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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2725_Библиотеки_им_академика_М_И_Перельмана.pdf
Teaching Advocacy: Cultivating aVoice
forChange
ChristinaKelly andBich-MayNguyen
28
Key Points
• Health advocacy promotes social, economic, educational,
and political system transformation by ensuring access to
care, mobilizing resources, addressing health inequities,
and inuencing health policy. Addressing the root causes
of health inequities can result in system change.
• Health advocacy differs from health promotion.
• Advocacy training is needed in graduate medical education (GME) so residents understand how healthcare and
sociopolitical factors are intertwined, the causes of health
inequities, and their impact on the health of patients, communities, and populations.
• Residents’ meaningful engagement in advocacy training
can mitigate burnout and promote well-being.
• Historical barriers to teaching health advocacy in GME
include schedule and curricular time constraints, lack of
curricular exibility, and inadequate assessment tools.
Other potential barriers and/or facilitators include faculty
expertise and experience, dedicated resident and faculty
time, institutional support, nancial restrictions, curricular resources, and resident interest.
• The Accreditation Council for Graduate Medical
Education (ACGME) recognizes the importance of GME
health advocacy training in the common program requirements and Family Medicine Milestones.
• Educational frameworks in the literature for health advocacy curricula include: (1) categorizing activities as
agency or activism and the approach as directed or shared;
(2) using a set of domains to group activities that directly
or indirectly improve health; and (3) adopting the
CanMEDS competency-based framework.
C. Kelly (*)
Department of Family Medicine, Uniformed Services University of
the Health Sciences, Bethesda, MD, USA
B.-M. Nguyen
Department of Health Systems and Population Health Sciences,
Tilman J.Fertitta Family College of Medicine, Houston, TX, USA
• Institutions and GME programs must demonstrate they
value advocacy training and create a culture to support it.
• For health advocacy curricula to be educator-friendly, faculty need protected time and training to gain relevant
skills and experience because faculty serve as educators,
mentors, and role models for advocacy behaviors.
• Curriculum design should be attuned to the learners’
needs, action-oriented, and timely with real-world
application. The educational methodology should utilize various teaching modalities and incorporate active
learning opportunities and participation in real-world
applications.
• Using Kirkpatrick’s Model of Training Evaluation can
provide a comprehensive assessment of the advocacy curriculum’s impact, from immediate reactions to long-term
outcomes.
Introduction
The specialty of family medicine was created through advocacy and was a product of social change in the 1960s. In
1989, Dr. Gayle Stephens, one of the founders of family
medicine, described “uninhibited access to medical care for
everybody, especially the medically underserved, personal
and family oriented care on a continuing basis, and comprehensive care at a reasonable cost were critical in the modern
rise of family medicine” [1]. Advocacy is at the heart of why
we are family physicians. It plays a pivotal role in our specialty, inuencing patient care, policy, health equity, and
non-medical drivers of health (NMDOH).
As Rudolph Virchow, a pathologist and one of the found-
ing fathers of social medicine, famously stated, “Medicine is
a social science, and politics nothing but medicine at a larger
scale” [2]. The successes and failures of our society signicantly impact population health and disease. To improve
health and reduce disease incidence, advocacy and political
action are needed to change society [2].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_28
299
300
C. Kelly and B.-M. Nguyen
Dening aHealth Advocate
There are many denitions of “health advocate” in the literature. Earnest’s denition (2010) is “action by a physician to
promote those social, economic, educational, and political
changes that ameliorate the suffering and threats to human
health and well-being that he or she identies through his or
her professional work and expertise” [3]. Earnest’s denition
is used in this chapter. Health advocacy can include activities
such as ensuring access to care, mobilizing health resources,
addressing health disparities, inuencing health policy, and
creating system change [4].
The health advocate role within the CanMEDS Physician
Competency Framework (CanMEDS) is dened as a physician who will “contribute their expertise and inuence as
they work with communities or patient populations to
improve health. They work with those they serve to determine and understand needs, speak on behalf of others when
required, and support the mobilization of resources to effect
change” [5].
Health advocacy differs from health promotion. Although
health promotion undoubtedly plays a role in an individual’s
health, it does not result in systemic change nor address the
root causes of health inequities [4]. Additionally, it does not
account for the impact of the environment and social policies
on health behaviors or outcomes [4].
