“Do you think she’ll be ready to go home tomorrow?” The team turns toward the father’s 6-year-old daughter. This is her tenth admission for status asthmaticus, and she is now on day 2 of continuous albuterol. “I know the roaches make her asthma worse, but our landlord is useless,” he explains. “I pick up her medications as often as I can, but the inhaler costs $200 since I lost my job and insurance.” The team explains the necessary steps before discharge. Outside the room, after a period of silence, the attending says, “Let’s space her albuterol and get her out of bed today.” Walking to the next room, the attending adds, “We should reach out to social work too.”
As pediatric hospitalists, we encounter patients and families like this every day. Although we are confident in our ability to treat a patient’s acute illness and teach trainees evidence-based medical management, too often, we miss opportunities to both model and teach the role of the pediatrician-advocate in the hospital. Pediatrics was the first medical specialty to include “advocacy” in the Accreditation Council of Graduate Medical Education (ACGME) program requirements for residency training. However, the “advocacy” requirement is formally designated as an “ambulatory experience,” significantly limiting its scope and impact.1 Advocacy and advocacy training can, does, and should occur across all pediatric clinical settings and specialties. The inpatient setting, where pediatric residents spend the majority of their time, is particularly well-suited to advocacy training. Intentional advocacy training in the inpatient setting would improve the skills of future pediatrician-advocates while also elevating the quality of inpatient medical care. We propose, therefore, that the ACGME change the language of the advocacy training requirement to either explicitly include “inpatient advocacy” (advocacy on behalf of patients admitted to the hospital and/or in an effort to mitigate structural barriers to providing high-quality inpatient care), or list advocacy separately from the ambulatory requirement as a requirement that cuts across clinical settings. Doing so will promote the design, implementation, and evaluation of formal inpatient advocacy curricula as well as targeted faculty development in how to teach and model advocacy in inpatient settings.
Opportunities for Patient and Public Advocacy in the Hospital
Hospital admissions can reveal and underline the profound impact of structural inequities on child health. A recent issue of Hospital Pediatrics highlighted the many ways in which the social determinants of health intersect with the care and well-being of hospitalized children.2 Health care system barriers are associated with worse hospital outcomes.3 “Social disadvantage” factors are associated with prolonged length of stay and readmission rates.4 Structural racism has rendered children of color more susceptible to hospitalization from coronavirus disease 2019.5,6 An admission to the hospital, however, is also a unique opportunity for intervention, and the inpatient setting is ripe for resident training in patient and public advocacy. Patient advocacy is defined as advocacy efforts aimed at the interests of a specific patient, whereas public advocacy describes advocacy efforts aimed at social, economic, educational, and political changes that “ameliorate suffering and contribute to human well-being.”7,8
Although inpatient teams have fewer opportunities for longitudinal care relationships, in contrast to a twenty-minute primary care visit, an inpatient team often interfaces with a family over the course of hours to days. The prolonged nature of the inpatient interaction provides unique opportunities for patient advocacy. In navigating barriers to safe discharge, insurance coverage issues, and long-term follow-up planning, residents are presented with numerous and high-impact opportunities to advocate for individual patients and gain deeper understanding of the social determinants of health and systems-level barriers to care. Family-centered rounds (FCRs) are also advantageously structured to facilitate advocacy training. FCRs protect time for meaningful dialogue to better understand families’ needs and social context. FCRs also provide supervisors the opportunity to observe, model, provide feedback, and teach on the role of physician-advocate.9
Beyond patient-level advocacy, the inpatient setting also provides trainees a platform and inspiration for public advocacy. As hospitalists, we can encourage trainees to think critically about structural inequities and facilitate productive ways to channel our shared empathy and frustration into activism. Residents, as front-line providers, often bear witness to patients’ struggles and encounter system-level challenges to providing high-quality care. Patient stories are often the best ways to change hearts and minds. By writing about their experiences, via opinion pieces, other forms of media advocacy, or providing written or public testimony, residents can leverage their privileged position as physicians to call for structural changes to systems and policies that impact child health.10 Clinical experiences can also inspire health services research that highlights disparities and/or evaluates equity-focused interventions. As residents learn to use existing resources such as the Medical Legal Partnership11 and Street Cred12 to expand access to services for hospitalized patients, they might also consider the potential for new community and public partnerships that disrupt structural barriers to health.
