Abstract
Background
Although internal medicine (IM) physicians accept public advocacy as a professional responsibility, there is little evidence that IM training programs teach advocacy skills. The prevalence and characteristics of public advocacy curricula in US IM residency programs are unknown.
Objectives
To describe the prevalence and characteristics of curricula in US IM residencies addressing public advocacy for communities and populations; to describe barriers to the provision of such curricula.
Design
Nationally representative, web-based, cross-sectional survey of IM residency program directors with membership in an academic professional association.
Participants
A total of 276 IM residency program directors (61%) responded between August and December 2022.
Main Measurements
Percentage of US IM residency programs that teach advocacy curricula; characteristics of advocacy curricula; perceptions of barriers to teaching advocacy.
Key Results
More than half of respondents reported that their programs offer no advocacy curricula (148/276, 53.6%). Ninety-five programs (95/276, 34.4%) reported required advocacy curricula; 33 programs (33/276, 12%) provided curricula as elective only. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous; experiential learning in required curricula was low (23/95, 24.2%) compared to that in elective curricula (51/65, 78.5%). The most highly reported barriers to implementing or improving upon advocacy curricula (multiple responses allowed) were lack of faculty expertise in advocacy (200/276, 72%), inadequate faculty time (190/276, 69%), and limited curricular flexibility (148/276, 54%).
Conclusion
Over half of US IM residency programs offer no formal training in public advocacy skills and many reported lack of faculty expertise in public advocacy as a barrier. These findings suggest many IM residents are not taught how to advocate for communities and populations. Further, less than one-quarter of required curricula in public advocacy involves experiential learning.
Supplementary Information
The online version contains supplementary material available at 10.1007/s11606-024-08753-3.
KEY WORDS: physician advocacy, graduate medical education, curriculum, professionalism, survey study
INTRODUCTION
As clinicians, internal medicine (IM) physicians routinely advocate for individual patients. As trusted professionals, IM physicians also advocate for the health of communities and populations. This public advocacy role is both an important means to promoting health and health equity and a professional obligation. For example, organizations like the American Board of Internal Medicine (ABIM), the American College of Physicians (ACP), and the American Medical Association (AMA) regard public advocacy as a doctor’s duty.1–3 Practicing IM physicians in the United States also view public advocacy as a professional responsibility; in a survey of US physicians, collective advocacy for the public’s health was rated as important by 90% of respondents overall and by 97% of IM respondents.4 In medical education, IM residency program requirements from the Accreditation Council for Graduate Medical Education (ACGME) declare that residents must demonstrate competence in advocacy for patients and for optimal patient care systems.5
Although physicians accept public advocacy as a professional responsibility, emerging research suggests few physicians-in-training are taught advocacy skills. In undergraduate medical education (UME), accreditation standards from the Liaison Committee on Medical Education (LCME) exclude advocacy or health policy training and few US medical schools teach advocacy skills in required coursework.6,7 In graduate medical education (GME), the ACGME common program requirements for all specialties endorse a general commitment to advocacy.8 Despite this, published advocacy curricula in surgical specialties are sparse.9–11 In primary care–oriented fields, where publications on advocacy curricula are most common, a recent cross-sectional analysis of family medicine residency programs showed that 37% reported mandatory advocacy curricula.12 In psychiatry residency programs, seven of 236 US programs provided any advocacy training.13 In pediatrics, where ACGME program requirements include specific training in advocacy skills, advocacy curricula for communities and populations are highly prevalent.14
To our knowledge, no studies describe the prevalence and characteristics of curricula in IM residencies addressing public advocacy for communities and populations. Our study aims to address this gap in the literature by describing the prevalence and characteristics of public advocacy curricula in IM residencies. Following Earnest et al., we define advocacy as “action by a physician to promote social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being.”15 Examples of public advocacy curricula include lectures on how to communicate with policymakers or workshops on how to write an op-ed. Our secondary purpose was to identify barriers to the provision of public advocacy curricula in IM residency programs.
METHODS
Study Design, Setting, and Participants
This was a national cross-sectional survey of IM residency program directors (PDs) conducted by the Association of Program Directors in Internal Medicine (APDIM) of the Alliance for Academic Internal Medicine (AAIM). The APDIM Survey and Scholarship Committee oversees and fields an annual, research survey of IM residency PDs. The 2022 Annual Survey was disseminated to IM PDs from all 456 APDIM member residency programs. At the time of the study, APDIM member programs represented 80.0% (456/571) of US IM residency programs with (a) “initial” or “continued” ACGME accreditation status prior to the most recently completed academic year (AY), and (b) one or more filled IM resident positions as of that AY. Those study criteria ensure that the most recently accredited programs, which would not yet be capable of providing representative responses, are excluded from the survey population.
