Advocacy in Action: Medical Student Reflections of an Experiential Curriculum

Abstract

Introduction:

Patient advocacy is a core value in medical education. Although students learn about social determinants of health (SDH) in the pre-clinical years, applying this knowledge to patients during clerkship rotations is not prioritized. Physicians must be equipped to address social factors that affect health and recognize their roles as patient advocates to improve care and promote health equity. We created an experience-based learning curriculum called Advocacy in Action (AiA) to promote the development and application of health advocacy knowledge and skills during an Internal Medicine clerkship rotation.

Methods:

Sixty-six students completed a mandatory curriculum, including an introductory workshop on SDH and patient advocacy using tools for communication, counseling, and collaboration skills. They then actively participated in patient advocacy activities, wrote about their experience, and joined a small-group debriefing about it. Forty-nine written reflections were reviewed for analysis of the impact of this curriculum on student perspectives.

Results:

Written reflections had prominent themes surrounding advocacy skills development, meaningful personal experiences, interprofessional dynamics in patient advocacy, and discovery of barriers to optimal patient care.

Discussion:

AiA is a novel method to apply classroom knowledge of SDH to the clinical setting in order to incorporate advocacy in daily patient care. Students learned about communication with patients, working with interprofessional team members to create better health outcomes, and empathy/compassion from this curriculum. It is important to utilize experiential models of individual patient level advocacy during clerkships so that students can continuously reflect on and integrate advocacy into their future careers.

INTRODUCTION

Patient advocacy and health equity are fundamental values that are linked in medical education. The definition of patient advocacy is the action by a physician, through professional work and expertise, to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being (1). Health equity, is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification (2). Physicians must be equipped to address social factors that affect health and recognize their roles as patient advocates to improve care and promote health equity (3).

Social determinants of health (SDH)—the environmental conditions in which people “are born, grow, live, work, and age,”—account for the majority of negative health outcomes, functioning, and quality of life (2). To achieve health equity, patient advocacy can address differences in SDH, which are the drivers for healthcare disparities in the United States (4). Patient-level advocacy focuses on individuals in the clinical setting with immediate medical or social needs (2).

To prepare for their work as physicians, students require the opportunity to practice advocacy work in direct patient care settings. Despite the educational value of patient-based teaching in the clerkship year, inclusion of SDH in the undergraduate medical education (UME) curriculum remains primarily in pre-clinical years via didactics, case-based instruction, and community engagement projects (5). Given the lack of practical curricular guidance, teaching students how to directly apply advocacy skills to individual patients in clinical settings is challenging (5). Leveraging the impact of experience-based learning theory (6), we addressed this curricular gap by developing and implementing a required experiential curriculum focusing on individual health advocacy in hospitalized patients during an Internal Medicine (IM) clerkship rotation.

Advocacy skills come in many forms, and in this curriculum, we focus on developing patient communication skills, patient education and counseling skills within their social context, and collaborative care skills to achieve better health outcomes. In this hospital system, the individual medical student cannot be alone in advocating for patients; it requires team effort on the part of the residents and attending physicians, as well as the knowledge and expertise of an interprofessional staff (which consists of nurses, case managers, social workers, pharmacists, nutritionists, and rehabilitative therapists). As students are empowered to practice and experience physician advocacy within their clerkships, they may be able to discover where advocacy lies in their professional identity.

METHODS

Setting and participants

Sixty-six medical students rotating on their 8-week inpatient-based, IM clerkship at a tertiary care hospital in San Francisco were required to participate in curriculum during 2018.

Program description

We created a four-part curriculum (Table 2), titled Advocacy in Action (AiA), with specific learning objectives (Table 1) to facilitate student development of patient level advocacy.

Table 2.

Curricular components of the AiA curriculum.

Curricular Component	Activities
1) Introductory workshop	• Faculty-led introductory workshop reviewing social determinants of health and their impact on patient care  • Role-playing about how to ask patients questions related to SDH  • Review of an “advocacy toolkit” with resources and tools to help practice individual advocacy during hospitalization and at time of vulnerable transitions, such as discharge  • Meeting with social workers and case managers to discuss roles and responsibilities in patient advocacy
2) Direct Patient Advocacy	• Students use the skills they obtained from the introductory workshop to advocate for their patients  • Students perform a post-discharge patient follow-up phone call to assess how they are and determine if there were any barriers to care that arose
3) Active Reflection	• Students complete a written reflection focusing on successes, challenges, and lessons learned from the activity
4) Debriefing workshop	• Faculty-led to facilitate reflection of student experiences  • Peer-to-peer sharing of challenges and successes  • Large group sharing of advocacy resources discovered during the rotation  • Large group brainstorm about the role of patient advocacy in their future careers

Table 1.

