Fundamental components of a curriculum for residents in health advocacy

Abstract

Purpose: To develop components of a curriculum for teaching and evaluating Residents as health advocates.

Method: Modeled on the Delphi technique, the first step involved a multidisciplinary panel of 10 Queen's University health care providers with expertize in education and patient advocacy. In the context of four Advocacy questions: What is it?, Who does it?, How to teach it?, and How to evaluate it?, they discussed a curriculum framework including graded education, scholarly activity, role modeling, and case examples. In the second step, 24 faculty experts addressed two goals: (1) to identify attributes discussed by the expert panel in step 1 and corresponding measurable behaviours and (2) to refine the curriculum framework proposed in step 1 with emphasis on content and evaluation.

Results: Six attributes of a health advocate were identified; knowledgeable, altruistic, honest, assertive, resourceful, and up-to date. Behaviours that reflect these attributes were identified as desirable or undesirable and means of teaching were matched to the attributes. For most residents, skills would be developed in a graded fashion, progressing from advocating for the individual to society as a whole.

Conclusions: This study provides a general framework from which specialty-specific curriculums for training health advocates can be developed.

Introduction

Medical educators have become increasingly aware of the need to better prepare medical students and residents for their role in society (Frank et al. 1996; Halpern et al. 2001; Brill et al. 2002; Gruen et al. 2004; Verma et al. 2005). Health care professionals need to be not only medical experts but to also develop skills which will enable them to have a broader role in society. The Royal College of Physicians and Surgeons of Canada and the Canadian College of Family Physicians have been leaders in this field, in large part through the initiation of the CanMEDs project (2005; Frank et al. 1996) and the development of the Four Principles of Family Medicine. An innovative framework of physician competencies has emerged from the findings of these groups and these are recognized as essential competencies of all highly skilled physicians. There are seven identified CanMEDs competencies or roles: Medical Expert, Communicator, Professional, Collaborator, Manager, Scholar, and Health Advocate. These are now well entrenched as the accreditation standards, objectives of training, and competencies to be evaluated both during and at completion of training. It is within the domain of Health Advocacy that social accountability can be directly addressed in the preparation of physicians for the future.

Despite the growing importance of the physician as health advocate, there is increasing recognition that this role can be easily lost between the competing needs of the physician, the individual patient, and the availability of health care resources. The complexity of these issues may be particularly daunting for residents, coping with the challenges of mastering their profession. Although there is a rapidly growing dialogue concerning the importance and selected issues about health advocacy and residency training, medical curricula have been slow to introduce curriculum content on Health advocacy (Halpern et al. 2001). We recently evaluated the views of our faculty and residents about teaching and evaluating health advocacy (Verma et al. 2005). Our study concluded there is little known about how to teach and evaluate the role of the health advocate. Moreover, it was evident that role modeling, although invaluable, was alone insufficient and that a graduated curriculum was needed.

Table

Practice points
The role of Health Advocate speaks to social accountability. Health Advocacy can be defined by six attributes. These attributes can be characterized by desirable and undesirable behaviours. Health Advocate can be taught in a graded fashion from individual to society. Evaluation of Health Advocate can be measured by observable behaviours.

Taken together, these studies and others (Helitzer & Wallerstein 1999) suggest that a major barrier to effectively teaching competencies, such as the health advocate, in residency training programs is the lack of an ‘operational’ curriculum framework. This is of particular concern because some accrediting bodies have already mandated that this role be taught and evaluated in postgraduate training programs. As a first step towards addressing these issues, this study developed a curriculum framework for training health advocacy in residency training programs. The study builds directly upon our recent report which identified barriers to the health advocate and reaffirms the need for curriculum development.

Methods

This study was approved by the Research Ethics Board of Queen's University. An iterative process was employed which was modeled on the Delphi technique (Windle 2004). There were two major steps. The first step involved a panel of multidisciplinary health care providers who facilitated the development of a curriculum framework and identified important content issues. This information was brought forward in the second step to a group of educators in a workshop format for refinement and the development of content.

In the first step of the process, the expert panel consisted of 10 health care professionals who were invited and agreed to participate. These individuals were identified within the Queen's University faculty because of their expertize in education and/or as patient advocates. The panel consisted of a family physician, with expertize in palliative care, three physician specialists in endocrinology, infectious disease and gerontology, three nurses, one from management in community care access, a hospital nursing administrator, a nurse manager at the cancer clinic, an academic physiotherapist with prior experience in advocating for patient services, a social worker with experience in mental health advocacy, and a hospital administrator whose role is defined as Patient Advocate. The session was introduced to this group with the presentation of four questions about Advocacy: What is it?, Who does it?, How to teach it?, and How to evaluate it? To facilitate the discussion, the authors presented the Royal College's Definition of a Health Advocate and summarized the findings from our previous focus groups. This study identified there are many perceived barriers to physicians functioning as health advocates and that both residents and physician educators feel that there is no deliberate approach to the teaching and evaluation of this role. In the context of the four questions concerning advocacy, as stated above, the panel was also asked to consider curriculum framework such as graded education, scholarly inquiry, role modelling and case examples.

