Grappling with key questions about assessment of the Health Advocate role
DOI:
https://doi.org/10.36834/cmej.73878Abstract
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.
Metrics
References
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
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Kori A LaDonna, Renate Kahlke, Ian Scott, Theresa van der Goes, Maria Hubinette
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Submission of an original manuscript to the Canadian Medical Education Journal will be taken to mean that it represents original work not previously published, that it is not being considered elsewhere for publication. If accepted for publication, it will be published online and it will not be published elsewhere in the same form, for commercial purposes, in any language, without the consent of the publisher.
Authors who publish in the Canadian Medical Education Journal agree to release their articles under the Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 Canada Licence. This licence allows anyone to copy and distribute the article for non-commercial purposes provided that appropriate attribution is given. For details of the rights an author grants users of their work, please see the licence summary and the full licence.
