Dharamsi S, Shroff F, and Mu L. Faculty of Medicine

Inspiring Advocacy among ResidentsMu L, Shroff F, Dharamsi S. Inspiring health advocacy in family medicine: A qualitative study (Education for Health Journal)Medical Education Monthly RoundsNov 3, 2010 Dharamsi S, Shroff F, and Mu L. Faculty of Medicine

DIALOGUE How can we improve the training of future physicians, so that they may respond more effectively to health disparities, the broader determinants of health, and the related healthcare needs of vulnerable populations.

Inspiring health advocacy in family medicine: a qualitative study. • Context: The physician’s role as health advocate is identified as a key competency by the Royal College of Physicians and Surgeons of Canada (RCPSC). HA relates to the physician’s responsibility to identify and respond appropriately to the social determinants of health and the healthcare needs of vulnerable and marginalized populations. However, HA is regarded as one of the more difficult CanMEDS roles to integrate into residency training. • Question: What inspires family medicine residents, educators and physicians to engage in health advocacy and how to meaningfully incorporate HA into medical training. • Methods: In-depth, semi-structured interviews conducted with a purposive sample of residents, physicians and educators who self-identified or were identified by peers as health advocates. 9 interviews in total.

Findings • Inspiration came mainly from outside of medicine • Family: parents • Other role models • Travels: SW • Other exposure to inequities Farah Shroff 2010

Findings 2 Pivotal moments within medicine …there was a program that we were encouraged to apply for that had us volunteering in this inner city health clinic… [it] gave us the opportunity to live in a northern First Nations community.… [Another] experience was living for a summer in rural Mozambique… I was excited about that program and in that found another sort of community of people who were interested in working in marginalized communities but also working on changing health status and improving health in those communities. And that became a very formative part of my medical education so far. Farah Shroff 2010

HA in Residency • Mixed feelings • Clinical skills [R]esidency is a time when the focus is on developing competency at clinical practice…Learning [about advocacy] may therefore not be optimal or even as good as it is in medical school when students are less stressed with the day-to-day aspects of providing care.

HA in Residency 2 • Opportunities ♦ research project ♦ could negotiate Lots of verbal support but not much time, funding or other support • Less valued: para-clinical nature

Integrating HA into the Curriculum • time and flexibility • health advocacy-oriented research • specific advocacy electives • longitudinal residency structures which give residents control over their own schedules • part-time residencies

Community of Practice and Mentorship • Peers very important to research participantsWhatever one gets involved and passionate about, if there’s people to share that with that becomes very very important, …you realize how important those friendships, connections are, and I realized that a group of people that I worked with, I protested with, or you know tried to change things with, often came up against big roadblocks with, those are hugely bonding experiences and that’s really become my community and that sustains me a lot… if we spent more time thinking about that idea of community around activism or… around health advocacy that we could find some ways to encourage and create that a little bit more, at least facilitate the process.

For decades, physicians and medical institutions have been called upon to take a more active role in addressing inequities in health, health promotion and disease prevention. • While most physicians recognize the importance of working on population health issues, many are not undertaking activities in this arena. • Residency education provides an opportunity for HA efforts Brill, J.R., S. Ohly, and M.A. Stearns, Training community-responsive physicians. Academic Medicine. 2002;77(7):747. Gruen, R.L., S.D. Pearson, and T.A. Brennan, Physician-citizens--public roles and professional obligations. Journal of the American Medical Association. 2004;291(1):94-8. Furler, J., et al., Health inequalities, physician citizens and professional medical associations: an Australian case study. BMC Medicine. 2007;5:23. Oandasan, I., et al., Being community-responsive physicians. Doing the right thing. Can Fam Physician, 2004. 50: p. 1004-1010. Parboosigh, J., Medical schools' social contract: more than just education and research. Can Med Assoc J, 2003. 168(7): p. 852-853. Rubenstein, H.L., E.D. Franklin, and V.J. Zarro, Opportunities and challenges in educating community-responsive physicians. Am J Prev Med, 1997. 13(2): p. 104-108. Verma, S., Honouring the social contract: medical schools take social responsibility seriously, in University of Toronto Bulletin. 2005.

