Abstracts
Abstract
Introduction: Although the CanMEDS framework sets the standard for Canadian training, health advocacy competence does not appear to factor heavily into high stakes assessment decisions. Without forces motivating uptake, there is little movement by educational programs to integrate robust advocacy teaching and assessment practices. However, by adopting CanMEDS, the Canadian medical education community endorses that advocacy is required for competent medical practice. It’s time to back up that endorsement with meaningful action. Our purpose was to aid this work by answering the key questions that continue to challenge training for this intrinsic physician role.
Methods: We used a critical review methodology to both examine literature relevant to the complexities impeding robust advocacy assessment, and develop recommendations. Our review moved iteratively through five phases: focusing the question, searching the literature, appraising and selecting sources, and analyzing results.
Results: Improving advocacy training relies, in part, on the medical education community developing a shared vision of the Health Advocate (HA) role, designing, implementing, and integrating developmentally appropriate curricula, and considering ethical implications of assessing a role that may be risky to enact.
Conclusion: Changes to assessment could be a key driver of curricular change for the HA role, provided implementation timelines and resources are sufficient to make necessary changes meaningful. To truly be meaningful, however, advocacy first needs to be perceived as valuable. Our recommendations are intended as a roadmap for transforming advocacy from a theoretical and aspirational value into one viewed as having both practical relevance and consequential implications.
Résumé
Introduction : Bien que le référentiel CanMEDS établisse les normes en matière de formation et de pratique médicale au Canada, la compétence de promotion de la santé (PS) ne semble pas peser lourd aux étapes décisives du continuum de la formation médicale. En l’absence de facteurs incitatifs, les programmes de formation sont peu enclins à intégrer des pratiques solides d’enseignement et d’évaluation en matière de PS. Un système de soins de santé marqué par l’iniquité appelle pourtant des efforts de sensibilisation. En adoptant le référentiel CanMEDS, le milieu canadien de l’éducation médicale a reconnu que la PS est nécessaire à la pratique compétente de la médecine. Il est temps que cet engagement soit traduit en actions concrètes.
Méthodes : Employant une méthode d’analyse critique, nous avons examiné les écrits qui peuvent éclairer les obstacles à l’évaluation sérieuse de la PS et avons formulé des recommandations. L’examen a été effectué de manière itérative en cinq étapes : définition de la question de recherche, recherche documentaire, évaluation et sélection des sources, et analyse des résultats.
Résultats : L’amélioration de la formation en matière de PS suppose, entre autres, que le milieu de l’éducation médicale s’attèle aux enjeux clés suivants : 1) l’élaborer une vision commune de la PS, 2) concevoir, mettre en œuvre et intégrer des programmes d’études évolutifs et 3) considérer les répercussions éthiques de l’évaluation d’un rôle qui comporte une part de risque.
Conclusion : Le manque de visibilité et d’attention accordées à la PS dans la formation amène de nombreux apprenants à se demander si leur compétence en la matière compte vraiment. Nous estimons que la promotion de la santé est au cœur des soins centrés sur le patient. Nous lançons donc un appel à redoubler nos efforts collectifs pour faire passer la PS du statut de simple aspiration et de valeur théorique à celui d’une valeur ayant une pertinence et des incidences concrètes.
Download the article in PDF to read it.
Download
Appendices
Bibliography
- Hubinette MM, LaDonna KA, Scott I, van der Goes T, Kahlke R. When I say…health advocacy. Med Educ. 2022;56(4):362–4. https://doi.org/10.1111/medu.14728.
- Frank JR, Snell LS, Sherbino J, eds. CanMEDS 2015 Physician Competency Framework. Ottawa: The Royal College of Physicians and Surgeons of Canada. 2015:11-12. http://canmeds.royalcollege.ca/en/framework
- Shaw E, Oandasan I, Fowler N, eds. CanMEDS-FM 2017: A Competency Framework for Family Physicians across the Continuum. Mississauga, Canada; 2017. https://www.cfpc.ca/CFPC/media/Resources/Medical-Education/CanMEDS-Family-Medicine-2017-ENG.pdf
- Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements. Effective July 1, 2013; 2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf.
