Advocating for the advocate

In 1849, German pathologist Rudolf Virchow, regarded as the father of modern pathology, released a report that stunned the medical establishment. His report, commissioned by the Prussian government to investigate a typhus epidemic in Upper Silesia, a poor rural area of ethnic Poles, advocated 4 “radical” recommendations: the introduction of Polish as an official language, democratic self-government, separation of church and state, and the creation of agricultural cooperatives.¹

More than 150 years later, physicians such as Paul Farmer, an advocate of liberation theology and pioneer of community-based tuberculosis treatment, and Canadian physician James Orbinski, recipient of the 1999 Nobel Peace Prize as President of Médecins Sans Frontières, continue this tradition. Physicians can have a transformational effect on the health of a society without the use of stethoscopes or scalpels. But as residents, do our training programs prepare us for such potential?

In June 2009, the College of Family Physicians of Canada adopted health advocate as 1 of the 7 domains of the CanMEDS–Family Medicine Physician Competency Framework, defined as “family physicians responsibly us[ing] their expertise and influence to advance the health and well-being of individual patients, communities, and populations.”² Postgraduate programs across the country have now adopted this competency. Although previously encompassed in the 4 principles of family medicine,³ the role of advocate has never before been so explicitly articulated. As family physicians we see patients as they live their lives, deal with problems of health service access, and suffer the economic and social consequences of poor health. We gain a broader perspective on what health means and are in an ideal position to advocate for systemic change. Yet in medical education, residents are frequently left wondering how they might best hone the skills necessary to effect change. Similarly, educators struggle to impart advocacy knowledge and training creatively and effectively.

In the face of such a challenge, many residents wonder how we can be effective advocates when there is an apparent training gap. How often do departments encourage trainees to pursue advocacy opportunities and offer protected time to do so? Do we identify community problems and link them with action? We are resources to our communities, but in our academic departments are we involved with campaigns to remove vending machines from schools? Without a doubt there are residents acting as advocates, but is this cultivated in residency? Recognizing such skills in performance evaluations and integrating advocacy opportunities into residency is vital to developing this competency and to promoting a broader culture of advocacy.

Internationally, training programs are using various strategies to foster expertise in advancing the health and well-being of communities. In Wisconsin, in the St Luke’s Family Practice Program, each resident is expected to develop a community health improvement project. Recognizing literacy as a contributor to poverty and poor health, one graduate has implemented an intervention in which residents read with their pediatric patients during each visit and give them a book to take home.⁴ The Latin American School of Medicine in Cuba has a curriculum focused on the needs of the vulnerable. Physician educators act as role models for students and draw on their experiences serving marginalized communities in Latin America and Africa. Students are also exposed to population health principles and prevention, with 17% of all in-class hours dedicated to public health.⁵

In Canada, an early leader is the pediatrics program at the University of Toronto in Ontario. Residents have undertaken community child advocacy projects generated through literature reviews and focus groups with teachers and parents. Workshops about nutrition and first aid serve as outcomes.⁶ Medical students at Queen’s University in Kingston, Ont, host an annual Health and Human Rights conference featuring discussions on the future of Canadian health care and the abuse of human rights.⁷ Institutional change is in its early stages, and although it might be tempting to stop if accreditors are satisfied, such change cannot stop. Advocacy should not be deemed a side project. Trainees will develop skills through lived experience, working for change on causes they feel personally connected to. By creating space to do such work in residency, the opportunity for professional growth through the support of mentors and peers is immense.

Although it is true that not every trainee exposed to an experience in advocacy will be compelled to continue in the future, it is important to recognize the potential of those who do. Having the resources, dedicated faculty, and commitment to high-quality programs for those who choose to build such skills can create a generation of physician leaders in the tradition of Rudolph Virchow. Finding leaders with the vision to lead change is a challenge every residency program must meet. Empowered with the right tools and motivation to strengthen communities, we can train the leaders today who will be at the edge of social change tomorrow.

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