The second part of the process was the faculty workshop. This was a 4-hour invitational workshop entitled: Teaching and Evaluation the CanMEDs role of Health Advocate. The enrolment included 24 participants. The invitees were teachers and educators at Queen's University, all of whom play a significant role in the administration of education at the postgraduate or undergraduate level. Prior to the workshop a pre-workshop needs survey was distributed.

The purpose of the workshop was 2-fold: (1) to discuss the attributes requested of a health Advocate as identified by the expert panel and to list corresponding measurable behaviours and (2) to further refine the curriculum framework which had been developed, with a particular emphasis on its content and the means of evaluation. Following the presentation of the findings of the expert panel, the participants were divided into three working groups. A facilitator, who had been invited to participate in this role, led each group. Each group was assigned the specific task of determining the desirable behaviours, undesirable behaviours, and means of evaluating the attributes of a physician health advocate. The group was provided with a menu of assessment methods used in medical education which was adapted from the Toolbox of Assessment Methods Accreditation Council for Graduate Medical Education (ACGME) to facilitate this exercise.

Results

Findings of the expert panel

What is it?

The Expert Panel was presented with two definitions of an advocate: one obtained from Webster's dictionary and the other as defined by the Royal College of Physicians and Surgeons of Canada (Frank et al. 1996). Using this as a background, they were asked to define what they believed to be the characteristics of a health advocate. They approached this question by first recognizing that an advocate is a health care professional in a position of power or authority. Because they have this position they are able to use it to the advantage of the patients. In order to then use this power/authority in a beneficial manner the advocate must have particular qualities or attributes. In this discussion, the panel then proceeded to identify a list of key personal attributes that they felt were essential to the role, as summarized in Table 1. Several key descriptors were attached to each of these attributes. To be knowledgeable, the health advocate must be well versed in the determinants of health and they must understand the link between these determinants and health. Ultimately this understanding will enable the health professional to promote health and disease prevention. An advocate is altruistic, that is a person who demonstrates a desire to attend to the welfare of others. This will occur on occasion at the advocate's own expense in terms of time, energy, or personal resource. Honesty is an attribute of physicians who are advocates. They must present a truthful and legitimate argument on behalf of the patient. Assertiveness refers to the role of arguing on behalf of another by presenting/pleading the best case possible and presenting the facts in a cogent and direct fashion. It followed that a health advocate who lacks assertiveness will have difficulty with advocacy and be less effective. It is clear that assertiveness is not equivalent to aggressive confrontation or being confrontational which would be an undesirable attribute for an advocate. An advocate must be resourceful. They must be able to meet a challenge and develop a strategy to arrive at a solution, keeping in mind the pressures to bear on health care resources. Finally, the advocate must remain up-to-date. They must be aware of available resources and pair these with the current knowledge of best practices for patients both in terms of provision of care and preventative health.

Table 1.  Attributes of health advocate identified by expert panel

Knowledgeable

Altruistic

Honest

Assertive

Resourceful

Up-to-date

Who does it?

The panel concluded that all members of the health care team, including Physicians at all levels of their training and practice, should be health advocates and that this is a fundamental requirement of their social responsibility.

How do we teach it?

While role modelling is deemed by many as the most common method the panel recommended that this teaching must be explicit and that role modeling alone is not sufficient. Established objectives and clear expectations are required. These skills should be developed in a graded fashion. This training should occur in parallel with the expansion of the scope of an advocate from advocating for individual to ultimately society as a whole, as modeled in Figure 1.

Figure 1. Progression of training and the scope of health advocate. Figure 1(a) demonstrates the inseparable relationship between advocating for the individual, community, and society. Figure 1(b) demonstrates a curriculum framework for teaching the Health Advocate. The model incorporates the graded teaching of advocacy skills in parallel with the progressive training of the scope of health advocate. Content examples are given at appropriate training levels. The double arrow lines are meant to reflect that some residents will have varied life experiences and a ‘sliding scale’ is needed to account for these.

How to evaluate?