- Chou S, Cole G, McLaughlin K, Lockyer J. CanMEDS evaluation in Canadian postgraduate training programmes: Tools used and programme director satisfaction. Med Educ. 2008;42(9):879-886. https://doi.org/10.1111/j.1365-2923.2008.03111.x
- Hakim J, Black A, Gruslin A, Fleming N. Are Canadian postgraduate training programs meeting the health advocacy needs of obstetrics and gynaecology residents? J Obstet Gynaecol Can. 2013;35(6):539-546. https://doi.org/10.1016/S1701-2163(15)30913-0
- Binnendyk J, Pack R, Field E, Watling C. Not wanted on the voyage: Highlighting intrinsic CanMEDS gaps in Competence by Design curricula. Can Med Educ J. 2021;12(4):39–47. https://doi.org/10.36834/cmej.70950
- Stutsky BJ, Singer M, Renaud R. Determining the weighting and relative importance of CanMEDS roles and competencies. BMC Res Notes. 2012;5(1):354. https://doi.org/10.1186/1756-0500-5-354
- LaDonna KA, Watling CJ, Cristancho SM, Burm S. Exploring patients’ and physicians’ perspectives about competent health advocacy. Med Educ. 2021;55(4):486–495. https://doi.org/10.1111/medu.14408
- Hubinette MM, Scott I, van der Goes T, Kahlke R. Learner conceptions of health advocacy: ‘Going above & beyond’ or ‘kind of an expectation.’ Med Educ. 2021;55(8):933–941. https://doi.org/10.1111/medu.14526
- Hubinette MM, Ajjawi R, Dharamsi S. Family physician preceptors’ conceptualizations of health advocacy: Implications for medical education. Acad Med. 2014;89(11):1502–1509. https://doi.org/10.1097/ACM.0000000000000479
- Arya N. Advocacy as medical responsibility. CMAJ. 2013;185(15):1368. https://doi.org/10.1503/cmaj.130649
- Gallagher S, Little M. Doctors on values and advocacy: A Qualitative and evaluative study. Health Care Anal. 2017;25(4):370-385. https://doi.org/10.1007/s10728-016-0322-6
- LaDonna KA, Field E, Watling C, Lingard L, Haddara W, Cristancho SM. Navigating complexity in team-based clinical settings. Med Educ. 2018;52(11):1125–1137. https://doi.org/10.1111/medu.13671.
- Endres K, Burm S, Weiman D, et al. Navigating the uncertainty of health advocacy teaching and evaluation from the trainee's perspective. Med Teach. 2022;44(1):79-86. https://doi.org/10.1080/0142159X.2021.1967905.
- Medical Council of Canada. Health Advocate. 2022. Available from: https://mcc.ca/objectives/health-advocate/
- The Royal College of Physicians and Surgeons of Canada. CanMEDS Guide. 2022. Available from: https://canmeds.royalcollege.ca/guide?role=HA&key-competency
- Logiudice AB, Sibbald M, Monteiro S, et al. Intrinsic or invisible? An audit of CanMEDS roles in entrustable professional activities. Acad Med. 2022;97(8):1213–8. https://doi.org/10.1097/ACM.0000000000004731.
- Martin D, Hum S, Han M, Whitehead C. Laying the foundation: Teaching policy and advocacy to medical trainees. Med Teach. 2013;35(5):352–358. https://doi.org/10.3109/0142159X.2013.770453.
- McDonald M, Lavelle C, Wen M, Sherbino J, Hulme J. The state of health advocacy training in postgraduate medical education: a scoping review. Med Educ. 2019;53(12):1209-1220. https://doi.org/10.1111/medu.13929
- Luft LM. The essential role of physician as advocate: How and why we pass it on. Can Med Educ J. 2017;8(3):e109-e116. https://doi.org/10.36834/cmej.36925
- Norcini J, Anderson B, Bollela V, et al. Criteria for good assessment: Consensus statement and recommendations from the Ottawa 2010 Conference. Med Teach. 2011;33(3):206-214. https://doi.org/10.3109/0142159X.2011.551559
- Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR, Collaborators for the IC. The role of assessment in competency-based medical education. Med Teach. 2010;32(8):676-682. https://doi.org/10.3109/0142159X.2010.500704
- Scott IM. Beyond ‘driving’: the relationship between assessment, performance and learning. Med Educ. 2020;54(1):54–59. https://doi.org/10.1111/medu.13935
- The Royal College of Physicians and Surgeons of Canada. CanMEDS 25: Ensuring value for years to come. 2022. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-25-e
- Grant MJ, Booth A. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91-108. https://doi.org/10.1111/J.1471-1842.2009.00848.X
- Dixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6(1):1-13. doi:10.1186/1471-2288-6-35/TABLES/2
- Depraetere J, Vandeviver C, Keygnaert I, Beken T vander. The critical interpretive synthesis: an assessment of reporting practices. Int J Soc Res Methodol. 2021;24(6):669-689. https://doi.org/10.1080/13645579.2020.1799637
- Kahlke R, Lee M, Eva K. Critical reviews in health professions education research. J Grad Med Educ. Forthcoming
- Norman G, Eva KW. Quantitative research methods in medical education. In: T. Swanwick, ed. Understanding Medical Education: Evidence, Theory and Practice. John Wiley & Sons; 2014: 349–369.
