Reflections on Piloting a Health Policy and Advocacy Curriculum for Psychiatry Residents

Possibly more than other medical specialties, psychiatrists are made aware of the social determinants of their patient’s health during routine care [1]. Moral injury can occur when clinical care is not addressing the conditions of patients’ housing, work, education, worship, and recreation that ultimately determine their well-being. Identifying the laws, regulations, and institutional procedures that create these social determinants is possible through training in health policy analyses. Action to change policies that interfere with patient and population health requires familiarity with advocacy tools [2]. Advocacy is a proposed solution for moral injury in the healthcare context [3]. As a specialty, Academic Psychiatry is uniquely positioned to provide training in health policy analyses and advocacy [4]. By developing psychiatry residents’ advocacy skills, they are better prepared to address the social factors impacting patient health, thereby reducing the burden of moral injury threatening the healthcare workforce. This manuscript describes piloting the development of an elective health policy and advocacy seminar for psychiatry residents. The curriculum was created to introduce residents to health policy analyses and advocacy to improve their patient’s health and increase their own sense of agency as physicians.

Advocacy for health policy is essential to the professional identity of psychiatrists. That is the premise of the recently published American Psychiatric Association book: A Psychiatrist’s Guide to Advocacy [2]. Unfortunately, formal health policy and advocacy training are atypical in post-graduate psychiatry education [5]. Nor are the specific health policy metrics defined by the Accreditation Council for Graduate Medical Education [6], which recommends that residents develop competency in advocacy for quality care of their patients.

The lack of standardized curricula is a barrier to the broader dissemination of resident advocacy training. Uniform coursework for psychiatry resident advocacy training is not the recommended approach. Instead, the advocacy curriculum requires tailoring to the local context, considering the training programs’ “unique culture, identity, and other qualities including strengths and weaknesses. Regional political and geographical constraints or advantages should play a role, too…” ([2], p. 155). Because of this need for custom curricula, more representation is needed in the academic literature (for review, see [7]) documenting psychiatry health policy and advocacy training.

Course Participants

The course was offered during August 2021 as an elective to psychiatry residents in post-graduate years 2 through 4. This 4-week course met weekly, for 4 h, every Tuesday afternoon. Residents were eligible to participate in elective coursework who scored ≥ 25 percentile on the Psychiatry Resident-In-Training Examination® (PRITE) [8] the prior year. Of the 45 residents eligible for elective coursework, 12 enrolled in this course, while the remainder enrolled in either other electives or PRITE exam preparation [9].

Curriculum Development

A new elective seminar, Mental Health Policy & Advocacy in Action, was created to (a) orient residents to the significant role public policy plays in clinical practice and patient health and (b) introduce skills in advocating for policy change. The learning objectives were to describe how and why health policy and advocacy are relevant to psychiatry; explore current policy issues and initiatives on the national, state, community, and institutional levels; review the legislative process and how professional organizations develop position statements; and identify ways to advocate as a physician. This health policy and advocacy content were not available in other course coursework within this residency training program.

Curriculum design focused on two strategies: didactic learner-centered content and an experiential workshop component. Didactic content focused on orientation to health policy and advocacy, communication strategies for advocacy, professional identity formation, and opportunities for ongoing policy and advocacy after the course. Experiential activities focused on writing and role-playing for advocacy, creation of SMART goals guiding activity after course completion, and presentation on policy analyses and advocacy activity to their cohort. The goals of these sessions were (a) skill development in health policy analyses and approaches to advocacy and (b) formation of advocacy in resident professional identity [2]. An overview of the didactic and experiential course content is presented in Table 1.

Table 1.

Description of course content for a psychiatry resident curriculum on health policy and advocacies

Sessions	Course content
Week 1 Introduction to mental health policy and advocacy	Didactics: overview of the different structural levels of jurisdiction over health policies. Health policy analysis strategies were introduced for identifying allies, opposition, jurisdiction, and policy windows for health policy change
	Experiential: a writing workshop was conducted on health policy analytic approaches to inform the resident selection of health topics
Week 2 Approach to effective communication as physician advocates	Didactics: overview of storytelling techniques as a physician advocate and review of resources for strategic communication. Presentation by our institution’s media relations director
	Experiential: engaged in role play for developing effective communication skills for addressing public media and policy audiences. Residents were provided with a reference guide on how to write a letter to a policymaker, a policy brief, and an Op-Ed
Week 3 Building health policy and advocacy into your career	Didactics: a panel discussion by three senior psychiatrists with significant advocacy accomplishments in changing mental health policy at the institutional, state, and federal levels
	Experiential: residents were provided feedback on their advocacy writing by a psychiatrist with experience in health policy advocacy. Residents began constructing SMART goals for putting advocacy in action for the upcoming academic year
Week 4 Resident presentations and next steps	Didactics: resources were introduced on finding advocacy events to participate in and how to become more involved in health policy activity through professional organizations
	Experiential: residents presented a summary of their health policy analyses, their written advocacy activity, and SMART goals for how they will put advocacy into action. Residents and course directors were debriefed with reflections on the seminar experience and ideas for expanding health policy training and advocacy efforts within the residency training program