The panel recommended that the evaluation process be integrated into the in-training evaluation records (ITERs). However, given the fluidity of this role and the graduated objectives at three levels (individual, community and societal, see Figure 1), the panel felt that evaluation should include both formative and summative components. This process would further enhanced by including the perspective of other members of the allied health care team (e.g. 360° evaluation). Residents should be challenged to conduct self-evaluation to examine their insight and strengthen their awareness via the use of innovative techniques such as log books, portfolios, and self-reflection exercises. Formal evaluation settings could include MCQ and OSCE formats.

Faculty workshop

Following a review of the findings of our previous resident and faculty focus groups (Verma et al. 2005) and the findings of the expert panel, the first task of the workshop was to further explore the health advocate attributes (Table 1) and to describe observable, measurable behaviours, which would lend themselves to explicit means of teaching and evaluation. To facilitate this process, the authors linked the identified attributes in Table 1 with the CanMEDs roles (Table 2). Although the linked attributes did not completely capture the roles, it became apparent that the skills and attitudes required of the advocate shared common threads with other CanMEDs roles. The importance lay in creating a format whereby the role of advocate became more tangible for the participants. The second task of this workshop was to refine the framework for a curriculum and examine specific content including the determinants of health (Figure 2).

Figure 2. Schematic model of the Determinants of Health emphasizing that education is the most important determinant and influences all of the other determinants (arrows). Social environments is broken into multiple components e.g. social support network and income and social status.

Table 2.  Matching the attributes of health advocate with the CanMEDs roles

Attribute	CanMEDS role
Knowledgeable	Expert
Altruistic	Professional
Honest	Communicator
Assertive	Collaborator
Resourceful	Manager
Up-to-date	Scholar

The workshop identified behaviours for each attribute which were desirable and undesirable and the methods for evaluation (Table 3).

Table 3.  Attribute desirable and undesirable behaviours and their evaluation

Attribute	Desirable Behaviour	Undesirable	Teaching method	Evaluation
Knowledgeable	Supports information Applies knowledge Disseminates Knows limitations	Fails to share Inaccurate	Clinical moment Role model Dossier	OSCE Review dossier
Altruistic	Demonstrates concern of welfare of others Steps out beyond expected Listens to needs	Martyrdom Procrastination	Role modeling Story telling	Clinical observation
Honest	Sensitivity, discloses errors Communicates about difficult issues Balances life Realistic expectations	Insensitive Fearful to discuss difficult issues Unfulfilled promises Defensive communicator	Role model, case discussion, standardized patients videotapes	Case audits, bedside Evaluation, Standardized patients Videotapes
Assertive	Confidence, initiative to solve problems, consults allied professionals, notifies GP of discharge, prescription, refers to CCAC	Passiveness Lacks sensitivity Aggressiveness Bullying	Role modeling, clinical moment Case review	Case Review Case Presentation
Resourceful	Priority setting Flexibility and Resourceful Perseverance Co-operative Knowledgeable about system	Rigidity Poor relationship with other disciplines Dismissive of team members	Cases Small groups Lectures Standardized patients	Performance on ward and clinic Problem simulation Case record audits Chart review OSCE
Up-to-date	Activities (e.g. rounds, conferences, journal clubs) Disseminates information Reflects on role of health advocate in above activities	Stagnates	Didactic, PBL, Role modeling, Journal club	MCQ,OSCE, Case Formulation, Oralv Presentation, Clinical observation

Note: OSCE = Office Simulated Clinical Exam; CCAC = Community Care Access Center; MCQ = Multiple Choice Question; PBL = Problem Based Learning.

The workshop participants incorporated the graded teaching of advocacy skills and parallel expansion of the scope of the advocate into a curriculum framework (Figures 1b and 3, Table 3). They expanded this framework by providing content examples appropriate for the level of training.

Figure 3. Proposed pyramid model of the CanMEDS role reflecting the complexity and diverse skill set needed to be a successful health advocate. To develop as a heath advocate, students must acquire the multiple skill sets required of a physician in an incremental fashion.

Discussion

There is a rapidly growing literature on the teaching of physician competencies as defined in Canada by CanMEDS and the Four Principles of Family Medicine and in the United States by the Accreditation Council for Graduate Medical Education. However, within this growing body of understanding there is surprisingly little written concerning the role of Health Advocate. This is of particular concern because the need for teaching health advocacy in residency training programs has been widely recognized (El et al. 2003; Frank & Langer 2003;Verma et al. 2005) but has proven to be a difficult task. Educators have always had an innate sense of this role but curriculums have lacked operational models and evaluation techniques. Without these, educators cannot specify whether the competence has been successfully achieved. Thus, our study employed an iterative process to develop the necessary curriculum framework Our goal was to define the components of a curriculum which provide a general framework from which specialty-specific curriculums can be developed.