As health advocacy becomes more visible within medical
education, there is a growing recognition that physicians are
responsible for participating in activities that contribute to
the improved health of their individual patients, communities, and populations by identifying and addressing health
inequities [4].
Why Advocacy Education Is Needed inGME
Many health organizations include an advocacy role as a
physician’s responsibility. The American Medical
Association’s Declaration of Professional Responsibility
states physicians commit themselves to “advocate for social,
economic, educational, and political changes that ameliorate
suffering and contribute to human well-being” [6]. In their
2019–2025 Strategic Plan, the American Board of Family
Medicine includes a goal to promote professionalism and the
social contract, and they commit to supporting “organizations and people developing innovative curricula in professionalism, the social contract, advocacy, health equity, and
social drivers of health at all levels of education” [7]. Other
family medicine organizations supporting family physicians’
advocacy efforts include the American Academy of Family
Physicians and constituent chapters, the Society of Teachers
of Family Medicine, the Association of Family Medicine
Residency Directors, the Association of Departments of
Family Medicine, and American College of Osteopathic
Family Physicians [8–12].
Frequently, family physicians face bureaucratic and other
barriers to caring for individual patients within their practices. From calling in prior authorizations and writing letters
to keep a patient’s electricity on to completing accessible
parking placard applications and citizenship forms, family
physicians strive to assist patients access to health care and
social services. Faculty can role model and teach residents
how to address these patient concerns. After noticing that
patients have challenges, family physicians can use their
expertise and experience to advocate within healthcare systems and communities for broader impact.
State and federal health policy decisions impact our
ability to provide patients and communities with what is
considered the standard of care. Over the last several years,
these policy decisions have spanned from attempts to limit
a physician’s ability to provide counseling to patients
about gun safety to restricting medically indicated treatments for various health conditions [13–15]. Physicians
need to be health advocates by (1) sharing their unique
insights about the impact of health policies on communities, especially historically marginalized populations and
(2) helping legislators design solutions to address public
health challenges [16].
Health advocacy goes beyond treating individual
patients—it’s about impacting systems and communities to
improve health on a broader scale. Family physicians are an
integral part of the healthcare system and are uniquely positioned to serve as public advocates and contribute to system
transformation [4]. Physicians clearly understand the medical aspects of health issues and how health and social factors
connect [4].
Graduate medical education (GME) has traditionally
been heavily focused on clinical skill development. However,
there is an increasing awareness of how healthcare and
sociopolitical factors are intertwined and the importance of
developing socially responsible residents. To be competent
health advocates, physicians must understand the causes of
health inequities and recognize their impact on patients and
communities [4]. Family medicine residency education
transformation efforts have proposed that residents “learn to
understand and navigate their community’s territory, connecting horizontally across public health, community organizations, and pharmacies, and vertically within health
systems, and acquire techniques for advocacy and community engagement” [17].
With the growing recognition of the role of physicians
as advocates, GME has started to embed advocacy training
within its curricula. The Accreditation Council for
Graduate Medical Education (ACGME) Common Program
Requirements state all residents should “learn to advocate
for patients within the health care system to achieve the
28 Teaching Advocacy: Cultivating aVoice forChange
301
patient’s and family’s care goals” [18]. In the requirements
specic to family medicine, the ACGME denes family
physicians as advocates for “high-quality, cost-effective,
and high-value care that improves health outcomes,”
“social justice and ethical principles to remove barriers to
equitable care for all populations,” and “patients through
the development and promotion of health policy by working with local organizations and partnering to promote better health within the intricacies of the healthcare system”
[19].
Meaningful engagement in advocacy training during
residency could address physician burnout by giving residents space to play an active role in shaping the healthcare
landscape and creating meaningful change [20, 21]. Health
advocacy can reinforce physician identity, serve as an outlet for stress, and support resident professional development [21].
Facilitators andBarriers toTeaching
Advocacy inGME
A historical barrier to teaching health advocacy in GME has
been schedule conicts, time constraints, and a lack of curricular exibility due to competing ACGME family medicine program requirements [22]. The updated 2023 family
medicine accreditation requirements support education in
advocacy through (1) a structured population health experience, including curricula on education and integration of
health inequity assessment, (2) a dedicated experience in
health system management, and (3) increased elective time
from 3 to 6months [19]. These updates create schedule space
and opportunity for residents to experientially learn how
health advocacy applies to the micro (clinical), meso (local
community), and macro (state and federal) levels [23].