The Importance of Formal Inpatient Advocacy Curricula
Although informal advocacy teaching likely already occurs in the hospital, there is a dearth of literature describing formal advocacy curricula in the inpatient setting.13 The current literature describes diverse approaches to advocacy training (discrete versus longitudinal rotations, didactics versus experiential and/or service learning), but all approaches reflect the ACGME requirement’s contextualization of advocacy within the ambulatory setting.14–17 To be sure, some advocacy training taught in ambulatory curricula is transferrable. However, similar to our teaching of pathophysiology and clinical reasoning, we must provide trainees with structured opportunities to develop advocacy skills across varied clinical settings. Crafting and implementing a safe discharge from the hospital is a different process than developing a longitudinal preventive health plan in the ambulatory setting.
Previous experience suggests that changes to the ACGME requirements prompt curricular innovation and engagement, for example, changes to duty hours restrictions and the addition of training in quality improvement. Explicitly including inpatient advocacy education in the ACGME’s program requirements will galvanize residency programs to design, implement, and study inpatient-specific advocacy curricula that provide an applied experience and a framework for faculty to lead inpatient-specific training.
Pediatric Hospitalists Require Faculty Development in Advocacy and Advocacy Training
Barriers to advocacy teaching during residency include time constraints, lack of role modeling, absence of formal curricula, and devaluation of advocacy knowledge relative to medical knowledge.18 To effectively deliver advocacy curricula to residents, hospitalists must also be prepared and empowered to teach about advocacy. Although some inpatient faculty already incorporate advocacy into their teaching and are even leaders in advocacy education at their institutions and nationally, we recognize that others are less comfortable. In one study published in Hospital Pediatrics, researchers found that only 34% of pediatrics hospitalists felt competent screening for social determinants of health and 83% agreed that they would screen more often if they were provided with resources or training.19 Although most medical schools now incorporate coursework on the connection between health and systemic racism, bias, poverty, language, immigration status, and other social and structural determinants of health, these topics may or may not have been a part of faculty’s medical training or continuing education. Faculty need baseline knowledge, language, and tools to be able to teach pediatric trainees how to address bias and systemic racism and to create population and systems-level change.20 Formal faculty development in inpatient advocacy will equip hospitalists with the necessary skills to teach residents and improve the quality of inpatient care they provide.
As one example, pediatric hospital medicine (PHM) fellowship would provide an opportune platform for this type of faculty development. The ACGME’s PHM requirements recognize patient-level advocacy as a critical skill, asking that fellows “demonstrate…responsiveness to the larger context and system of health care…as well as the ability to call effectively on other resources to provide optimal care.”21 PHM fellowship requirements should consider expanding on this foundation to include public advocacy, empowering fellows to recognize barriers to care, and leading systems-level change within and outside the hospital walls.
Training the Next Generation of Pediatrician-Advocates
As pediatric hospitalists, we know that child health outcomes are largely determined by factors outside of the medical care we provide. We teach residents how to treat pediatric disease on the basis of our medical expertise, but we recognize that it is not enough to simply address patients’ diagnoses and treatment regimens. As the medical community reflects on the coronavirus disease 2019 pandemic, the Black Lives Matter movement, and our role in perpetuating health inequities and structural racism, we must reflect on what meaningful changes we can make from our unique role as pediatric hospitalists. Integrating advocacy training into the inpatient setting will better equip and empower pediatric residents to make an impact in and beyond their pediatric training. Revising the ACGME residency requirements to be inclusive of inpatient advocacy education will signal their importance and facilitate the necessary curriculum and faculty development to thoughtfully and rigorously train future pediatrician-advocates across the care continuum. These structural changes will improve the quality of the care we provide to hospitalized children and send the message that all pediatricians can and should be expert physician-advocates, regardless of the setting.
