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Characterizing Resident Advocacy Work: Reflecting Back to Move Forward

February 20, 2024

Editor’s Note: Courtney Duckworth, MD (she/her) is a resident physician in pediatrics at The Boston Combined Residency Program (Boston Children's Hospital/ Boston Medical Center). She is interested in the intersection of sports medicine and chronic disease, which she hopes to combine in her career as a pediatrician at an academic medical center. Within the realm of chronic disease, she is passionate about health equity with ongoing work to increase access to diabetes technology. - Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

As pediatricians, we see firsthand how the health and development of children are at the mercy of their environments. As children often cannot speak up or vote for the conditions they deserve, we as their doctors are given the unique opportunity to advocate for their needs.

Advocacy on behalf of children is multidimensional, considering both the individual and the systems that impact the individual. It potentially involves many stakeholders, including families/patients, physicians, community members, and politicians.

Advocacy work in residency has been connected to increased ability and likelihood to pursue advocacy throughout one’s career. The Accreditation Council for Graduate Medical Education (ACGME) has recognized advocacy as a key part of pediatricians’ work, and since 2001, has required that advocacy be taught in residency curricula. However, there is no standardization of curricula, and not much is known about the types of projects residents pursue, skills and lessons learned, or benefits and barriers of advocacy work in residency.

In “A Qualitative Study of Resident Advocacy Work,” Hannah Anderson, Noreena Lewis, JD, and Dr. Beth Rezet from the Children’s Hospital of Philadelphia performed a qualitative analysis to better characterize 45 resident advocacy projects in 2013–2021 and reflections about these experiences (10.1542/peds.2023-061590).

Using the University of British Columbia’s health advocacy framework, the authors found that residents took part in 4 main types of advocacy:

  1. Directed activism: Physician-led, systems-level health interventions, such as finding anticipatory guidance resources in primary care clinics for patients with language barriers, and designing an intervention to increase use of these resources.
  2. Shared activism: Physician participation in community-led, systems-level health interventions, such as county-wide school series that teach health topics to students.
  3. Directed agency: Physician-led, individual-focused health interventions, such as surveying parents about barriers to using a spacer with inhaled asthma medicine, and then offering educational resources to patients based on reported barriers.
  4. Shared agency: Physician participation in community-led, individual-focused health interventions, such as helping to start a group wellness and exercise class series for hospital employees.

The type of advocacy project affected the acquired skills and experiences documented in residents’ reflections:

  • Shared forms of advocacy yielded themes such as “partnering,” “evaluating,” and “planning.”
  • Directed forms of advocacy yielded themes such as “leading,” “presenting,” and “intervening.”
  • Activism involved larger collaborative teams made up of more interprofessional mentors. Additionally, activism often involved peer-mentorship to ensure project sustainability after a resident graduated.
  • Agency involved smaller teams of one or more physician mentors and often involved quality-improvement techniques to improve health systems issues.

The authors also found that the larger political and social climate affected residents’ reflections. From 2013 to 2016, projects were largely based on personal experiences with patients, families, or colleagues. After 2016, residents were more likely to describe themselves as “advocates” for their patients, and there was an increase in health equity and community-based projects.

Additionally, residents found social benefits to engaging in advocacy work, especially if it involved peer-to-peer mentorship that created connections with other residents.

Though time to balance clinical and advocacy work was routinely described as a challenge, this more often affected residents taking part in activism, partly due to additional burdens such as transportation to community sites and finding resources to support stakeholders.

This article increases understanding of the types of advocacy work in which residents participate, skills gained based on specific experiences, and potential challenges. In turn, pediatrics residency programs will be more equipped to provide the appropriate guidance, support, and mentorship to prepare their residents for careers in which advocacy is a cornerstone.

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