, 2010

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RESEARCH ARTICLE Open AccessEvaluation of resident attitudes and self-reportedcompetencies in health advocacySara Stafford1, Tara Sedlak2, Mark C Fok3, Roger Y Wong4*AbstractBackground: The CanMEDS Health Advocate role, one of seven roles mandated by the Royal College of Physiciansand Surgeons Canada, pertains to a physician’s responsibility to use their expertise and influence to advance thewellbeing of patients, communities, and populations. We conducted our study to examine resident attitudes andself-reported competencies related to health advocacy, due to limited information in the literature on this topic.Methods: We conducted a pilot experience with seven internal medicine residents participating in a communityhealth promotion event. The residents provided narrative feedback after the event and the information was usedto generate items for a health advocacy survey. Face validity was established by having the same residents reviewthe survey. Content validity was established by inviting an expert physician panel to review the survey. The refinedsurvey was then distributed to a cohort of core Internal Medicine residents electronically after attendance at anacademic retreat teaching residents about advocacy through didactic sessions.Results: The survey was completed by 76 residents with a response rate of 68%. The majority agreed to accept anadvocacy role for societal health needs beyond caring for individual patients. Most confirmed their ability toidentify health determinants and reaffirmed the inherent requirements for health advocacy. While involvement inhealth advocacy was common during high school and undergraduate studies, 76% of residents reported nocurrent engagement in advocacy activity, and 36% were undecided if they would engage in advocacy during theirremaining time as residents, fellows or staff. The common barriers reported were insufficient time, rest and stress.Conclusions: Medical residents endorsed the role of health advocate and reported proficiency in determining themedical and bio-psychosocial determinants of individuals and communities. Few residents, however, were activelyinvolved in health advocacy beyond an individual level during residency due to multiple barriers. Further studiesshould address these barriers to advocacy and identify the reasons for the discordance we found betweenadvocacy endorsement and lack of engagement.BackgroundThe CanMEDS framework was designed as an innova-tive framework for medical education with the goal ofensuring the highest standards and quality of healthcare [1]. It was first approved by the governing councilof the Royal College of the Physicians and Surgeons ofCanada (RCPSC) in 1996, and subsequently revised witha new edition, CanMEDS 2005 [1,2]. This frameworkhas since been incorporated into the objectives for resi-dency training, examinations, and program accreditationacross Canada for all specialty post-graduate medicaleducation programs accredited by the Royal College ofPhysicians and Surgeons.There are seven CanMEDS roles, each outlining keyphysician competencies to address the multi-facetedroles that physicians play. The central role is that of amedical expert, while the six other roles include that ofa communicator, collaborator, manager, health advocate,scholar, and professional. To date, teaching and evaluat-ing the six non-medical expert roles has been challen-ging. In 2003, at the annual meeting of the Associationof Canadian Medical Colleges in Quebec City, Frank etal. described the results of a 2001 RCPSC survey [3].They reported that significant progress had been madein implementing the CanMEDS framework in Canada,but that the roles of manager and health advocate were* Correspondence: rymwong@interchange.ubc.ca4Clinical Professor, Division of Geriatric Medicine, Department of Medicine,University of British Columbia, Vancouver, CanadaFull list of author information is available at the end of the articleStafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82© 2010 Stafford et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.the most difficult roles to teach and evaluate. In 2006,recent graduates of Canadian general internal medicine(GIM) programs were surveyed to determine whetherthey felt well prepared in different aspects of medicinefor their future careers [4]. In general, most graduatesfelt well prepared in the role of medical expert and overhalf felt adequately taught in the CanMEDS roles ofcommunicator, collaborator, scholar, and professional.However, graduates felt inadequately prepared in theroles of health advocate and manager.The role of a health advocate, as per the CanMEDS2005 framework, is defined as “physicians (who) respon-sibly use their expertise and influence to advance thehealth and well-being of individual patients, commu-nities, and populations.”[5] The key competencies out-lined in this framework are that physicians are able to:respond to individual patient health needs and issues aspart of patient care; to respond to the health needs ofthe communities that they serve; to identify the determi-nants of health of the populations that they serve; andto promote the health of individual patients, commu-nities and populations [5]. Similarly, the American Med-ical Association declaration of professional responsibilitystates that physicians must “advocate for the social, eco-nomic, educational, and political changes that amelioratesuffering and contribute to human well-being.”