Survey Development and Data Collection
The 2022 APDIM survey contained multiple thematic sections. Survey domains and questions for the thematic section on advocacy curricula, developed by study authors (JRB, KM, SSD, TLH) on the basis of a literature review of advocacy curricula in GME programs, were designed to elicit details of each program’s advocacy curricula and perceived barriers to the provision of advocacy curricula. To improve upon question, item, and construct validity, the authors reviewed and addressed peer-review-style comments from the APDIM Survey Committee (consisting of 12 members with extensive experience as residency program or associate program directors). The authors then revised the survey instrument, after which a second review was conducted by the committee. After the authors further revised the questions, MK programmed the instrument in the Qualtrics Surveys platform (Qualtrics, Version XM). Subsequently, the web survey was pilot-tested by the survey committee and by seven APDIM members (blinded to the authors) with expertise in GME, for functionality and to further strengthen construct validity. The final survey questions are included in the Appendix. The study was deemed exempt by Pearl IRB. The survey launched on August 16, 2022, included six email reminder messages to non-respondents, and closed on December 13, 2022. The email invitation and all email reminders included opt-out links for individuals who did not wish to participate in the survey.
Statistical Analysis
Statistical analysis was conducted in Stata 16.1 SE (StataCorp), SPSS version 29, and R version 4.1.3 (MK and BD, respectively). Before de-identifying the final responses, the study dataset was appended by MK with residency program data (using ACGME program identification numbers) from external sources, including the US Census Bureau for geographic regions.16 Characteristics such as number of approved resident positions were obtained from the ACGME Accreditation Database System (Public) online.17 Program type and other characteristics were obtained through a data license provided by the AMA.18 ABIM rolling 3-year residency pass rates were provided by ABIM as a courtesy to AAIM.19 Dataset transfers from AMA and ABIM were conducted via secure, 256-bit-encrypted web transfer platforms. Statistical significance was designated with an alpha level set to p ≤ 0.05.
To assess how closely the survey respondents represented the complete survey population, we tested for possible under- or over-representation using key residency program characteristics that most closely described the population (Table 1). Those characteristics were identified using a probit regression model (which is appropriate when multiple independent variables might be interrelated) with “respondent status: yes” as the dependent variable. The model accounted for likelihood of responding to the survey (e.g., programs accredited within the past 6 years are somewhat less likely to respond and are slightly less representative, due to the limited number of cycles for which they have been training residents). We tested for associations between categorical variables using the adjusted Wald (Pearson) chi-square test of association (with one degree of freedom). Due to the non-normal, nonparametric distribution of continuous variables in our dataset and unequal group sizes between respondents and non-respondents, we used a K-sample equality-of-medians test (continuity-corrected Pearson chi-square) to compare dichotomous variables by groups, reporting medians and interquartile ranges [IQRs] and means and standard deviations.
Table 1.
Essential Characteristics of Responding and Non-responding Internal Medicine Residency Programs: 2022 APDIM Annual Survey of US Internal Medicine Residency Program Directors
| Respondents (n = 276) | Non-respondents (n = 180) | Total (n = 456) | ||
| No. (column %) | No. (column %) | No. (column %) | p-value1 | |
| Program type (AMA-FREIDA) | ||||
| University-based | 97 (35) | 40 (22) | 137 (30) | 0.07 |
| Community-based | 46 (17) | 37 (21) | 83 (18) | 0.32 |
| Community-based, university-affiliated | 129 (47) | 100 (56) | 229 (50) | 0.20 |
| Military-based | 4 (2) | 3 (2) | 7 (2) | 0.90 |
| Census region (US Census Bureau)2 | ||||
| Midwest | 55 (20) | 39 (22) | 94 (21) | 0.69 |
| Northeast | 81 (29) | 56 (31) | 137 (30) | 0.78 |
| South | 98 (36) | 56 (31) | 154 (34) | 0.54 |
| West | 42 (15) | 29 (16) | 71 (16) | 0.84 |
| Offers preliminary positions: yes (AMA-FREIDA) | 201 (73) | 122 (68) | 323 (71) | 0.22 |
| VA affiliation: yes (ACGME) | 101 (37) | 60 (33) | 161 (35) | 0.51 |
| Accreditation status (ACGME) | ||||
| Continued or continued with warning | 260 (94) | 164 (91) | 424 (93) | 0.25 |
| Initial or initial with warning | 16 (6) | 16 (9) | 32 (7) | |
