Academic Careers in Advocacy: Aligning Institutional Values Through Use of an Advocacy Portfolio

The authoring group of this article consists of directors of community health and advocacy curricula, pediatric department chairs at 7 pediatric academic medical centers, and leadership from the American Academy of Pediatrics (AAP) Community Pediatrics Training Initiative (CPTI). The group proposes a call to action for academic children’s hospitals to support advocacy explicitly as an academic endeavor, including incorporation into the traditional promotion framework to establish its legitimacy. Institutions should embrace advocacy as a central component of their missions to discover new knowledge and improve the health of the communities and patients they serve. To do so, faculty need the tools to develop and articulate the work of advocacy as an academic endeavor. Academic medical centers and children’s hospitals can play a central role in the development, support, and promotion of faculty who are experts in community health and advocacy, which will assist in the transformation of more effective pediatric health care delivery and improved outcomes. In the same way that educator portfolios allow faculty to illustrate their educational career trajectory, an advocacy portfolio can be used to chart and illustrate the development and achievement of an academic career in advocacy.

Physician advocacy has been defined as: “Action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.”¹  Community-based approaches to population health and advocacy have been central to pediatrics, dating back to the inception of our field. Dr Abraham Jacobi, the “father of pediatrics,” worked tirelessly as an advocate for the health of children and youth at the community level, effecting true systems change.^1,2  Such transformative work requires child health providers to work both outside of the traditional clinical venues, and upstream, in terms of prevention. Examples include the pioneering injury prevention work of Barbara Barlow and her colleagues in Harlem³  and Mona Hanna Attisha’s courageous identification of the Flint Water Crisis.⁴  The presence of these pediatricians and many more of their colleagues who practice community pediatrics/advocacy have a large impact on many aspects of child health, including improved access to health services, enriched early childhood environments, decreased high-risk behaviors, food and housing support, and more.

The AAP has embraced the concept of “community health” as a crucial component of pediatric advocacy, beyond the provision of health care in a community-based setting. The AAP defines community pediatrics as “the practice of promoting and integrating the positive social, cultural, and environmental influences on children’s health as well as addressing potential negative effects that deter optimal child health and development within a community. Community pediatrics includes the following:

• A perspective that expands the pediatrician’s focus from one child to the well-being of all children in the community

• A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces affect the health and functioning of children

• A synthesis of clinical practice and public health principles to promote the health of all children within the context of the family, school, and community

• A commitment to collaborate with community partners to advocate for and provide quality services equitably for all children.⁵ 

Sadly, the need for advocacy is greater now than at any time in modern history; the COVID-19 pandemic, systemic racism, poverty and income disparities, mental health challenges, climate change, competing interests of an aging population, and immigration challenges are many of the ongoing crises facing children and families today. Children require pediatricians’ expertise for their “voice” to be heard.

Young families with children are often underresourced, and remain among the poorest, and most diverse, segments of the United States population. Both institutionalized racism and the devastating effects of the pandemic have shined a spotlight on inequities that lead to the persistent disparities in this country.⁶  The COVID-19 pandemic has also clearly demonstrated the need to strengthen advocacy efforts around the perception of science and vaccines. Although pediatricians can, and must, engage families in traditional clinical roles, that alone remains insufficient to effectively address systemic issues. Success requires community-based and population health approaches.^7,8  Similarly, the systemic racism that profoundly affects the health of children, adolescents, young adults, and their families requires sweeping change at both community and policy levels to achieve equitable health outcomes for all. To maintain this promise, and relevance to, the health and wellbeing of patients, academic departments of pediatrics need to act outside and upstream of our traditional clinical care roles to develop innovative policy initiatives and cross-sector partnerships, which are the core skills of effective child advocates. Examples of these core advocate skills include community engagement, coalition building, and system-based health care improvements through both partnerships and policy. Advocacy skills are needed to affect population and system change, translating across all the risk factors for poor child health outcomes. These skills will continue to be relevant and central to the field of pediatrics to reduce disparities. Faculty practicing community health and advocacy are the transformational agents to address the systemic crises we are facing in child health today.