[6]Despite these definitions and endorsements, teachinghealth advocacy is challenging. Advocacy has a broadscope and practice, thus contributing to a lack of clarityon expectations by teachers and learners alike. Advocacyoften blurs the roles of professional, communicator andmanager due to overlapping competencies, thus perhapsmaking its role less prominent for some. Lastly, manyresidency programs lack a distinct curriculum on advo-cacy due to a lack of recognition of this role, and diffi-culty in evaluating competency.A review of the literature on resident attitudestowards health advocacy revealed few published studies[7,8]. One study in the United States described a com-munity-based advocacy training program for pediatricresidents, where residents were assigned in a longitudi-nal manner to a community collaborative in their firstyear and eventually implemented a project in their lastyear of residency [7]. It was felt that resident attitudestoward community-centered advocacy were noticeablypositive within the program, but no qualitative data wasprovided [7]. A Canadian study explored the views offaculty and residents about teaching and evaluatinghealth advocacy in focus groups, and found that resi-dents required clarity on the definition of health advo-cate, and that many barriers to learning and teachinghealth advocacy exist. However, residents acknowledgeda health-advocate role as part of their social responsibil-ity to society as a physician [8].To our knowledge, resident viewpoints regardinghealth advocacy are poorly understood and self-reportedcompetencies are unknown. The objective of our projectwas therefore to describe resident attitudes and self-reported competencies towards the role of healthadvocate.MethodsStudy populationThis study was conducted in 2008 at the University ofBritish Columbia (UBC) in Vancouver, British Columbia,Canada. The UBC internal medicine residency programhas 111 residents in training with 43 post graduate year(PGY)-1, 33 PGY-2, and 35 PGY-3 residents. Wereceived approval from the UBC internal medicine resi-dency training committee to implement the study anddisseminate its results. We told all residents that byresponding to the survey, they have granted their verbalconsent for us to analyze and report our findings ingroup data format.Survey designWe conducted a pilot health advocacy experience inJanuary 2008. Specifically, seven residents from the UBCinternal medicine residency program volunteered to takepart in a community health promotion event in Vancou-ver’s downtown eastside, an area infamous in the cityfor poverty, crime and homelessness. This area alsoincludes Chinatown and the residents were involved inperforming blood pressure measurements and providedcardiovascular risk factor counseling to 200 Cantonese-speaking community-dwelling older adults. Subse-quently, these residents provided narrative feedbackregarding their experience and possible barriers to enga-ging in future health advocacy roles. The informationgathered was then used to generate the 20 items of thepilot Health Advocacy Questionnaire. Fourteen itemswere developed with 5-point Likert scale responses, 4items with yes/no/undecided responses, and 2 itemswith open-ended responses. Face validity of the ques-tionnaire was established by having the same 7 residentswho participated in the advocacy experience review thesurvey. Content validity was established by inviting anexpert physician panel to review the survey. The expertpanel consisted of 4 internists with extensive experiencein the health advocate role by means of being involvedin patient advocacy at the individual, population andsocietal levels. The panel consisted of a rural communityinternist, an urban community internist, an academicinternist, and an internist involved in internationalhealth. After the development of the Health AdvocacyQuestionnaire, the UBC internal medicine program helda weekend academic retreat for all UBC internal medi-cine residents focusing on health advocacy. The speakersStafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82Page 2 of 7at this weekend retreat included physicians, a pharma-cist and a lawyer who spoke about their local and inter-national experiences working with Doctors WithoutBorders, various HIV initiatives in Africa, the economicsof drug coverage and medico-legal advocacy. The HealthAdvocacy Questionnaire was distributed to all internalmedicine residents at the end of the “Advocacy inAction” retreat. (Table 1).Data analysisFor items with Likert responses, data is presented as apercentage of respondents who chose 1 (strongly dis-agree), 2 (disagree), 3 (neutral), 4 (agree) or 5 (stronglyagree). Percentages were reported for other items. Forthe open-ended items, respondents’ comments wereanalyzed for common themes by thematic content ana-lysis using the Atlas.ti software (version 6.0, 2009).ResultsThe survey was completed by 76 of 111 residents for aresponse rate of 68%. Thirty-two completed responsescame from the PGY-1 year (42%), 22 (29%) from thePGY-2 year and 22 (29%) from the PGY-3 year.Baseline attitudes and self-reported competencies inhealth advocacyThe majority of residents who responded agreed toaccept an advocacy role for societal health needs beyondTable 1 Health Advocacy QuestionnaireStronglyDisagreeDisagree Neutral Agree StronglyAgree1. It is part of my job as an internist to advocate for populations’ health needs within society. 