| Mean (SD), median (IQR) | Mean (SD), median (IQR) | Mean (SD), median (IQR) | p-value3 | |
| Program size: no. ACGME approved positions (AY 2021–2022) | 68.5 (42.5), 54 (61) | 59.0 (38.0), 45.5 (36) | 64.8 (40.4), 50 (47) | 0.13 |
| ABIM cumulative pass rate 2019–2021 (%); n = 254, n = 154, n = 408 | 90.5 (10.7), 93 (9) | 88.4 (12.0), 92 (10) | 89.7 (11.2), 93 (10.5) | 0.08 |
| Program director tenure (years) as of 2022 (ACGME) | 5.2 (5.5), 4 (6) | 5.8 (5.8), 4 (6) | 5.4 (5.6), 4 (7) | 0.96 |
| Program original accreditation year (ACGME) | 1976.9 (24.8), 1967.5 (45.5) | 1986.4 (26.8), 1980 (58) | 1980.6 (26.0), 1972 (57) | 0.07 |
| Average USMLE step 1 score (FREIDA); n = 208, n = 141, n = 349 | 211.8 (11.0), 210 (20) | 214.2 (12.7), 215 (22) | 212.7 (11.7), 215 (20) | 0.13 |
APDIM, Association of Program Directors in Internal Medicine; AMA-FREIDA, American Medical Association Residency and Fellowship Database; ACGME, Accreditation Council for Graduate Medical Education; ABIM, American Board of Internal Medicine; VA, Veterans Affairs; USMLE, United States Medical Licensing Examination; IQR, interquartile range; SD, standard deviation
The table displays variables that explained the most survey population variance and likelihood of responding to the survey: probit regression model (dependent variable: respondent status [yes/no]) with robust standard errors; pseudo R2 = 0.56
1 Adjusted Wald (Pearson) test of association (one degree of freedom) used to compare categorical variables
2 Collapses two programs from US territories into “West,” due to small cell sizes/data confidentiality
3 K-sample equality-of-medians test (continuity-corrected Pearson chi-square) [mean and SD reported for illustration]
Summary statistics in our analysis included frequencies and percentages for categorical variables and measures of central tendency or dispersion (e.g., mean, median, standard deviation, IQR) for continuous variables. Due to survey conditional logic or item non-response, denominators for certain questions did not sum to the total number of survey respondents. Descriptive statistics were used to summarize the reported prevalence, scope, structure, and content of advocacy education in IM residencies. We performed multiple logistic regression models with required advocacy programs (yes/no), elective advocacy programs (yes/no), and any advocacy program (yes/no) as the dependent variables to identify possible explanatory factors associated with advocacy education in IM residency programs including program size, type, and region, and age and gender of the PD. Program size was measured by the number of ACGME approved positions. Program region was derived from the US Census Bureau’s Census Region classifications into Northeast, Midwest, West, and South and type was dichotomized into “University-based programs” and “All other program types.”
RESULTS
The survey response rate was 61.0% (276 of 456 survey-eligible PDs). There were no statistically significant differences between respondents and non-respondents based on characteristics that closely described the complete survey population (Table 1). Although university-based programs were slightly over-represented (35.1% among responding programs; 22.2% among non-responding programs), that difference was not statistically significant (p = 0.074). The median ACGME original accreditation year for responding programs was slightly lower than that of non-responding programs, but that difference was not statistically significant: 1967.5 (IQR, 45.5) and 1980 (IQR, 58), respectively (p = 0.065).
Survey respondents were 53.3% male (n = 147/276) with a median age of 48 years (IQR, 12). More than half of respondents reported that their programs had no advocacy curricula (148/276, 53.6%). Ninety-five programs reported required advocacy curricula (95/276, 34.4%); thirty-three programs reported elective curricula only (33/276, 11.9%). Among the 95 programs with required curricula, 32 reported also offering elective curricula (32/95, 33.4%). Required curricula were most commonly taught longitudinally (72/95, 75.8%); elective curricula were more commonly offered as a single rotation (36/65, 55.4%).
Figure 1 shows that didactic learning (i.e., lectures, seminars) was the most prevalent method of teaching for required advocacy curricula (86/95, 91.0%) and second highest method for elective curricula (40/65, 61.5%). Experiential learning, such as participation in legislative “lobby days” with state or national professional societies, was more common for elective curricula (51/65, 78.5%). Foundational concepts of physician advocacy (i.e., general principles of advocacy, social determinants of health) were the most prevalent topics for required curricula while elective advocacy curricula were more varied.