Key decisions in the curriculum design process to meet our specific training program and residents’ needs included consideration of the recruitment of a course design and director team experienced in health policy and advocacy, solicitation of buy-in from residency education leadership, advertising for course recruitment, prioritization of content within the course time constraints, the timing of the course within the academic calendar and in relation to state/federal legislative sessions, access of locally recognizable psychiatrists with experiences pertinent for didactic presentations, input from institutional government relations and communications teams, the feasibility of different types of advocacy writing projects, and the essential elements of surveys for course quality improvement. The chapter Education as Advocacy informed the attention to these course design elements [9].

None of the residents entered the course with a health policy topic already identified. Presentations and workshops helped stimulate ideas for resident self-selection of topics for health policy analyses and advocacy activity. Conversations during the initial session focused on identifying their health policy interests, residents’ experiences in advocacy, and barriers experienced in voicing those perspectives. Policy research was conducted after the first session, and all residents identified a topic to advocate for by the second session. Topics ranged from mental health parity and telehealth access to decriminalizing mental illness. Advocacy strategies included publishing op-eds in local newspapers, writing letters to legislators, and joining a health policy subcommittee of a professional organization.

Course Outcomes

In pre- and post-course surveys, residents rated (scale of 0–100%) their motivation, knowledge certainty, and institutional perceptions about advocacy. These ratings were compared using paired-samples (pre-post) t-tests, reporting Hedges’ corrected Cohen’s d and p-values. Reflecting on the resident elective experience and outcomes, the course director’s Lessons learned are described in Table 2.

Table 2.

Lessons learned from piloting a health policy and advocacy curriculum for psychiatry residents

Lessons learned
Meeting residents’ where they are	Conducting a pre-course survey of residents’ backgrounds and reasons for taking the seminar was valuable for tailoring course content. Modeling health policy analyses on topics residents endorsed and methods of advocacy they expressed interest in produced active engagement in course content
Overcoming the “right” answer	Ultimately the resident’s selection of health policy analyses topics and advocacy activities promoted their engagement and motivation. Initially, some residents struggled to overcome seeking what they perceived as the “correct topic” before settling on a personally meaningful one
Modeling professional identity formation	Residents expressed that professional identity development was most impacted by exposure to senior psychiatrists discussing their personal journey in health policy analyses and advocacy to impact change
Post-course communication	Enthusiasm coming out of the course was sustained by personal messages to individual residents throughout the following 12 months to check on their advocacy projects and connect with resources and events. Residents continued to engage in advocacy writing and events
Institutional policy awareness	Despite annual institutional messages on compliance, residents entered the course with a general lack of awareness of policy on engaging policymakers. This awareness increased during the course. Misunderstanding of student and employee policies on lobbying and advocacy has significant implications for institutional tax-exempt status and compliance with state policy

This pilot program data was collected and analyzed for course evaluation and quality improvement. Before analyses of course outcomes, authors sought consideration by the institutional review board, which determined this activity was not regulated research according to US HHS 45 CFR 46 and US FDA 21 CFR 56.

Health Policy Outcomes

Residents expressed confidence in identifying the essential elements of their health policy topics. Residents’ post-course ratings (scale of 0–100%) were high for identifying the target population benefiting from (M = 91.40; SD = 9.73); allies supportive of (M = 79.20; SD = 23.44); opposition to (M = 79.50; SD = 17.72); and the parties of jurisdiction to make (M = 81.10; SD = 16.91) the proposed policy change. Comparison to pre-course ratings was not possible because topics were selected during the course. Residents’ ability to identify their state (6900% change; d = 1.4; p = 0.001) and federal (200% change; d = 0.7; p = 0.037) legislators and how to track a bill (7900% change; d = 1.8; p < 0.001) significantly improved from pre- to post-course ratings.