1 2 3 4 52. I feel that my role as a health advocate extends beyond the individual patient(s) I amtreating.1 2 3 4 53. I am able to identify the health needs of an individual patient during patient care (beyondbiomedical needs).1 2 3 4 54. I can describe the health needs of the communities that I serve. 1 2 3 4 55. I can identify the determinants of health (psychological, biological, social, cultural andeconomic aspects) of patients in my community.1 2 3 4 56. I can describe how public policy impacts on the health of populations that I serve. 1 2 3 4 57. I can describe the requirements inherent in health advocacy (e.g. altruism, social justice,autonomy, integrity and idealism), as described by the Royal College of Physicians andSurgeons of Canada.1 2 3 4 58. I understand the opportunities available for internists to function as health advocates. 1 2 3 4 59. I am able to help my patient(s) navigate the health care system. 1 2 3 4 510. My current competence in being a health advocate has increased compared to 1 monthago.1 2 3 4 511. My current knowledge about health advocacy has increased compared to 1 month ago. 1 2 3 4 512. Compared to 1 month ago, I feel more able to practice health advocacy in ways I wouldnot have otherwise done during a regular clinical rotation.1 2 3 4 513. The current likelihood of my engaging in health advocacy activity/activities has increasedcompared to 1 month ago.1 2 3 4 514. I am more likely to recommend health advocacy activity/activities to others compared to1 month ago.1 2 3 4 515. I engage(d) in health advocacy activities during (check all that apply):__ High school __ Medical school__ University/College __ Residency__ Graduate studies16. I am currently engaging in health advocacy activities __Yes __ No17. I plan to engage in health advocacy activitiesa. in my remaining time as a resident __Yes __ No __ Undecidedb. in fellowship __Yes __ No __ Undecidedc. post-fellowship __Yes __ No __ UndecidedIf Yes to 17 a), b), or c), please answer the following two optional questions.What population(s) or patient group(s) would benefit from your advocacy efforts?How would you hope to see them benefit, in both the short and long term?18. Comments?Stafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82Page 3 of 7caring for individual patients. Specifically, 96% of resi-dents agreed or strongly agreed that it was part of theirjob to advocate for populations’ health needs withinsociety (Figure 1a). Ninety-five percent of respondentsfelt their role as a health advocate extended beyond theindividual patient(s) they were treating (Figure 1b).Further, most residents self reported their ability toidentify health determinants and reaffirmed the inherentrequirements for health advocacy. Eighty-six percent ofresidents agreed or strongly agreed that they could iden-tify the health needs of an individual patient (Figure 1c)while 75% said they could identify the determinants ofhealth of (psychological, biological, social, cultural,economic aspects) of patients in their community(Figure 1d). Multiple target populations were identifiedas potential beneficiaries: geriatric populations, minorityor special populations (such as ethnic groups, women,immigrants, and patients of lower socioeconomic status),and international communities.Engagement in health advocacy activitiesSeventy-four percent of residents reported no currentengagement in advocacy activity. There was increasedreporting of participation or engagement in health advo-cacy activities from high school to university to medicalschool; however, a sharp drop-off in participation occurredduring residency training (Figure 2). Forty-five and thirty-four percent of residents said they were undecided as towhether they would engage in advocacy during their futurefellowship or post-fellowship, respectively (Figure 3).Figure 1a: "It is part of my job as an internist to advocate for populations' health needs within society" Neutral Agree StronglyAgreePercentage of Total Respondents (%)Figure 1c: "I am able to identify the health needs of an individual patient during patient care (beyond biomedical needs)" Neutral Agree StronglyAgreePercentage of Respondents (%)Figure 1b: " I feel that my role as a health advocate extends beyond the individual patients I am treating" Neutral Agree StronglyAgreePercentage of Total Respondents (%)Figure 1d: "I can identify the determinants of health (psychological, biological, social, cultural and economic aspects) of patients in my community" Neutral Agree StronglyAgreePercentage of Total Resondents (%)Figure 1 Baseline attitudes and self-reported competencies in health advocacy.Stafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82Page 4 of 7Perceived barriers to engagement in health advocacyA free text section for “Comments” at the end of thequestionnaire generated several comments about com-mon barriers to advocacy engagement. These includedlimited time, limited rest, and excess stress during resi-dency training. Some of the sample comments fromrespondents regarding these topics were as follows:“Physicians need time and rest. We need somebody toadvocate for our needs before we can advocate for thepatients that we serve.... We’re expected to give andgive...”