Figure 1.
Self-reported teaching methods and advocacy topics for required (n = 95) and elective (n = 65) advocacy curricula. A Comparison of teaching methods for required and elective advocacy curricula. B Comparison of advocacy topics for required and elective advocacy curricula.
The most prevalent self-reported barriers to implementing or improving upon advocacy curricula were lack of faculty expertise in advocacy (72%), inadequate faculty time (69%), and limited curricular flexibility (54%). These and other barriers are noted in Fig. 2.
Figure 2.
Reported barriers to teaching advocacy curriculum (n = 276, multiple responses allowed).
University-based programs were more likely to report having any advocacy curriculum than all other program types (63.9% vs 36.1%, p < 0.001). Programs in the top tertile of size (i.e., number of residents) were more likely to report having an elective advocacy program than small programs (37.0% vs 10.9%, p < 0.001). In logistic regression models accounting for program size, Census region, program type, and PD age and gender, region became a significant factor for the presence of any advocacy curricula. Compared to programs in the Northeast region, programs in the Midwest region were less likely to have a required curriculum (OR, 0.42; 95% CI, 0.19–0.91) and programs in the West region were more likely to have an elective curriculum (OR, 2.82; 95% CI, 1.12–7.18). No significant differences were found for other regions. The odds of having an elective advocacy curriculum were 3.74 times higher for university-based programs compared to all other program types (OR, 3.74; 95% CI, 1.64–8.79) but no significant differences were shown for required curricula.
DISCUSSION
To our knowledge, this is the first cross-sectional study describing characteristics of public advocacy curricula in IM residency programs. Our data show that more than half of PDs reported having no advocacy curricula in their IM residency programs; only 34% of PDs reported having required curricula. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous. The prevalence of experiential learning in required curricula was low. These results are significant because they suggest that few IM residency programs teach skills in advocacy for communities and populations, despite IM physician’s agreement on the importance of public advocacy. The results are also important because they add to a growing body of literature suggesting that public advocacy skills are not commonly taught in GME.
In addition to our primary findings, we found that barriers to implementing or improving public advocacy curricula in IM residency programs included lack of faculty expertise in advocacy, lack of faculty time, lack of time in resident curricula, and lack of curricular resources to teach public advocacy for communities and populations. We also found that university-based IM residency programs were more likely to offer curricula in public advocacy and that larger programs were more likely than smaller programs to offer elective curricula. These findings add important context to our understanding of facilitators and barriers to providing advocacy curricula in IM residency programs.
The heterogeneity of curricular content, structure, and teaching methods of public advocacy curricula in IM programs suggests a lack of consensus among IM programs on the topics to include in public advocacy curricula and how to teach them. Comparisons between required and elective curricula in our study highlight this lack of consensus. For example, legislative advocacy skills were taught in 24% of required curricula compared to 68% of elective curricula. Similarly, advocacy projects were a method of instruction in 12% of required curricula compared to 49% of elective curricula. These findings on curricular heterogeneity are consistent with data from UME and GME studies of public advocacy curricula, suggesting that the lack of consensus on curricular content for public advocacy training may be pervasive in US medical education.7, 9, 10, 20 Pediatrics residency programs, which teach to shared curricular objectives at a high rate, represent an exception to this trend.14 Two factors likely explain the outlier data from pediatric residencies. First, the ACGME Pediatrics Resident Review Committee (RRC) created program requirements with explicit expectations for advocacy training.21 Second, the American Academy of Pediatrics (AAP) directly supported residency programs in the development and implementation of advocacy curricula.14,22, 23 Analogous developments in IM residencies may improve the shared understanding of what to include in public advocacy curricula and how to teach it. Further, clearly defining advocacy standards and expectations at the level of ACGME common program requirements holds the promise of engendering changes to advocacy training for all ACGME specialties.
Although PDs reported varied teaching methods for public advocacy curricula in our study, research shows that experiential learning is the most effective method of instruction in advocacy education.24 According to experiential learning theory, learning is most effective when based in experiences and reflection on those experiences.25 In advocacy education, studies have found that lectures and role modeling alone do not prepare physicians for their advocacy role; that physicians-in-training value advocacy training through interactive experiences; and that direct experiences are associated with competence in advocacy and engagement in advocacy after completing residency.24,26–29 Although experiential learning is preferable in public advocacy education, it will require additional resources including time, funding, and access to diverse patient populations and community organizations. In settings where such resources are limited, experiential learning may not be feasible for all IM residents. This may explain the higher prevalence of experiential learning in elective compared to required curricula in our study. Further research is needed to understand the barriers and facilitators to experiential learning experiences in IM residencies.