Health Advocacy Spectrum • Health promotion • Disease prevention • Treatment • Palliation Farah Shroff 2010

Working Upstream • Health Promotion Determinants of Health income social status inequities etc • Changing unequal social structures • Sustainabilityenvironment economy society Farah Shroff 2010

Health For All • Large Scale Changes Cuba Kerala • Roots of Health: salutogenesis • But Why? story • Needs more than advocacy • Advocacy: terminology Farah Shroff 2010

Successful Canadian Campaigns ♦anti-smoking ♦seat-belts ♦D & D incorporated legislative changes, social norm changes etc carrot and stick role of physicians and surgeons Farah Shroff 2010

Successful HFA • Political will • People’s participation • Intra-sectoral cooperation • Intersectoral cooperation • Appropriate technology Farah Shroff 2010

Disease Prevention • Screening • Testing • Education • Lifestyle modifications etc Farah Shroff 2010

Treatment • Ever expanding clinical territory • Hospitals, clinics etc: medical system generally works well • HA helps: families, clinicians and others Farah Shroff 2010

Palliation • Assisting people to die with dignity • Dying at home • Finding peace at the end of life Farah Shroff 2010

Changing Systems • Hard work • Requires courage • Conflict • Other professions: lawyers, engineers, teachers Farah Shroff 2010

Universities’ Challenges • Funding structure • Embedded within hierarchies • Reproducing social system or challenging it? • Teaching HA, from within HP framework, challenging Farah Shroff 2010

Inspiring HA Within the HA spectrum, where is the best place for physicians and surgeons to work? Farah Shroff 2010

Case Study Your Department has recently had a Royal College review and received accolades for strengths in the Medical Expert Role. However, the Department as been cited for deficiency in the Health Advocate Role (HA). The Residency Program Committee has been gathered to discuss the matter. The Committee has brought in an ‘expert’ for advice. The ‘expert’ suggests that efforts to integrate HA into the training program is likely to be more effective if it is undertaken using a participatory approach (i.e., actively involving learners). The Committee is convinced and decides to involve the residents in reviewing the identified weaknesses in the existing curriculum, and to develop a plan to correct them with a focus on the Health Advocate Role.

A session with the residents is organized. The expert gives a passionate lecture on health advocacy in residency training and invites questions at the end. After an awkward silence, one resident says: “Health advocacy is important but we really need to develop proficiency in clinical and surgical skills…the other ‘stuff’ we can figure out later, once we get going in our careers.” Several residents nod in agreement.

Dharamsi HA Study: Preliminary findings • Many residents across disciplines not aware of HA competencies • HA not seen as a meaningful part of residency training • Few (if any) mentors to emulate • Participation in health advocacy is seen as important by residents, however, there is also concern that “we really need to develop proficiency in clinical and surgical skills...”

Qiu C, Kivipelto M, von Strauss E. Epidemiology of Alzheimer's disease: occurrence, determinants, and strategies toward intervention. Dialogues Clin Neurosci. 2009;11(2):111-28. More than 25 million people in the world today are affected by dementia, most suffering from Alzheimer's disease. Increasing evidence strongly points to the potential risk roles of vascular risk factors and disorders (eg, cigarette smoking, midlife high blood pressure and obesity, diabetes, and cerebrovascular lesions) and the possible beneficial roles of psychosocial factors (eg, high education, active social engagement, physical exercise, and mentally stimulating activity) in the pathogenetic process and clinical manifestation of the dementing disorders. The long-term multidomain interventions toward the optimal control of multiple vascular risk factors and the maintenance of socially integrated lifestyles and mentally stimulating activities are expected to reduce the risk or postpone the clinical onset of dementia, including Alzheimer's disease.