Acknowledgments
We thank Drs Lauren Crafts and Elizabeth Ernstberger for their help in formulating the initial concept of this article. We also thank Drs Ariel Winn, Fabienne Bourgeois, Christine Cheston, Katie O’Donnell, Jasmine Weiss, and Benjamin Howell for their advice and feedback on the article.
FUNDING: Funded by the National Clinician Scholars Program and the Clinical and Translational Science Awards grant TL1 TR001864 from the National Center for Advancing Translational Science, a component of the National Institutes of Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Institutes of Health. The funders or sponsors did not participate in the work. Funded by the National Institutes of Health (NIH).
Dr Winthrop conceptualized and designed this project and drafted the initial manuscript; Drs Nash and Michelson helped to conceptualize the project and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Comments
Faculty Support for Advocacy is Key to Training the Next Generation of Pediatrician-Advocates
Faculty development in advocacy is necessary but not sufficient to allow for advocacy training and curricular development in the inpatient setting. Inpatient faculty providing such training must also be given the time, resources, and support to perform and teach advocacy. This can only happen if advocacy scholarship is viewed as congruent to traditional scholarship including research and medical education. We propose the following additional faculty needs to establish more widespread integration of advocacy in the hospital practice setting:
1. The adoption of Advocacy Portfolios: Clinician-researchers generate scholarship to benefit patients and populations in the form of peer-reviewed grants and publications. Clinician-educators have gained support for scholarly activities and faculty promotion in medical education through the development and application of a standardized Educator Portfolio. Recognition of advocacy as a scholarly pursuit for faculty and trainees can only be achieved through the dissemination and widespread adoption of Advocacy Portfolios (APs).(2) Such portfolios supplement the CV to highlight how advocacy can be held to the same rigorous scholarly standards as research and medical education. Recognition of advocacy and APs in the academic faculty promotion process will allow those interested in pursuing advocacy scholarship to be successful in obtaining the time, financial, and training resources necessary for practice. A national group of pediatrician advocates has developed the first standardized Advocacy Portfolio Template in conjunction with the American Academy of Pediatrics Community Pediatrics Training Initiative.(3)
2. Advocacy recognition within the Pediatric Hospital Medicine Board Certification Process: The American Board of Pediatrics (ABP) has proposed a Pediatric Subspecialty Entrustable Professional Activity Focused on Population Health. Additionally, “Advocacy and Leadership” is a Content Domain for Pediatric Hospital Medicine Board Certification. Despite this, the ABP has not recognized advocacy specifically as a form of scholarship and “work product” allowable for pediatric subspecialty fellowship completion and subsequent board certification, even it if meets the criteria for scholarship defined by Glassick.4 Lastly, allowing physicians to submit advocacy projects for Maintenance of Certification Part 4 credit would greatly assist in recognizing the role of physician advocacy in improving population health.
Advocacy will gain congruence in academics through a simultaneous bottom-up and top-down approach: faculty use of APs as developmental and promotional tools, in conjunction with recognition and support from medical school leadership and the American Board of Pediatrics. Only if these criteria are met will faculty be recognized for population-level scholarly advocacy activities, thereby supporting the time, resources, and funding necessary for teaching such practice to the next generation.
References
1. Pediatric Hospital Medicine Core Competencies. Section 4: Healthcare Systems: Support and Advancing Child Health. J Hosp Med. 2020 June;15(S1):112-141.
2. Nerlinger AL, Shah AN, Beck AF, Beers LS, Wong SL, Chamberlain LJ, Keller D. The Advocacy Portfolio: A Standardized Tool for Documenting Physician Advocacy. Acad Med. 2018 Jun;93(6):860-868.
3. https:/www.aap.org/cpti
4. Glassick CE. Boyer’s expanded definitions of scholarship, the standards for assessing scholarship, and the elusiveness of the scholarship of teaching. Acad Med. 2000;75:877-880.