The development of a successful curriculum begins with the identification of the overall goals (Carraccio et al. 2002, 2004). These have been established for the Health Advocate by the Royal College of Physicians and Surgeons of Canada (Jabbour & Tugwell 1996; Frank 2005). These overarching goals are ‘to identify the determinants of health that affect a patient, so as to be able to effectively contribute to improving individual and societal health in Canada’ and ‘to recognize and respond to those issues, settings, circumstances, or situations in which advocacy on behalf of patients, professions, or society is appropriate.’ Education is the most important determinant of health (Winkleby et al. 1992; Caldwell 2005) and influences all of the other determinants (Figure 2). From these, specific objectives can be established. This requires the identification of attributes from which measurable behaviours can be developed in the form of objectives. For example, the attribute ‘assertive’ would have the measurable behaviour of ‘shows initiative to identify and address problems’ and the objective therefore would be ‘Demonstrates the ability to identify and address problems related to patients in their care.’

Our expert panel identified the six attributes; knowledgeable, altruistic, honest, assertive, resourceful and up-to-date. The subsequent workshop developed the objectives further by defining the desirable and undesirable behaviours (Table 3) of each of these attributes. During this process, it was recognized that these behaviours in turn depend upon the level of training, i.e. one would not have the same expectations of a first year resident as the resident nearing completion of training. This led to the conclusion that performance benchmarks must be established. Therefore, the curriculum requires a sequence of objectives, which specify the expected behaviours of a resident in the role of health advocate at each level. They would progress from easier tasks for the novice residents, such as advocating on the behalf of an individual patient, through to more difficult for those at a senior level (Figure 1b), such as an objective to write a letter to a politician regarding the AIDS pandemic in South Africa. However, it also became apparent that residents enter training with varied life experiences. There are those who may have significant experience advocating on a level beyond that of an individual and yet not know how to write a letter advocating for financial support from an insurance company. This led to the development of a model we called the ‘Sliding Scale of Health Advocacy.’ In this model, most residents will enter their training and will have objectives commensurate with learning to advocate at the level of the individual patient and learn about the determinants of health that affect all populations (Figure 1). There is a progression to more specialty specific objectives as the resident proceeds. The resident is expected to know the determinants of health (Figure 2) with particular relevance to their patient population and demonstrate the ability to advocate on their behalf. As the resident proceeds further the expectations will broaden. The sliding scale represents that: (1) not all residents will follow the process in strict sequence and (2) that although residents will demonstrate more sophisticated skills at a higher leveler of training, there will not ever be a time when the skills required of the easier tasks are no longer desired. This is because the role of Health Advocate is one in which the physician acts on behalf of the individual, who is within the community which in turn is in society. It is artificial to segregate them but better represented as three aspects of the whole (Figure 1).

Evaluation development naturally ensued from the proposed curriculum framework (Table 3). The objectives are articulated as established performance benchmarks. The evaluation is performance based and directly related to the desired outcomes in an appropriate format.

It was evident in this study that the role of Health Advocate is one of the most complex of the CanMEDs roles. We recognized that the attributes of the Health Advocate mirror the qualities required of each of the other individual CanMEDs roles. These qualities are firmly embedded in the role of Health Advocate. We propose that competency in Health Advocacy be viewed as a set of building blocks (Figure 3), reflecting growing complexity of these skills and the building of a knowledge, skill, and attitude set necessary to be a successful Health Advocate.

Using this curriculum framework, the educator may now put these into operation for their specific specialties using existing resources, such as Society and Specialty position papers and policies. This study also reaffirmed the previous recommendation of our faculty focus groups for faculty development in teaching health advocacy (Verma et al. 2005).

Acknowledgement

This work is supported by a grant from the Royal College of Physicians and Surgeons of Canada.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article

Additional information

Notes on contributors

Leslie Flynn

Dr LESLIE FLYNN is currently the Associate Dean of Postgraduate Medical Education at Queen's University and has served as Director of Continuing Medical Education and the Postgraduate Program Director in Psychiatry. She is a Psychiatrist whose research areas are medical education including inter-professional education and physician health.

Sarita Verma

Dr SARITA VERMA is currently the Vice Dean of Postgraduate Medical Education at the University of Toronto; Postgraduate Dean from 1998 to 2003 and Associate Dean Medical Education from 2003–2005 at Queen's University. She is a family physician whose areas of research are in international health, inter-professionalism, and medical education.