Additionally, the movement toward competency-based medical education and inclusion of advocacy in the ACGME
Family Medicine Milestones promotes the assessment of
resident skills in advocacy.
Other potential barriers and/or facilitators include faculty
expertise and experience, dedicated resident and faculty
time, institutional support, nancial restrictions, curricular
resources, and resident interest [22, 24]. There may also be
concerns about the need to maintain political neutrality,
especially at state-funded institutions [21].
Contextual factors impacting health advocacy training in
GME include the hidden curriculum that values the medical
care of individual patients within the healthcare system more
than systemic health advocacy actions [4]. Collaboration
between educational programs, medical institutions, and
communities is needed to address these contextual factors,
collectively value health advocacy efforts, and improve
health equity [4].
Frameworks forHealth Advocacy Curricular
Design
Most physicians are familiar with their role as an advocate
for individual patients, exemplied by taking extra steps to
ensure patients receive a needed service or treatment at their
clinic or hospital. While advocacy skills are essential at the
clinic and hospital, this chapter focuses on training family
medicine residents as stewards of community health through
involvement in professional organizations, development of
partnerships with nonmedical community groups, education
in public policy, research-based and legislative advocacy,
and grassroots organizing [24]. The goal is, for residency
graduates, to be competent in assessing the impact of health
policy on communities, identifying ways to inuence positive change, and successfully advocating through effective
communication and information sharing [23].
Four theoretical educational frameworks in the literature
describe conceptual maps for health advocacy curricular
design. Each framework can be used to align a health advocacy curriculum’s learning goals, instructional activities, and
assessment; create engaging and inclusive learning environments; and provide a path for learners to interconnect foundational knowledge and skills through the various curricular
components [25]. The following will review the Hubinette,
Nerlinger, Dobson, and CanMEDS models.
One educational framework by Hubinette et al. [4]
includes broadly grouping health advocacy activities as
agency or activism and determining the approach as shared
or directed based on the role of the advocate in relation to the
individual, community, or population [4]. Examples of
agency activities are navigating the health care system to
provide information about local reduced-cost mental health
services for a patient and overcoming an insurance coverage
denial on behalf of a policy-holder. Activism activities
involve working to change the broader system, hopefully
resulting in sustainable improved function for all. Examples
include raising awareness about the healthcare needs of the
homeless, mobilizing a concerned community group to
action, and directly promoting or evaluating a change in public policy. In shared advocacy, the individual, community, or
population determines the desired change, and the physician
collaborates and places their medical expertise alongside the
group’s perspectives. In directed advocacy, the individual
physician determines the need for change and advocates for
an individual, community, or population while creating
opportunities for patient and community involvement and
self-empowerment [4].
A second framework by Nerlinger etal. [26] does not use
the traditional categorization of advocacy based on the type
of advocacy or the level of intervention [26]. Instead, the
Nerlinger framework determines whether activities directly
or indirectly improve the target population’s health. It uses a
302
C. Kelly and B.-M. Nguyen
comprehensive set of domains to categorize advocacy activities. The domains include advocacy engagement, knowledge
dissemination, community outreach, advocacy teaching/
mentoring, and advocacy leadership/administration [26].
Dobson etal. [27] published a third framework that analyzed physician advocate survey data and identied ve categories of advocacy activities: clinical agency, paraclinical
agency, practice quality improvement, activism, and knowledge exchange [27].
A fourth framework, CanMEDS, is competency-based
and serves as the basis for the Royal College of Physicians
and Surgeons of Canada specialty education standards [5]. A
physician completes their training and becomes a medical
expert, which is the central role in the framework. A medical
expert integrates six intrinsic roles—professional, communicator, collaborator, leader, scholar, and health advocate—as
they “apply medical knowledge, clinical skills, and professional values in their provision of high-quality and safe
patient-centered care” [5]. CanMEDS was the rst educational framework to introduce the role of the physician as a
health advocate, as dened earlier in the chapter [28]. The
key competencies for a health advocate within this framework focus on responsiveness to patient, community, and
population health needs and advocating (1) with the patient
within and outside of the clinical environment and (2) with
communities and populations for system-level change in a
socially accountable manner [5]. Each key competency has
enabling competencies that address NMDOH, adoption of
healthy behaviors, and incorporation of disease prevention,
health promotion, and health surveillance activities [5].