Shevell MI. The Neurological Advocate. Can J Neurol. Sci. 2008;35:543-43. A 12 yr old, immobile, tube-fed GMFCS Level V spastic quadriparetic child with cerebral palsy was brought to your neurology clinic for a scheduled follow-up. Examination reveals multiple cutaneous lesions... ...which upon further investigation turn out to be rat bites.

A 4yr old child presents with severe global developmental delay without apparent etiology despite detailed investigations including metabolic, genetic and neuro-imaging studies. At follow-up, it is made known that previous home educator and rehab services visits have been suspended due to an extensive cockroach infestation in the family’s rental apt.

“To me, health advocacy in Neurology means...” “Effective ways to integrate HA competencies into residency training are....

To me.... • .... closely linked to the specialist’s concern with health equity - systematic differences in health between people who are at different levels of social position simply because of ethnicity, occupation, educational level, wealth, gender, geography, sexual orientation, and other such characteristics.... working hand-in-hand with your allies to influence measures that are necessary for protecting and promoting health for all, and reducing vulnerability.... Vulnerability leads to higher levels of morbidity and mortality..... Unfair social, economic, political, and environmental conditions limit people from protecting their own needs and interests leading to worse health outcomes, barriers to care, and having little or no control over the conditions that contribute to this situation.

Competence & Conscience The crisis of our time relates to the disastrous divorce of competence from conscience. Once professionals begin to practice, they stop thinking beyond the technical aspects of their work. Professionals must be able to make judgments that are not only technically correct but also ethically and socially considerate. Ernest Boyer

CanMEDS Health Advocate Role • physician’s duty to identify and respond appropriately to the needs of “vulnerable or marginalized populations” • physicians are required to attend to “the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism.”

Health Advocate Role: Key Competencies Physicians are able to… 1. Respond to individual patient health needs and issues as part of patient care; 2. Respond to the health needs of the communities that they serve; 3. Identify the determinants of health of the populations that they serve; 4. Promote the health of individual patients, communities and populations.

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 communities 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 appropriately

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

DIALOGUE How can we improve the training of future physicians, so that they may respond more effectively to health disparities, the broader determinants of health, and the related healthcare needs of disadvantaged populations.

Inspiring health advocacy in family medicine: a qualitative study. • Context: The physician’s role as health advocate is identified as a key competency by the Royal College of Physicians and Surgeons of Canada (RCPSC). HA relates to the physician’s responsibility to identify and respond appropriately to the social determinants of health and the healthcare needs of vulnerable and marginalized populations. However, HA is regarded as one of the more difficult CanMEDS roles to integrate into residency training. • Research: What inspires family medicine residents, educators and physicians to engage in health advocacy and how to meaningfully incorporate HA into medical training. • Methods: In-depth, semi-structured interviews conducted with a purposive sample of residents, physicians and educators who self-identified or were identified by peers as health advocates. 9 interviews in total.

For decades, physicians and medical institutions have been called upon to take a more active role in addressing inequities in health, health promotion and disease prevention. • While most physicians recognize the importance of working on population health issues, many are not undertaking activities in this arena. Brill, J.R., S. Ohly, and M.A. Stearns, Training community-responsive physicians. Academic Medicine. 2002;77(7):747. Gruen, R.L., S.D. Pearson, and T.A. Brennan, Physician-citizens--public roles and professional obligations. Journal of the American Medical Association. 2004;291(1):94-8. Furler, J., et al., Health inequalities, physician citizens and professional medical associations: an Australian case study. BMC Medicine. 2007;5:23. Oandasan, I., et al., Being community-responsive physicians. Doing the right thing. Can Fam Physician, 2004. 50: p. 1004-1010. Parboosigh, J., Medical schools' social contract: more than just education and research. Can Med Assoc J, 2003. 168(7): p. 852-853. Rubenstein, H.L., E.D. Franklin, and V.J. Zarro, Opportunities and challenges in educating community-responsive physicians. Am J Prev Med, 1997. 13(2): p. 104-108. Verma, S., Honouring the social contract: medical schools take social responsibility seriously, in University of Toronto Bulletin. 2005.

Dharamsi S, Shroff F, and Mu L. Faculty of Medicine