The awareness of the criticality of training medical professionals in these core skills to address social determinants of health has influenced training requirements across medical education.

Most United States medical schools now offer training in advocacy, and the Accreditation Council for Graduate Medical Education requires all pediatric residency programs to include some degree of advocacy training.^9,10  There is a clear interest from trainees, at all levels, to develop the skills needed to implement community health and advocacy strategies. A 2021 survey of medical students showed significant interest in collective advocacy, community participation, and political engagement.¹¹  A growing community of trainees and academic pediatricians fervently believes this skillset is a crucial part of their professional identity.

The unique aspects of the scholarship of advocacy, outside of peer-reviewed medical literature, have been neglected. Acknowledging that this work does align with the mission of academic institutions, it can be an important mechanism for institutions to improve the health of their communities and it must be recognized as maintaining relevance for future generations.

How can academic institutions support the work of their faculty in advocacy? Key first steps include (1) ensuring professional development with trainees and early-career faculty to develop and practice core skills in community health and advocacy and (2) providing opportunities and resources to allow faculty to pursue their passions using those skills to effect change in communities and systems. Many academic centers have similar support structures for their research and education missions. For example, educator portfolios have allowed academic institutions to assess the value and develop metrics relating to a faculty member’s contributions to education. As academic pediatricians build careers in advocacy, similar approaches can be used. For example, the AAP CPTI advocacy portfolio can be used with faculty development and mentorship programs to strengthen advocacy as a valued career endeavor. CPTI is an AAP initiative that focuses on training pediatricians, both residents and faculty, to be effective leaders and advocates through development of authentic community partnerships to impact systems and policy change for children. CPTI provides faculty development opportunities and resources, advocacy training and curricula, and collaboratives across institutions to accelerate advocacy on behalf of children. The CPTI advocacy portfolio builds on existing foundational work^12,13  and is a tool that will allow faculty to organize and catalog its work in engagement with communities and community-based organizations, media, leadership and health systems, and legislative/policy advocacy. This advocacy portfolio can be used as both a formative and a summative tool, helping create a roadmap for faculty to document the success and impact of their work in the community health and advocacy realm. Faculty can use an advocacy portfolio to both guide their work and to tell their story. The template, although initially drafted by CPTI leadership, has gone through an extensive review process, with feedback and editing from faculty and faculty leaders across the country. The resulting CPTI advocacy portfolio can be found at aap.org/cpti and the domains are outlined in Table 1.

Academic institutions can further their advocacy missions and support their faculty by aligning traditional academic values with the work of advocacy. This should include offering robust training opportunities for both faculty and residents, establishing advocacy leadership positions (e.g., vice chairs) within divisions and departments, and providing mechanisms to support this work through funding by time or compensation. Tying advocacy endeavors to institutional community benefit work and positioning academic health systems as anchor institutions within their communities can further facilitate ongoing focus and support. With the focus of Centers for Medicare and Medicaid Services on both social and health outcomes, along with accountable care models, expert advocacy faculty can support academic institutions on both the community benefit reporting and investment by a hospital system to ensure new initiatives and innovative care models have a lasting positive impact in the community.

To ensure an ongoing pipeline of expert advocacy pediatricians, faculty development sessions for both emerging and established faculty can support early-career trajectories and recognize ongoing advocacy work while fostering valuable collegiality. Such purposeful mentorship is another key strategy for increasing faculty interest, ensuring that advocacy efforts are supported. This support may also include modest institutional grant funding for advocacy projects by early-career physicians. Institutions can be called on to identify and support their faculty advocacy leaders who can serve to mentor trainees at all levels, including junior faculty, fellows, residents, and medical students.

The work of advocacy aligns both with the professional identity of health care professionals in general and child health professionals specifically. In this vein, engaging in such meaningful work may prove to be an antidote to the pervasive issues of burnout and dissatisfaction¹⁴  among health care providers. Should this be true, the impact on professional well-being, productivity, recruitment, and retention may be a powerful driver for institutional recognition of this important work.