Systematic Reviews ofGME Advocacy
Curricula intheLiterature
With the growing recognition of a physician’s professional
responsibility to be an advocate and an increasing focus on
addressing structural health inequities since the COVID-19
pandemic, GME programs are beginning to teach their residents health advocacy skills, and some have published their
curricula. In addition to sharing curricular details in their
publications, GME programs also describe lessons learned,
innovative solutions to implementation barriers, and the difculties in teaching learners advocacy concepts and skills
consistently, comprehensively, and effectively [21].
A consensus on the subject matter, curricular structure,
and assessment tools that residency health advocacy curricula should include does not currently exist in the literature.
Various curricular designs, formats, and approaches have
been used to teach health advocacy. As a starting point for
developing a model curriculum that GME programs can
adapt, the following three systematic reviews of published
advocacy curricula by Scott, Howell, and Agrawal identied
common objectives, educational content, instructional and
evaluation methods, outcomes, and lessons learned.
The systematic reviews are summarized below, and
Kirkpatrick’s Model of Training Evaluation is utilized to
describe how the studies objectively looked at the effectiveness of their health advocacy training. Kirkpatrick’s model is
an internationally recognized tool used for the evaluation of
educational and training programs [29]. It consists of four
levels: learners reaction to the intervention (level 1), the
impact of the intervention on knowledge, skills, and attitudes
(level 2), behavior change that occurred because of the intervention (level 3), and outcome results tied to the curricular
goals (level 4) [29]. See Table 28.1 for a summary of
Kirkpatrick’s model.
Systemic Review #1: Scott etal.
Scott etal. [28] analyzed 78 studies in English that investigated advocacy training approaches aligned with the
CanMEDS framework and implemented at GME programs
in the USA (69), Canada (8), and Switzerland (1) [28]. The
majority of curricula described in these studies were required
for residents [28].
• Instructional Methods: As part of the systematic review,
the studies’ educational interventions were assigned to
one of ve pedagogical categories: (1) classroom-based
interventions with a practice or interactive component, (2)
classroom-based interventions without a practice or inter-
active component, (3) clinical placements or practicums,
(4) observerships or eld trips, and (5) interventions with
both a classroom-based and clinical component [28]. The
interventions were mapped to the health advocate key and
enabling competencies in the CanMEDS framework [5].
The authors noted that many studies highlighted the
importance of (1) transformative, experiential learning
and (2) allowing residents to critically reect on their
beliefs and values and whether their practices align [28].
• Training Evaluation: Most studies reported Kirkpatrick
level 1 and 2 ndings and a few noted Kirkpatrick level 4
ndings [28].
• Objectives and Outcomes: There was signicant hetero-
geneity in the educational interventions’ objectives and
outcomes, and the authors could not identify commonali-
ties among the goals and effectiveness measures [28].
Systemic Review #2: Howell etal.
Howell etal. [24] analyzed 38 studies that described GME
advocacy curricula published through 2017, representing 32
distinct residency programs in different specialties in the
28 Teaching Advocacy: Cultivating aVoice forChange
Table 28.1 Kirkpatrick’s Model of training evaluation to assess a GME health advocacy curriculum [29, 33]
Kirkpatrick’s
level Description of level Example evaluation question(s) for a GME health advocacy curriculum
1 Reaction Residents’ reaction to the
educational components
within the curriculum and
whether they valued the
training
2 Learning How the advocacy
curriculum impacted
residents’ knowledge, skills,
and attitudes
3 Behavior Behavior change that
occurred because of the
advocacy curriculum and
how residents apply the
training
4 Results Outcome results tied to the
curricular goals and could
demonstrate a return on
investment
Questions with 5-point Likert scale response options (i.e., strongly disagree to strongly agree)
The training was worth my time
My personal needs were accommodated during the training
The presentation style during lectures matched my learning style
I enjoyed the interactive parts of the curriculum
Curriculum adequately covered health advocacy topics
Short-answer responses:
What were the strengths of the training?
How should the training change for future sessions?
What are 2–3 things you learned from the training?