Learning Objectives for the AiA curriculum

Inquire about and identify SDH that create vulnerability in achieving optimal health for hospitalized patients  • Ask about the SDH that affect patient care in the hospital  • Prioritize the SDH to intervene upon during the hospitalization

Understand the role of interprofessional staff in advocacy within the hospital  • Collaborate with non-physician critical members of the hospital care team (social workers, case managers, nurses, pharmacists, nutritionists, occupational/physical/speech therapists) to act upon SDH that affect patient care

Develop specific advocacy skills to overcome barriers in the hospital setting and ensure successful transitions on discharge  • Acknowledge advocacy practices that can be used for all patients in the future

Reflect on the practice of advocating for patients in the hospital  • Discuss the impact of medical student advocacy on patients  • Consider how to practice advocacy in future career

Recognizing that faculty and residents also needed to support the medical students in practicing patient advocacy, we led a faculty development session and emailed resource guides to equip them with tips on facilitating discussions surrounding patient advocacy during work rounds.

Part 1: Introductory workshop

At the beginning of the rotation, a two-hour faculty-facilitated workshop led by two of the authors covered knowledge and skills needed to advocate for patients in the inpatient setting. We reviewed interview strategies to elicit SDH from patients during admission, and how to address these SDH when approaching interprofessional team members. This review included role-play activity on how to respectfully inquire about SDH in patient encounters and then relay these discussions to other team members during inpatient rounds. We shared an advocacy toolkit—a pocket-sized handout with resources for patient care. This tool kit, informed by advice from social workers and attending physicians versed in patient advocacy within our community, included language interpretation resources, community resources for patients, and communication tips for working with an interprofessional team to act on patient needs. Lastly, students met with a case manager and social worker as a way to understand roles and optimize interprofessional collaboration when addressing SDH-related factors influencing patient health during hospitalization and discharge.

Part 2: Direct patient advocacy

Each student used their advocacy toolkit and guidance from their medical and interprofessional team members to apply their advocacy skills to at least one patient for each admitting cycle (one patient every 3–4 days of their 6-week rotation). After patients were discharged from the hospital, students followed up by phone, asking about how the patient was doing and any challenges faced afterward. Students reviewed their advocacy experience with the medical team to brainstorm solutions together for any barriers that arose.

Part 3: Written reflection

To reflect upon the lessons learned through AiA, students were required to complete a written assignment. Students were asked about the impact of their advocacy work on patients’ well-being, specific skills used, and how they see themselves advocating for patients in the future. The questions also discussed obstacles to patient advocacy and systems challenges. This assignment was deliberately put forth for personal reflection, and was therefore not graded or related to their overall clerkship performance. All students consented to analysis of their reflection.

Part 4: Debriefing workshop

At the end of the clerkship rotation, a faculty-facilitated 1-hour debriefing (delivered by two of the authors) gave students an opportunity to discuss their written reflections with each other after they had finished their assignments. Students shared challenges and lessons learned, community resources, and strategies for individual advocacy that they had learned from others on the medical team.

Curriculum Evaluation

This was an IRB-exempted study reviewed by the UCSF Committee on Human Research, and all identifying information in written reflections were redacted prior to any review from the authors. We conducted a thematic analysis (7) of students’ written reflection assignments to categorize their inquiry of SDH, their perceptions of any successes and challenges related to patient advocacy, new advocacy skills that they intended to apply to future patient care, and tips and resources they had discovered. Three authors (CL, NC, SD) independently reviewed the assignments and used a data-driven (inductive) approach to develop a codebook (7,8). To ensure methodological rigor, all authors met regularly throughout analysis to iteratively refine and define coding categories. Coding disparities were discussed and resolved by negotiated consensus (9). Codes were then grouped into higher order themes.

RESULTS

Written reflections

The thematic analysis of 49 submitted written reflections revealed 12 codes that were nested within the four over-arching themes (Table 3). Seventeen of the written reflections were excluded due to being incomplete for the questions that we evaluated, or from not being able to be retrieved electronically at the end of the rotation. Most comments were related to specific skills students learned, suggesting retention of advocacy skills delivered through the curriculum. Additionally, students most commonly identified barriers to care that patients face, and their experiences surrounding communication with patients, implying deliberate attention to these details may impact daily care.

Table 3.