As faculty engage in advocacy as part of a longitudinal academic career, there is a growing need to translate the work into existing academic promotion pathways. Traditionally, these pathways compartmentalize faculty work into 3 domains: scholarship, education, and service. Community health and advocacy work can be easily incorporated into these domains and the advocacy portfolio can be used to do so. Faculty should be recognized for teaching advocacy as a core pediatric competency (education, curriculum development), for disseminating and studying the impact of advocacy efforts (scholarship, research, or quality improvement leading to publications and policy statements), and for the service they provide to the community. Recognition of faculty excellence and expertise at the local, regional, national, and international levels is also a common driver of academic promotion, and work associated with community health and advocacy would be no exception. Ultimately, the question remains as to whether advocacy should stand alone as a core component to the promotion pathway, achieving status as a fourth leg among the traditional 3-legged stool that includes the 3 domains noted previously. Successful community health and advocacy work requires translating new knowledge into action and applying advocacy and community engagement skills to successfully engage with community-based organizations, government, health systems, and others to effect impactful, lasting change to improve the health and well-being of children and families. Critical to this process in academic medicine is the recognition and attribution of rigor to the work (Glassick Criteria).¹⁵  This requires outcomes and measurements for policy advocacy changes, metrics of impact with community engagement, and community leadership roles that include outcomes of the organization. Examples might include translating the primary literature regarding contraception with a school board to make family planning options accessible in a high school or working on a state governor’s task force to create a statewide immunization registry. Developing a framework that can speak to the level of engagement/leadership role for each of these activities alongside the impact and outcomes for the community is the key task for academic institutions as they work to support efforts and foster growth in advocacy among their faculty.

What steps are necessary to help our current academic promotion systems evolve to acknowledge and incorporate advocacy as a core component? Many well-respected academic institutions have already taken first steps.

At Nationwide Children's Hospital, a free-standing children’s hospital academically affiliated with The Ohio State University, advocacy is called out in the Department of Pediatrics’ mission statement. A new Clinical Excellence Pathway for promotion allows clinicians to advance toward promotion using metrics differing from traditional scholarship requirements. Clinical Excellence Pathway faculty may be promoted based on a portfolio of academic pursuits including the scholarship of practice, integration, community engagement, advocacy and education, and discovery of new knowledge. Development, facilitation, or oversight of policies, advocacy initiatives, diversity programs, antiracism initiatives, programs, or procedures that result in improvements in patient outcomes, health equity, more efficient or value-based care, or more effective means of delivering care may support promotion.

At Oregon Health and Science University, pediatric faculty worked with the institutional promotion committee chair to introduce specific language into the promotion criteria that recognize service to the community as equivalent to service to the institution and profession of medicine. The school of medicine procedures and general guidelines for promotion and tenure specifically states: “Service includes professional and administrative activity within the institution, to the candidate’s profession, and to the public. Service on medical school or university committees, on committees of scientific societies, to granting agencies and scholarly journals, public relations activities on behalf of the University, and other administrative assignments can be used to demonstrate commitments to service. Professional service to the community at local, state, regional, national or international levels shall also be recognized.”¹⁶  This also included adding several new, unique fields to the required institutional curriculum vitae template specifically cataloging Health Policy and Advocacy Service, Service to the Community, and Honors and Awards for Service. The Department of Pediatrics established a vice chair for Community Health and Advocacy in 2018.

In Rochester, New York, the Hoekelman Center for Health Beyond Medicine is dedicated to community outreach and advocacy efforts. Through the Hoekelman Center, pediatric residents have the option of entering the Community Health & Advocacy Resident Education track, a 2 year longitudinal training experience focused on advocacy and community outreach. In addition, pediatric trainees may join the Frederick Douglass and Susan B. Anthony Scholars program, which provides training in health care equity. A formal junior faculty mentoring program supports early faculty career development and helps faculty prepare for promotion. The Department of Pediatrics recognizes excellence in community service and outreach annually through the Ruth A Lawrence Academic Faculty Service Award, and there is a vice chair of Community and Government Affairs, as well as a vice chair for Behavioral and Population Health. Both the vice chair of Community and Government Affairs and the director of the Hoekelman Center are standing members of the departmental promotions and tenure committee. When being considered for promotion, an advocacy portfolio may be submitted in lieu of an educator’s portfolio.