Questions that can be asked before and after the training with 5-point Likert scale response
options (i.e., well below average to well above average). How would you rate yourself on the
following topics related to advocacy?
Knowledge
I can describe how health policy impacts the health of my patient population
I can identify ways to be a health advocate during my residency training.
I have a strong knowledge of various levels of advocacy (local, state, federal) and different
ways to engage in advocacy.
Skills
I am able to engage with local city councils, community organizations, and state/federal
legislators on advocacy issues.
I can effectively communicate my position on a health advocacy issue with stakeholders
Attitudes
I believe it is important to be a health advocate for my community
I believe my role as a health advocate goes beyond the needs of individual patients
I plan to engage inlocal, state, or federal advocacy on issues that I am passionate about.
Things to consider before evaluating for behavior change: (1) what behavior changes does your
residency program wants to see in residents, (2) are the institutional or community conditions are
favorable for resident application, (3) did residents have enough time to apply what they learned,
and (4) is coaching needed to support behavior change. Evaluation that can occur over weeks to
months through surveys, observations, demonstrations, and/or interviews:
How did you put what you learned from your advocacy training to use?
Have you participated in an advocacy-related event since you completed the training?
You can dene your expected outcomes and measure your actual outcomes. Short-term
measurements for advocacy training could include:
Number of residency graduates who play an active role in health advocacy in their community
Number of residency graduates who have advocacy-related leadership positions with
professional organizations
Number of collaborations between the residency and community organizations on health
advocacy issues
How a residents’ advocacy project or initiative inuences (along with other factors) a policy
change
303
United States and Canada [24]. The systematic review aimed
to identify the spectrum of educational approaches to teaching advocacy skills in GME published in the literature. The
authors used the Earnest etal. denition of health advocacy.
The studies included in the review described a formal GME
advocacy curriculum focused on systemic changes at the
community and population levels and assessed for improvement in resident knowledge, skills, and attitudes (KSAs).
The systematic review excluded studies if they limited community engagement to resource exposure or limited educational content to quality improvement, hospital/clinic-based
population health, or individual patient advocacy topics.
Thirty-one of the 38 studies required residents to participate
in advocacy training as part of the program’s curriculum
[24].
• Curricular Objectives: All studies had clear objectives to
improve residents’ KSAs as physician advocates.
• Instructional Methods: The 38 studies included in the
review had heterogeneous educational methodologies.
Residency programs tended to use more than one methodology. Programs used lecture/didactic (55% of studies), small groups/seminars (34%), experiential
learning (60%), and individual or group projects (57%)
[24]. Some studies (24%) had educational interventions centered around collective group projects. Most
studies (63%) described advocacy activities that recognize and act upon community and system-level factors
impacting patient care outside of the clinical environment, with a particular focus on health inequity and
NMDOH [24].
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C. Kelly and B.-M. Nguyen
• Educational Content: Topics included community partnership (63%), health policy/legislative advocacy (26%),
persuasive communication (21%), grassroots advocacy
(7%), and research-based advocacy (3%).
• Training Evaluation: Kirkpatrick level 1 and 2 evaluation
results were most often reported for evaluation of the curriculum [24].
Both the Scott et.al and Howell etal. systematic reviews
identied various methods to teach advocacy in GME.They
demonstrated the need for standardized goals, content, and
outcome measures to better correlate with the stated educational objectives.
Systemic Review #3: Agrawal etal.
Agrawal etal. [21] analyzed 26 English-written studies in
the USA and Canada published from 2017 to 2022 to build
on the work of Howell etal. and try to fulll the need for
standardization of curricular goals, content, and outcome
measures [21]. Thirty-one unique curricula were reviewed.
Inclusion criteria were the same as those used by Howell
etal. The authors used the denition of advocacy by Earnest
etal. [21]
• Teaching Methods: Of all, 77% (n=31) of the curricula
described using several teaching methods: lecture (65%),
experiential learning (61%), small group discussion/seminar (48%), required reading (26%), group project (23%),
and independent project (19%) [21]. One curriculum used
web-based modules. Other unique teaching methods
included panel debates, writing an online blog, creating
advocacy alerts, and coaching. A total of 94% of the curricula provided training on at least one advocacy tool, the
most common being legislative advocacy skills, community partnership strategies, and advocacy writing [21].