“... My main barrier to doing more advocacy is time,given all our other requirements for clinical learning,research, and clinical service”“Residency is a very stressful period....”DiscussionWe believe this is the first study of its kind that sur-veyed Canadian internal medicine residents to examinetheir attitudes and self-reported competencies in healthadvocacy. Our results demonstrate that residents gener-ally agreed that the role of health advocate is an impor-tant aspect of an internal medicine specialist, and thatthis role extends beyond looking after the individualpatient. Residents felt that they possessed the main com-petencies in health advocacy. Specifically, they believedthat they were able to identify the health needs of theindividual patient beyond their biomedical needs, andthe determinants of health within their community (psy-chological, biological, social, cultural, and economicaspects). These are important aspects to recognizebecause they suggest an awareness of the significance ofthe health advocate role, as well as an ability to carryout this role in society.Despite this endorsement of the importance of healthadvocacy, and the related self-reported competencies,there was a marked deficit of self-reported engagementin health advocacy activities within the resident cohort.Seventy-four percent of residents stated that they werenot currently engaging in health advocacy activities; thisis even more striking when compared to the priorengagement of this cohort of residents earlier in theireducation. While it is possible that residents might nothave identified/recognized advocacy activities that theywere already participating in during residency andlabeled them accordingly, there were likely other sys-tematic reasons. In the free text “Comments” section,residents frequently spoke of perceived barriers to healthadvocacy engagement. The themes of lack of time,insufficient rest, and the high-stress environment of resi-dency were predominant. Such comments are not sur-prising given the competing interests of educationalcommitments, frequent on call-shifts and long hours indemanding residencies, all of which contribute to0102030405060708090High School University/CollegeMedicalschoolResidencyPercentage of Respondents (%)Figure 2 “I engaged in health advocacy during...”.010203040506070Yes No UndecidedPercentage of Total Respondents (%)In Fellow shipPost-Fellow shipFigure 3 “I plan to engage in health advocacy activities during fellowship or post-fellowship”.Stafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82Page 5 of 7resident stress [9-11]. In one of the few prior publica-tions of advocacy education, one resident noted that“the clinical time demands of residency are often a sig-nificant barrier to resident participation in the commu-nity activities.”[7]Interestingly, a large proportion of residents wereundecided as to whether they would engage in healthadvocacy in the future during their fellowship or inde-pendent practice. This discordance between the endor-sement of the role of health advocacy and the lack ofcurrent and possibly future participation is a surprisingfinding, especially in light of residents’ self-reportedcompetency in this area and their prior engagement inhealth advocacy activities. One possible reason may betime constraints and or the lack of remuneration forparticipating in such events. Other hypotheses that havebeen suggested include a gradual erosion of altruismduring residency resulting in poor engagement, andendorsement of advocacy because it is socially desirable,but not inherently believed [12]. Such hypotheses needto be explored in further studies.There were several limitations in our study. We usedself-assessed competence as a surrogate for determiningresident competency in the role of health advocate, butself-assessment has never been validated in the literaturefor this purpose. We also did not have data from non-respondents, and therefore could not comment on anypossible differences between respondents and non-respondents. Future development of a gold-standard forassessing competency in the role of health advocate isneeded to determine the validity of self-reporting in thisnon-medical expert role. Additionally, we asked resi-dents to recall their prior engagement in health advo-cacy activities. This method is susceptible to recall bias,and hence it would be informative to survey a matchedcohort of students during earlier stages of medical train-ing in order to quantify engagement at those times.Health advocacy has reached a critical junction inmedical education. If it is to be a core competency rolefor practicing physicians, attitudes towards advocacyneed to be examined, its teaching be emphasized, itspractice be adopted and its evaluation be more clearlydefined by medical educators and their institutions. Ourstudy of resident attitudes and competencies