- Dharamsi S, Ho A, Spadafora SM, Woollard R. The physician as health advocate: translating the quest for social responsibility into medical education and practice. Acad Med. 2011;86(9):1108-1113. https://doi.org/10.1097/ACM.0B013E318226B43B
- Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med. 2010;85(1):63-67. https://doi.org/10.1097/acm.0b013e3181c40d40
- Lax Y, Braganza S, Patel M. Three-tiered advocacy: using a longitudinal curriculum to teach pediatric residents advocacy on an individual, community, and legislative level. J Med Educ Curric Dev. 2019;6. https://doi.org/10.1177/2382120519859300
- Dobson S, Voyer S, Regehr G. Perspective: Agency and activism: Rethinking health advocacy in the medical profession. Acad Med. 2012;87(9):1161-1164. https://doi.org/10.1097/acm.0b013e3182621c25
- Meili R, Buchman S, Goel R, Woollard R. Social accountability at the macro level. Can Fam Physician. 2016;62(10):785-788.
- Flynn L, Verma S. Fundamental components of a curriculum for residents in health advocacy. Med Teach. 2008;30(7): e178-83. https://doi.org/10.1080/01421590802139757
- Law M, Leung P, Veinot P, Miller D, Mylopoulos M. A qualitative study of the experiences and factors that led physicians to be lifelong health advocates. Acad Med. 2016;91(10):1392-1397. https://doi.org/10.1097/acm.0000000000001316
- Mu L, Shroff F, Dharamsi S. Inspiring health advocacy in family medicine: A qualitative study. Educ Health. 2011;24(1):1-11.
- Howell BA, Kristal RB, Whitmire LR, Gentry M, Rabin TL, Rosenbaum J. A systematic review of advocacy curricula in graduate medical education. J Gen Intern Med. 2019;34(11):2592-2601. https://doi.org/10.1007/s11606-019-05184-3
- Basu G, Pels RJ, Stark RL, Jain P, Bor DH, McCormick D. Training internal medicine residents in social medicine and research-based Health Advocacy: a novel, in-depth curriculum. Acad Med. 2017;92(4):515-520. https://doi.org/10.1097/ACM.0000000000001580
- Knox KE, Lehmann W, Vogelgesang J, Simpson D. Community health, advocacy, and managing populations (CHAMP) longitudinal residency education and evaluation. J Patient-Cent Res Rev. 2018;5(1):45-54. https://doi.org/10.17294/2330-0698.1580
- Oandasan IF, Barker KK. Educating for advocacy: Exploring the source and substance of community-responsive physicians. Acad Med. 2003;78(10): S16-S19. https://doi.org/10.1097/00001888-200310001-00006
- Boroumand S, Stein MJ, Jay M, Shen JW, Hirsh M, Dharamsi S. Addressing the health advocate role in medical education. BMC Med Educ. 2020;20(1):28. https://doi.org/10.1186/s12909-020-1938-7
- Kane MT. Current concerns in validity theory. J Educ Meas. 2001;38(4):319-342. https://doi.org/10.1111/J.1745-3984.2001.TB01130.X
- Kogan JR, Hess BJ, Conforti LN, Holmboe ES. What drives faculty ratings of residents’ clinical skills? The impact of faculty’s own clinical skills. Acad Med. 2010;85(10):S25-S28. https://doi.org/10.1097/ACM.0B013E3181ED1AA3
- Hubinette M, Dobson S, Voyer S, Regehr G. ‘We’ not ‘I’: health advocacy is a team sport. Med Educ. 2014;48(9):895–901. https://doi.org/10.1111/medu.12523
- Heise L, Greene ME, Opper N, et al. Gender inequality and restrictive gender norms: Framing the challenges to health. Lancet. 2019;393(10189):2440-2454. https://doi.org/10.1016/S0140-6736(19)30652-X
- Dielissen P, Bottema B, Verdonk P, Lagro-Janssen T. Attention to gender in communication skills assessment instruments in medical education: a review. Med Educ. 2011;45(3):239-248. https://doi.org/10.1111/j.1365-2923.2010.03876.x
- Mueller AS, Jenkins TM, Osborne M, Dayal A, O’Connor DM, Arora VM. Gender differences in attending physicians’ feedback to residents: a qualitative analysis. J Grad Med Educ. 2017;9(5):577-585. https://doi.org/10.4300/JGME-D-17-00126.1
- Sabin JA, Nosek BA, Greenwald AG, Rivara FP. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009;20(3):896-913. https://doi.org/10.1353/HPU.0.0185
- Sharda S, Dhara A, Alam F. Not neutral: Reimagining antiracism as a professional competence. CMAJ. 2021;193(3):E101-E102. https://doi.org/10.1503/CMAJ.201684
- Hafferty F. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403-407. https://doi.org/10.1097/00001888-199804000-00013
- Sukhera J, Watling CJ, Gonzalez CM. Implicit bias in health professions: From recognition to transformation. Acad Med. 2020;95(5):717-723. https://doi.org/10.1097/ACM.0000000000003173