• Educational Content: Curricular frameworks used
included Asset-Based Community Development and
Community-Based Participatory Research [21]. A total of
60% of the educational content contained at least one of
three topics: health equity/racial justice, NMDOH, and
structural competency [21].
• Training Evaluation: The authors analyzed training eval-
uation methods using a 3-tier grading system for multimodal, single, and no evaluation [21]. A total of 68% of
the curricula completed a formal training evaluation, and
42% used multi-modal evaluation. A total of 68% of the
curricula evaluated training through resident feedback
and perceptions (Kirkpatrick level 1), and 45% evaluated
resident KSAs (Kirkpatrick level 2). A total of 10% evaluated participant outcomes (Kirkpatrick level 4), such as
grant success and pursuit of an advocacy career path.
Evaluation tools included surveys (48%), written feedback (10%), focus groups (13%), interviews (13%), and
stakeholder feedback (16%) [21].
• Learning Lesson Themes: Several authors described what
worked and what didn’t in their article, and Agrawal etal.
collated the information. Identied themes included (1) It
is critical for institutions and GME programs to demonstrate they value advocacy training and create a culture to
support it, (2) tailoring advocacy curricula to residents’
unique needs and interests can increase engagement, (3)
faculty need protected time to gain relevant skills and
experience, as they are expected to serve as role models
for advocacy behaviors, and (4) teaching methods should
utilize various modalities and incorporate active learning
opportunities and participation in real-world applications
[21].
Family Medicine Residency Advocacy Curricular Development
For an advocacy curriculum to succeed, there must be a supportive residency program and institutional culture [21].
Agrawal etal. [21] proposed a framework for an advocacy
curriculum that includes three core features—learner- centric,
educator-friendly, and action-oriented [21]. To develop a
curriculum with these core features, a six-step approach can
be utilized. The six steps include problem identication and
general needs assessment, targeted learner needs assessment,
well-dened goals and objectives, development of educational strategies, implementation, and a process for feedback
and evaluation [16].
Table 28.2 outlines an advocacy curriculum that could be
used in a family medicine residency program. The table lists
curricular goals and focus areas, educational categories and
objectives, and sample content topics.
Agrawal’s systematic review described core components
of an advocacy curriculum—content and topics, teaching
methods, advocacy tools, and evaluation [21]. There is a
wide range of potential topics in an advocacy curriculum
(see Table 28.2). Teaching methods include didactics (lecture or small groups), experiential learning, and projectbased work. Advocacy tools include legislative advocacy,
community partnership, persuasive writing (op-eds, letters to
the editor, and blogs), and research [21].
The curricular categories in Table 28.2 are considered
foundational to an advocacy curriculum. However, there can
be a spectrum of curricular levels, from basic to more
advanced, based on learner interest and experience, faculty
capacity, and program resources. Any level of curriculum
should be learner-centric and action-oriented. A basic curriculum could cover at least one educational category from
28 Teaching Advocacy: Cultivating aVoice forChange
Evolution of health care policy in the USA
Types of advocacy and impact level (grassroots,
research- based, legislative)
Health systems in developed countries
Medicare and Medicaid
Health care safety net
Reform proposals
NMDOH conceptual frameworks
Historical context for NMDOH
Determinants of health models
What NMDOH are linked to and inuenced by
Fundamental components of health disparities
and why they matter
Identify health disparities and what contributes
to them, using the NMDOH
Upstream medicine
Power and privilege
Institutional racism
LGBTQ+ health, substance use disorder,
undocumented immigrants,
Refugees, asylees, and human rights, farm
worker’s rights, reproductive rights
How to advocate with patient and communities
Advocacy action plans
Engaging communities and building and
sustaining partnerships
Collective impact techniques
Legislative process and budget
Health information technology
Methods to advocate for policy change
305
medical malpractice, and reform
Storytelling and framing/messaging
Writing for advocacy (op-ed, letter to the editor,
blog)
Social media and media training
Dene advocacy in healthcare
Discuss the importance of advocacy in family medicine
Explore historical examples of successful healthcare
advocacy efforts
Describe the political and economic philosophies behind
how a nation structures its health system
Describe the history, structure, and function of the US
healthcare system
Introduction to advocacy
systems and principles
Understanding the health
advocacy landscape
Curricular goals Curricular focus areas Educational categories Educational category objectives Possible educational content topics
Recognize that being an
Table 28.2 Sample curricular goals, educational objectives, and content ideas for a GME health advocacy curriculum
advocate is a physician’s
Structure and function of
the US health care system
professional
responsibility
Understand family
physicians can serve in
multiple advocacy roles
Gain knowledge and
Discuss safety-net providers’ role in facilitating access to
care
Describe the non-medical drivers of health (NMDOH)
Analyze the NMDOH and how they impact health
Discuss the historical and political context of
contemporary health disparities
Social determinants of
health
Understanding health
disparities
experience as an
advocate for system
change with
communities and
populations
Learn how to analyze
Examine disparities in healthcare access and outcomes
Discuss cultural humility and health equity
Health disparities Discuss how advocacy can address health disparities
health policy issues,
process, economic
concepts, legal
health disparities.