The Duke University School of Medicine (SoM) Appointment, Promotion and Tenure (APT) Committee recently expanded its definition of scholarship to endorse both traditional and alternative/nontraditional forms of scholarship. Faculty worked with the SoM APT chair to develop a structure for defining advocacy scholarship within the academic framework of the SoM APT process, using the advocacy portfolio as a tool for documentation of impact and academic value of clinician advocacy. Through this framework, scholarly output of advocacy work can include, but is not limited to, the following: nonpeer-reviewed content; institutional reports and presentations; social media (blogs, Web sites, and other digital platforms); visiting professorships; participation in local, regional, and national taskforces; participation in local, regional, and national legislative efforts; invited presentations at national meetings; public health intervention that becomes a standard of care; establishment of community partnerships; national recognition from press (print, media, online); coauthorship of clinical policy statements, legislative briefs, consensus statements, or practice guidelines; columns in professional trade journals or nontechnical medicine-related academic books; and invention disclosures, patent applications, and/or awarding of patents reflecting clinical innovation.

The Department of Pediatrics at the Geisel School of Medicine at Dartmouth College has had an endowed clinical chair of Community Pediatrics at its Children’s Hospital at Dartmouth-Hitchcock since 1997. The current holder of this chair serves as the department’s de facto vice chair for Advocacy and provides faculty development updates alongside the vice chairs for Education and Research at monthly department meetings. The Appointments, Promotions and Titles Committee at Dartmouth Geisel identifies 4 areas of academic endeavor that merit appointment and promotion: teaching, research, advancement of clinical care and promotion of (population) wellness, and engagement. Furthermore, the Geisel Appointments, Promotions and Titles Committee notes, “many areas of engagement fall under the rubric of Advocacy…faculty members may have substantive impacts at the regional and national levels through advocacy.”¹⁷  It therefore recognizes the value of the CPTI Advocacy Portfolio, which has been used successfully as a foundational element for promoting pediatric faculty. Specifically, recognition of legislative advocacy, curriculum development and teaching advocacy methodology, and mentorship of specific community-based advocacy projects as scholarly activities has been established.

Although these examples represent important first steps at a few academic medical institutions, they are just the beginning of a needed evolution toward incorporating advocacy explicitly into the promotions process. Currently, 2 of the faculty authors of this article have used this updated promotion language and the advocacy portfolio to support their applications with success at both Dartmouth and Nationwide Children’s Hospital, but more widespread adoption, integration, and faculty development is needed to expand the effect.

The factors that affect child health and well-being have changed over the past century. Palfrey and Richmond described the “Millennial Morbidities” in 2005,⁸  including child poverty, social determinants of health, health disparities including racism, overweight and obesity, and escalating mental health concerns. These morbidities, and other social determinants of health, have been exacerbated by the COVID-19 pandemic and cannot be adequately addressed by the traditional medical model of clinical care alone. Advocacy, at the individual, community, and systems/policy change levels must be a central component of the work we do as pediatricians to truly improve the health of our patients, their families, and our communities. This shift in focus from the delivery of health care in clinic and hospital rooms to include work done outside the traditional clinical paradigms to improve health and well-being requires a concomitant shift in how the work is valued. Academic institutions play an essential role in supporting this work through the acknowledgment and support of advocacy as an academic endeavor at all levels. This should include formal integration of advocacy into existing academic promotion processes as service, education, and scholarship. Use of an advocacy portfolio can help drive that integration.

AAP

American Academy of Pediatrics

APT

Appointment, Promotion and Tenure

CPTI

Community Pediatrics Training Initiative

SoM

School of Medicine