Advocacy Outcomes

Resident motivation increased in readiness (44% change; d = 1.6; p = 0.006), confidence (55% change; d = 1.3; p = 0.005), and likelihood (40% change; d = 1.1; p = 0.014) of engaging in advocacy based on the course. There was no significant change in the importance (17% change; d = 0.8; p = 0.059) of advocacy, which was interpreted as selection bias among residents who chose to enroll in this elective and small sample size impact on power. Residents’ knowledge of distinguishing advocacy from activism (145% change; d = 1.9; p < 0.001) and lobbying (115% change; d = 1.5; p = 0.001) significantly increased.

Institutional Perception

Residents entered the course with the perception that the institution was moderately supportive of advocacy, and this perception of support significantly increased by the end of the course. Residents were largely unaware of institution policies regarding communications with legislators, and this awareness significantly increased by the post-course ratings. Residents’ perception of institutional support for engaging in advocacy significantly (48% change; d = 1.5; p = 0.006), as did their awareness of institutional policies on advocacy (375% change; d = 2.7; p < .001). 

Course Satisfaction

Residents reported positive ratings of the course. Post-course surveys had high ratings for satisfaction with course content (M = 85.30; SD = 11.97) and course director performance (M = 93.40; SD = 7.89). All the residents agreed or strongly agreed with the following statements: (1) the course fulfilled the stated objectives; (2) the length of the course was appropriate; (3) the speakers were effective at teaching the course content; and (4) remote learning was used effectively.

Timing and Format

The outcomes of this course’s pilot analysis should be interpreted in the context of the time and logistical constraints the course was operating within. The course was offered over 1 month’s time, with four 4-h classes. Class time was split evenly between didactic and experiential content. Recognizing these constraints, course directors emphasized that this course was intended to start residents on their journey and to engender the shared expectations that they continue to engage in health policy analysis and advocacy after the conclusion of the course. Course directors continued to communicate with residents to promote health policy and advocacy events they may participate in after the course.

The online format of the course also likely impacted the learner experience. The course was designed for in-person delivery, but a local surge in COVID-19 cases during July 2021 necessitated a shift to online course delivery. While the didactics and some parts of the experiential components of the course could be adapted, institutional safety protocols were a challenge to the planned interactive learner engagement activities. For example, these restrictions also prevented “Hill visits” to the state legislature for in-person engagement with policymakers. Capital Days are common for training programs like this and are reinforcing for the residents [7]. As an alternative, we presented residents with options for engaging in Hill visits hosted by professional societies. For instance, in May of 2022, the course directors and cohort of learners participated in the American Academy of Child and Adolescent Psychiatry Virtual Legislative Conference [10] meetings with congressional members and staff. Course directors conducted a post-conference debriefing with residents to reflect on their experience and synthesize it with concepts covered in the didactic portion of the seminar. The increased offerings of virtual legislative interactions have the potential to open the process to a broader audience of residents than would have been possible before the pandemic.

Workforce Capability

This pilot elective was designed to provide foundational skills in health policy analyses and instill an interest in using advocacy as another tool for advancing patient and population health. If we are successful in sparking psychiatry residents’ interest in health policy, we can bolster the pipeline of those choosing to “participate in government decision-making that constantly shapes the ways clinicians practice, patients are treated, and mental health care is organized” [11], p. 47. Inspiring residents to pursue more intensive experiences (e.g., Jeanne Spurlock Congressional Fellowship [12]) will expand the workforce’s capability to affect health policy change through advocacy.

This manuscript describes lessons learned in implementing a tailored course on health policy and advocacy for psychiatric residents. This adds to the literature on emerging innovation in psychiatry residency curricula by describing the development of an elective health policy and advocacy seminar. Introducing residents to health policy jurisdiction and its analysis prepares residents to identify policies impacting their patients’ health. Advocacy training prepares residents to act to change policies to improve the conditions of housing, work, education, worship, and recreation that drive their patient’s well-being.

Funding

The authors were supported in their roles as faculty by The University of Texas Health Science Center at San Antonio, San Antonio, TX.

Data Availability

This presentation of data was based on educational records from a residency training course. These data are not available to protect trainees’ privacy under the Family Educational Rights and Privacy Act (FERPA; 20 U.S.C. § 1232g; 34 CFR Part 99).

Declarations

Disclosures

On behalf of all authors, the corresponding author states that there is no conflict of interest.