suggestsendorsement of advocacy as a principle and self-reported competency, but limited engagement in presentand possibly future advocacy events. Based on our data,we recommend the following steps: Residents reportedlimited time as one of the barriers for engaging in healthadvocacy. Thus, allowing dedicated time to engage inhealth advocacy projects within residency training in alongitudinal manner should be explored. Future studiescould be also be directed toward performing a timeaudit to further quantify the time required to engage inhealth advocacy activities, and to determine if there aremechanisms by which the time required for participa-tion can be limited such that it is perceived to be less ofa barrier to health advocacy engagement. Residents alsoreported excessive stress during the training period asbeing a significant deterrent to health advocacy engage-ment. Health advocacy activities should include healthcare providers amongst the targeted populations, focus-ing on stress management as this is known to be a sig-nificant issue within the profession. It would be valuableto determine the contributors to perceived stress duringthe residency training period, in order to target theseissues. Teaching and curriculum advancement in advo-cacy needs further development and methods of assess-ment need to be evaluated. Finally, we identified certainpopulation groups “at risk” through the questionnaire:geriatric populations, people with a lower socio-eco-nomic status, women in poverty and minority popula-tions. These marginalized groups should be approachedto develop potential community advocacy projects on along-term basis.ConclusionsResident attitudes towards advocacy were generally posi-tive with recognition of the need to advocate beyondthe level of patients to that of society. Residents feltcompetent identifying determinants of health; however,few residents were actually engaging in advocacy events.Further studies should address barriers to advocacy andidentify the reasons for the discordance we foundbetween advocacy endorsement and lack of engagement.AcknowledgementsWe would like to thank Irene Ma for her input into the content andconstruction of the questionnaire used in this study.Author details1Fellow, Division of Endocrinology, Department of Medicine, University ofBritish Columbia, Vancouver, Canada. 2Fellow, Division of Cardiology,Department of Medicine, University of British Columbia, Vancouver, Canada.3Chief Medical Resident, Department of Medicine, University of BritishColumbia, Vancouver, Canada. 4Clinical Professor, Division of GeriatricMedicine, Department of Medicine, University of British Columbia,Vancouver, Canada.Authors’ contributionsRYW conceived of the study. SS, TS, MCF and RYW participated in its designand coordination, and helped draft the manuscript. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 16 April 2010 Accepted: 18 November 2010Published: 18 November 2010References1. Frank JR, Jabbour M, Tugwell P, et al: Skills for the new millennium: reportof the societal needs working group, CanMEDS 2000 Project. AnnalsRoyal College of Physicians and Surgeons of Canada 1996, 29:206-216.Stafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82Page 6 of 72. Frank JR: The CanMEDS 2005 physician competency framework. Betterstandards. Better physicians. Better care 2005 [http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf], Accessed March 23, 2010.3. Frank JR, Cole G, Lee C, Mikhael N, Jabbour M: Progress in paradigm shift:the RCPSC CanMEDS Implementation Survey. 2003.4. Card SE, Snell L, O’Brien B: Are Canadian General Internal Medicinetraining program graduates well prepared for their future careers? BMCMed Educ 2006, 6:56.5. Frank JR, Danoff D: The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach 2007,29(7):642-647.6. American Medical Association: Declaration of Professional Responsibility:Medicine’s Social Contract With Humanity. 2001 [http://www.ama-assn.org/ama/upload/mm/369/decofprofessional.pdf], Accessed March 23, 2010.7. Hufford L, West DC, Paterniti DA, Pan RJ: Community-based advocacytraining: applying asset-based community development in residenteducation. Acad Med 2009, 84(6):765-770.8. Verma S, Flynn L, Seguin R: Faculty’s and residents’ perceptions ofteaching and evaluating the role of health advocate: a study at oneCanadian university. Acad Med 2005, 80(1):103-108.9. Collier VU, McCue JD, Markus A, Smith L: Stress in medical residency:status quo after a decade of reform? Ann Intern Med 2002, 136(5):384-390.10. Bergman AB: Resident stress. Pediatrics 1988, 82(2):260-263.11. Bergman AB: More on resident stress. Pediatrics 2003, 112(2 I):414-415.12. Earnest MA, Wong SLMSPH, Federico SG: Perspective: Physician Advocacy:What Is It and How Do We Do It? Acad Med 2010, 85(1):63-67.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/10/82/prepubdoi:10.1186/1472-6920-10-82Cite this article as: Stafford et al.: Evaluation of resident attitudes andself-reported competencies in health advocacy. BMC Medical Education2010 10:82.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitStafford et al. BMC Medical Education 2010, 10:82http://www.biomedcentral.com/1472-6920/10/82Page 7 of 7


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