Themes and Representative Comments from Student Reflections

Overarching Themes & Codes	Code Definitions	Representative comments
Student Education: Comments related to skills obtained during the curriculum
Advocacy skills	Skills, tools, and resources introduced in their workshops	• “I learned that even small acts of advocacy, like collecting outside records or calling providers in the patient’s medical team, can improve a patient’s experience at the hospital and ultimately lead to better care.”
Supervisor role modeling	Modeling from supervisors (attendings or residents)	• “The attending was very good about medication reconciliation at discharge so I learned that making sure patients understand the medication changes and writing the medication changes in the discharge instructions can help a lot with clarity.”
Discharge process	Any component of best practices for the discharge process	• “Additionally, [the patient] and I would go on walks to clear his mind and get him physically active. Given his ongoing anxiety and his multiple symptoms, I consulted with the symptom management team so that he was as comfortable as possible. Prior to discharge, I organized all of his medications onto a sheet with explanations of each medication as well as the dates of his follow up appointments.”
Communication with other providers	Communicating with other providers, like consultants, outside-hospital providers, or patient’s primary care providers	• “In my future clinical practice, I will definitely make a follow-up phone call to discharged patients to see how they are doing and answer any question. Also, it is very important to see what the patients’ needs are and refer them to appropriate teams for the best outcome.”
Student Experience: Comments related to a student’s personal experience and feelings while completing the advocacy assignment
Experience with empowerment	Feeling empowered to advocate and related actions	• “As I develop in my career, I hope to advocate on a policy level. The San Francisco housing crisis is detrimental to the health of our residents, and physicians need to be at the forefront of advocating for policies and funding for safe, affordable housing.”
Communication with patients	Direct patient communication	• “Based on this exercise, I’ve learned that it’s important to always speak directly to the patient and their family about the next steps/plan; you can’t expect things to fall magically into place, because sometimes, a clinic may not necessarily call to remind for the appointment.”
Experience with compassion	Experiencing compassion, which can include: with other providers, with patient, or with providing it	• “The most important skill I’ve learned through this curriculum and through this rotation generally is the tremendous gift we can give of time, attention, and listening. There was little I could do to fix the underlying problems, but I could create space by listening attentively.”
Student gratitude	Student gratitude related to any part of the patient’s care	• “I learned that we can significantly improve our patients experience and outcomes in the hospital by advocating for them. I too learned the joy it brought me knowing that I could be a source of help to my patients in times of difficulty. I believe as healthcare providers, we need to understand our patient’s backgrounds and what barriers to care they face so that we can give them the most comprehensive and competent care. Learning more about my patients, who they are and what is important to them, is something I do plan on incorporating into my clinical practice.”
Stigmas or Labeling	Stigmas or labels around their patients	• “I will also strive to understand the subtleties of various cultural differences of my patients in order to prevent the inappropriate grouping of people into a single cultural box, when they are in fact members of distinct groups.”
Caregiver dynamics	Experiences with patient’s caregivers, including support and challenges	• “Being a hospitalist allows access to a cross-sectional slice of a patient’s life, confined to one moment in time but comprehensive in that we get to see and coordinate all aspects of the patient’s health. From taking care of A. in the hospital I knew her family has been caring for her all her life; now that she is 19 they are struggling to determine a sustainable plan that balancing her needs with allowing her some independence.”
Barriers to Care: Comments related to SDH that play a part in patient care
	SDH that play a part in patient care	• “[The patient] taught me a lot about the conditions in SROs (single room occupancies). It is easy to assume that any housing is better than no housing, but I learned that people can feel even more unsafe in a building than they do outside. [The patient] experienced sexual violence in her SRO and genuinely fears the drug-related activity that occurs in her hallways.”
Interdisciplinary Dynamics: Comments related to the role of interprofessional team members in patient advocacy
	Role of interprofessional team members in patient advocacy	• “I learned to communicate with team members such as social workers, in finding the best possible resources for our patients. While these services are not available at every hospital, I know have knowledge about community resources available for my future patients and can contact them on my own.”

DISCUSSION

Despite broad emphasis on the importance of SDH education to improve patient care and promote health equity, a paucity of published curricula guide medical educators on how students should learn to apply such advocacy concepts to individual patients (1). This curricular gap is particularly noticeable in the clerkship year, when students often have their first meaningful clinical experiences and are in the position to advocate for health equity as they form their professional identity. Our clerkship-based, experiential curriculum promoted students’ learning about SDH in the context of real patients and enabled them to apply their knowledge and skills to direct patient advocacy.

Experiential learning uses experience to interpret and integrate into existing knowledge, but reflection is critical to this learning process. The impact of this curriculum is shaped by the reflections of the students. Within this curriculum, students reflected most on patient encounters where they personally made a difference in the patient’s course, and they left this experience with clear resolutions on how they would practice advocacy in the future. Additionally, their responses reflected their appreciation of education on how to navigate advocacy using interprofessional teamwork and community resources.

There were several limitations to this study, including the fact that it focused on one institutional site. Our qualitative analysis of reflections consists of a subset of student reflections during a limited time period, meaning they likely do not represent all students. A larger sample size, and more diverse reflections, could be achieved if we included all students at all internal medicine clerkship rotation sites at our institution, rather than those at a single hospital site. Secondly, many students described their perceptions of their own impact on patients, rather than describing their own advocacy experience. This perceived impact may be different than what the patients truly experience, and in the future it would be important to obtain patient perspectives of their care.

Medical students immersed in experience-based learning by actively advocating in clinical practice—and reflecting on real patient experiences—can build the personal characteristics that will form their professional identities as physicians (4). To create generational change and prompt the movement of learners towards advocacy and health equity, students must understand how clinicians can directly advocate for patients, and how they themselves can do this independently. This curriculum begins to put advocacy skills into practice, and we hope that students will continue to reflect on these experiences throughout their careers.

Pullout points:

To prepare for their work as physicians, students require the opportunity to practice advocacy work in direct patient care settings.

Advocacy skills come in many forms, and in this curriculum, we focus on developing patient communication skills, patient education and counseling skills within their social context, and collaborative care skills to achieve better health outcomes

As students are empowered to practice and experience physician advocacy within their clerkships, they may be able to discover where advocacy lies in their professional identity.

Within this curriculum, students reflected most on patient encounters where they personally made a difference in the patient’s course, and they left this experience with clear resolutions on how they would practice advocacy in the future.