Discuss evidence-based advocacy approaches to prevent
and address health disparities
populations
Social justice Evaluate policies and interventions proposed to address
requirements, and
stakeholder participation
Develop knowledge,
Vulnerable populations Discuss advocacy for underserved and marginalized
skills and attitudes that
can be used for
long-term advocacy
Highlight successful advocacy initiatives for vulnerable
groups
community-centered advocacy
Learn how to engage in and help plan advocacy efforts
System level change Describe the difference between individual- and
Community engagement
and collaboration
Community partnership Discuss effective teamwork in advocacy efforts
Emphasize the importance of collaboration with
community groups
Provide an overview of the healthcare policy landscape
Explore the role of family physicians in policy
development
Health policy and
legislative advocacy
Health law Explain the legislative process and key healthcare laws Affordable care act, EMTALA, HIPPA, ADA,
Policy awareness and
inuence
Practice frameworks to share stories and elicit other’s
stories
Discuss messaging through social media and other forms
of media
Persuasive communication Identify communication strategies and when to use them
Effective communication
skills
306
C. Kelly and B.-M. Nguyen
each of the ve curricular areas of focus. An intermediate
curriculum could cover at least one educational content topic
from each educational category. An advanced curriculum
could have multiple content topics from each educational
category and immersive advocacy experiences through academic-community partnerships or observerships.
Evaluation
Methods forCurriculum Evaluation
Kirkpatrick’s Training Evaluation Model can be a helpful
way to evaluate the efcacy of advocacy training [21, 28,
30]. Using all four Kirkpatrick levels to evaluate training can
provide a comprehensive overview of the advocacy curriculum’s impact, from immediate reactions to long-term outcomes. Most published GME advocacy curricula described
in the systematic reviews used level 1 and 2 evaluation methods. Level 3 and 4 evaluation is an opportunity to show the
value of advocacy training [21, 28]. Outcomes-based metrics, such as policy changes or community health improvements, can provide a holistic view of training effectiveness.
Methods forLearner Evaluation
As we continue toward competency-based medical education, the ACGME Family Medicine Milestones can be a useful assessment tool to measure growth in KSAs and other
attributes after advocacy training. Systems-based practice
(SBP) is a core ACGME competency, and one sub- competency
is advocacy (SBP-4) [31]. Advocacy elements are also
described in the milestones for two other sub-competencies—
system navigation for patient-centered care (SBP-2) and physician role in the health care systems (SBP-3) [31].
Residency programs can use their regular assessment
tools to evaluate resident’s competencies, whether the training is at basic, intermediate, or advanced curricular levels. At
the basic level, faculty, peers, and stakeholders can perform
direct observation and provide continual multi-source feedback for residents during advocacy-related events or simulated exercises [4]. Residents can complete reective writing
or short-answer questions about their advocacy experiences,
providing insights into their self-efcacy, values, and perspectives, and development of a growth mindset [4, 32]. At
the advanced curricular level, training evaluation data from
Kirkpatrick levels 3 and 4 could be used for resident assessment. Observation, self-assessment, and multi-source feedback can identify specic behavior changes that represent
growth as an advocate [4].
An advocacy portfolio can be another way to document
residents’ learning, skill development, and reections [4].