Seventy-two percent of survey respondents reported lack of faculty expertise in advocacy as a barrier to the provision of public advocacy curricula in their IM residency programs, suggesting many teaching faculty in IM residencies themselves lack public advocacy skills. This finding has not been reported to this degree in prior studies; however, it coincides with qualitative evidence that practicing physicians lack formal training in advocacy.28,30 The absence of expertise in public advocacy among teaching faculty might explain the absence of curricula in many IM programs. While many faculty role model advocacy for individual patients, public advocacy for communities and populations involves discrete skill sets requiring specific experiences or training. Creation of advocacy-focused faculty development programs may facilitate greater expertise among IM teaching faculty. Leveraging inter-specialty collaboration between pediatricians and IM educators could also address the lack of advocacy expertise among IM faculty.
Our finding that 69% of PDs perceived lack of faculty time as a barrier to teaching advocacy skills is consistent with prior findings. Among GME programs with published advocacy curricula, competing time demands and conflicts with clinical responsibilities are the most common barriers to providing advocacy training.9 The converse is also true: protected faculty time facilitates the implementation and sustainability of advocacy curricula.9 More research is needed to understand factors contributing to the perception that faculty lack time for advocacy education. One likely factor, long-recognized by academic pediatricians, is the perceived misalignment of advocacy and advocacy education with traditional academic structures, including academic promotion pathways.31,32 The AAP and others have created toolkits and portfolio templates to facilitate greater recognition of advocacy in academic promotion and tenure.33,34 Working with academic medical centers to increase recognition of the value of advocacy and its alignment with the missions of academic medical centers may facilitate prioritization of advocacy education against competing demands.34,35
Regression analysis of our data showed that university-based IM residency programs were more likely to offer any curricula in public advocacy and that larger programs were more likely than smaller programs to offer elective curricula. These results suggest that smaller, non-university-based programs may face additional barriers to providing public advocacy curricula or that the barriers we have identified are more concentrated in these programs. Fostering relationships with IM professional societies to directly support advocacy education in IM residencies with shared, nationally developed resources—much like the AAP supported training for pediatrics residencies—could improve the availability of curricular resources in all IM residency programs, especially for smaller programs with fewer resources.
Our study has limitations. As others have noted, there is no standardized definition of “advocacy.”9 Survey respondents may have misunderstood the meaning of some questions due to the lack of consensus on the meaning of advocacy; however, we sought to mitigate that misunderstanding by providing multiple references to the definition used in the survey instrument, including examples. Another limitation was the focus on formal education. Our study methodology was not intended to measure advocacy instruction through informal teaching or “hidden” curriculum. Finally, the 61% survey response rate might have resulted in some degree of non-response bias. However, respondents were generally reflective of the underlying population of residency PDs eligible to complete the survey, and the characteristics used to assess the representativeness of the results explained much of the population variance. Further, the relatively high item response rate for most questions suggests that the findings were broadly representative.
In conclusion, 20 years after the ABIM and ACP called for “commitment to…public advocacy on the part of each physician,” we find that IM physicians’ commitment to public advocacy is not broadly supported with specific residency training.1 Our study shows that over half of IM residency programs offer no formal public advocacy curricula. If future IM physicians are to be effective advocates for the health of our communities and populations, this should serve as a call to action to the IM community for greater support of public advocacy training in IM residency programs.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements:
The authors thank Dr. Tom Cooney, Dr. Ben Hoffman, Dr. Ankita Sagar, and Dr. Lainie Yarris for comments on early drafts of the survey instrument and manuscript.
Data Availability
The data that informed this research survey study include a limited number of U.S. internal medicine residency program characteristics that were obtained through a data sharing license granted to the study personnel or through databases that are publicly available for querying but are not the property of the study personnel. As per the license or usage terms designated by the parties that maintain ownership of those data, the study personnel may not transfer or publish datasets that contain that information (identified or de-identified), which is intended for descriptive or comparative analyses of the survey data collected by the study personnel but may not be transferred beyond those personnel.
Declarations:
Conflict of Interest:
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that informed this research survey study include a limited number of U.S. internal medicine residency program characteristics that were obtained through a data sharing license granted to the study personnel or through databases that are publicly available for querying but are not the property of the study personnel. As per the license or usage terms designated by the parties that maintain ownership of those data, the study personnel may not transfer or publish datasets that contain that information (identified or de-identified), which is intended for descriptive or comparative analyses of the survey data collected by the study personnel but may not be transferred beyond those personnel.