Portfolios provide a standardized way to display training advocacy activities and deliverables from training, such as presentations, articles, policy briefs, or op-eds [16]. Domains for an
advocacy portfolio could include “advocacy engagement,
knowledge dissemination, community outreach, advocacy
teaching, and advocacy leadership” [26]. Advocacy portfolios
can also supplement faculty educators’ portfolios [16].
Conclusion
Advocacy training in GME is not a supplementary skill; it’s
a fundamental aspect of producing socially responsible medical professionals capable of effecting systemic change. As
the world continues to grapple with complex health challenges, from pandemics to chronic diseases, the role of the
physician-advocate becomes ever more crucial. GME is rising to this challenge, ensuring the next generation of family
physicians is clinically competent and adept at navigating
the complex sociopolitical landscapes that inuence health.
Creating a culture in residency programs and teaching
institutions that support health advocacy is crucial. Published
systematic reviews assessed the many approaches to teaching health advocacy. Health advocacy curricula should
accommodate faculty through dedicated time and training,
be designed with the residents’ educational needs in mind,
and provide experiential learning and interactive teaching
methods.
Acknowledgments The authors would like to thank Drs. Anastasia
J.Coutinho, Alexandra Sharp, and Paige Ely for their contributions to
the GME advocacy curriculum outlined in Table28.2. Many of the listed
educational categories and content topics were adapted from their work
as student and resident leaders of the Health Policy, Research, Education
and Advancement Team, which was part of the Student and Resident
Collaborative for the Family Medicine for America’s Health Workforce
Education and Development Tactic Team from 2015 to 2018.
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Teaching andEvaluating
Professionalism inFamily Medicine
ElizabethT.Perryman andMarkA.Dixon
29
Key Points
• Maintaining wellness is a key component of physician
professional behavior.
• Leadership development, conict resolution and self-advocacy skills are important components of professionalism.
• A professionalism curriculum with attention to the hidden
curriculum and models of adult learning should be developed and evaluated in each residency program.
Dening Professionalism
The concept of professionalism is not a nebulous one. Every
career eld has set spoken and unspoken expectations of
behavior and conduct when it comes to the work environment and the context in which one operates. The eld of family medicine is no different in this regard, however, the ways
in which professionalism is taught and learned vary greatly
depending on the teacher, the student, and the expectations
or standards to be met—it is a belief system. In addition to
the variability in teaching and evaluating professionalism, it
is not an all-or-nothing concept; development of professionalism requires self-reection, role-modeling, adaptation,
skill, and practice. Physicians are uniquely charged with
nding the balance between practicing the art and science of
medicine. In other words, it is a notion that can be learned, a
belief system that can be adopted, and a trait that can be
acquired. It can either be improved or worsened, and it
requires a continuous process of professional identity formation and reformation.
Residents striving to work as physicians in the eld of
family medicine are expected to have great baseline medical
knowledge entering residency, but the expectations for, and
practice of, professionalism are less clear and more inconsistent. The American Board of Family Medicine (ABFM)
identies professionalism to be the foundation of medicine’s
social contract with society [5]. ABFM further describes professionalism as the ability to place patients’ interests above
physicians’, maintain standards of competence and integrity,
and consistently demonstrate trustworthiness with patients,
colleagues, coworkers, and the public. ABFM further eluci-
dates the concept by describing core competencies that physicians are expected to demonstrate and become procient in
including the ability to:
• Subordinate a physician’s individual interests to the interests of others
• Adhere to high ethical and moral standards
• Respond to societal needs in a manner that reects a
social contract with the communities served
• Evince core humanistic values, including honesty and
integrity, caring and compassion, altruism and empathy,
respect for others, and trustworthiness
• Exercise and accept accountability for themselves and for
their colleagues
• Maintain the knowledge and skills essential for good
medical practice and exhibit a commitment to scholarship
and advancement of clinical skills, medical knowledge,
professional behavior, and personal development
• Demonstrate the interpersonal skills necessary to work
cooperatively in the interest of patients and the public
• Demonstrate a continuing commitment to excellence
• Deal with high levels of complexity and uncertainty
Professional Qualities ofaConscientious
Physician
As discussed, in the introduction, the professional qualities of
E. T. Perryman (*) · M. A. Dixon
United States Air Force, Washington, DC, USA
e-mail: elizabeth.t.perryman.mil@health.mil
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_29
a physician can oftentimes overlap with the professional qualities in many other elds. The American Board of Family
309