Zhu M, Neufeld M, Keller S, Boden A, Janeway M, Allee L, Dechert T. Advocacy toolbox: training for preclinical medical students interested in surgery. HPHR. 2021;32.
Health advocacy is a critical way to influence health policy and the wellbeing of our patients. Surgeons are increasingly recognizing the impact of the social determinants of health on surgical outcomes. Socially responsible surgery requires surgeons to advocate for their patients and communities to address inequity resulting from disparities related to the social determinants of health. However, further work is needed to teach aspiring surgeons how to advocate effectively. Introduction of surgical advocacy to medical students can help future surgical trainees understand that socially responsible advocacy is the work of surgeons and learn to incorporate advocacy into their future careers. To this end, we have developed a curriculum termed the Advocacy Toolbox: a program centered on surgical mentorship, advocacy didactics, and a longitudinal project. The Advocacy Toolbox aims to equip first year medical students with the tools needed to advocate for their patients and communities in a variety of contexts. The program is currently being implemented with a group of 15 first year medical students, with plans to expand the program in future years.
For too long, status quo has taught aspiring surgeons that they have no place in public health. Medical student Max Zhu recalls, “As an undergraduate student, I confirmed my desire to go to medical school while volunteering for my school’s mobile clinic. I witnessed how the social determinants of health created health outcome disparities for those experiencing homelessness in Los Angeles. At that time, I also started to realize my interest in surgery. That doesn’t make sense, I remember my friends telling me. You can’t enjoy community health work AND be a surgeon.”
Admittedly, surgery and public health fields have not traditionally gone hand in hand. However, as surgical practice continues to evolve, many surgeons now acknowledge that the social determinants of health (SDH) are fundamental to the health outcomes of surgical patients (Robinson, 2017; Spruce, 2019). The concept of socially responsible surgery has emerged as an avenue to empower surgeons and trainees to partake in public health interventions and advocacy to address these disparities (Robinson, 2017).
Beyond realizing that SDH affect surgical outcomes, it is imperative that surgeons and aspiring surgical trainees not only learn of these health disparities, but also learn how to address and ameliorate them as physician advocates. Earnest et al. (2010) define a physician advocate as a physician who not only advocates for their patients on an individual level, but who also goes further and addresses the root causes of the health disparities their patients face. Some examples include advocating for state and national healthcare reform, improving nutrition policy for school lunches, and redistributing resources at a local hospital to better address a patient’s social needs, such as housing and environmental exposures (Earnest, 2010). Many medical schools have begun to emphasize the importance of SDH and associated advocacy efforts through class-based instruction (Doobay-Persaud, 2019). Marsh et al. (2019) have recently described an advocacy curriculum for students on their third-year pediatrics rotation. Perhaps the most well-known program is the Leadership Education Advocacy Development Scholarship (LEADS) program at the University of Colorado Denver School of Medicine: a track for medical students with exposure to advocacy training throughout their four years of medical school and an opportunity to practice advocacy through a paid internship after their first year (Long, 2011).
On an international scale, one exciting area of physician advocacy has been the expansion of global surgery initiatives within the past decade. In 2015, the World Health Organization signed World Health Assembly 68.15 recognizing surgery and anesthesia a fundamental component in building a country’s health infrastructure (Price, 2015). In 2021, the US global health appropriations bill designated the use of United States Agency of International Development funds in part to treating “neglected surgical conditions” such as cleft lip and hernias in developing countries (“Explanatory Statement,” 2021). This expansion of care for surgical diseases globally has only become possible due to the work of physician advocates within surgery such as the Global Alliance for Surgical, Obstetric, Trauma, and Anesthesia Care (the G4 Alliance): an alliance of several organizations fighting for surgical equity (“The G4 Alliance,” 2021). One member organization, the International Student Surgical Network (InciSioN), is a medical student organization that champions the expansion of global surgery (“InciSioN,” 2021). With the recent surge in global surgery support, it is imperative to train physician advocates who can have impact locally, nationally, and globally in efforts to achieve surgical equity.
Despite increasing interest in physician advocacy and a greater emphasis on SDH in surgery, very few programs have trained medical students or residents to become physician advocates in surgery. One academic center has implemented a mandatory health advocacy curriculum for its first- and second-year surgical residents, in which 76% of participants responded that they learned something meaningful from this experience (Ying, 2019). Thus, there is interest in advocacy training among surgical trainees, and earlier introduction of surgical advocacy at the medical school level can further cultivate this interest as students decide upon their career path. An obstacle to implementation of medical advocacy curricula nationally is perhaps the ambiguity of what advocacy entails. In an implementation of a health disparities course covering advocacy topics for medical students, an analysis of student reflections noted that one student thought of advocacy “as literally speaking out or speaking up for a certain cause, whereas I think that the approach… is [actually] a more encompassing [one] that includes identifying, testing, and intervening, not just raising one’s voice. I don’t have a better term for it, but ‘advocacy’ seems to somehow undersell and nebulize the work that is being done on these topics” (Press, 2015). These studies suggest that further work is required to create an optimal advocacy curriculum for medical students, especially one which encourages participation from medical students interested in surgery and recognizes the many forms that advocacy and social responsibility can take.
In Boston, the organization Socially Responsible Surgery (SRS) was founded in 2014 to introduce medical students at Boston University School of Medicine (BUSM) to how SDH affect surgical patients and provide students with the tools to advocate for change. Since its conception, SRS has expanded into a national organization which aims to bring surgical equity through research, education, service, and health advocacy to medical centers across the country (“Socially Responsible Surgery,” 2021). At BUSM, mentors within SRS have shown medical students that it is possible to balance surgery and healthcare advocacy and have demonstrated the extent to which surgical advocacy can take shape. In 2019, the SRS Advocacy Track for medical students was started to answer the questions how and what. How does one advocate for surgical patients? What are the techniques to accomplish this? Over the past year, we developed and implemented our answer: the Advocacy Toolbox.
The Advocacy Toolbox is a curriculum aimed at teaching preclinical medical students techniques for practicing healthcare advocacy in an actionable manner, while still studying medicine. The Advocacy Toolbox has been implemented with a group of 15 first year medical students with an interest in surgery at BUSM over the 2020-2021 academic year, and qualitative feedback has suggested that students have enjoyed and learned from the curriculum. The curriculum hinges upon three components: 1) mentorship, 2) didactics, and 3) a longitudinal project.
Mentorship is the most important aspect of the curriculum. It is essential that students are exposed to and interact with role models who serve as healthcare advocates within the field of surgery. Through SRS, medical students have regular interaction with surgical trainees and faculty dedicated to health equity, social justice, and medical advocacy. Advocacy resident mentors in SRS have had Masters’ level training in public health with emphasis on health policy. Our faculty advocacy chair has had extensive experience in local, regional, and national advocacy on injury and violence prevention, has sat on national committees, and testified to government bodies regarding surgical advocacy issues. Example events include a panel discussion of attending physicians discussing their career paths and advocacy work to medical students, and a research panel where surgical residents discuss their current advocacy research projects.
Didactics are focused on four key techniques that students can implement in their advocacy efforts: 1) Legislative Advocacy, 2) Research as Advocacy, 3) Engagement and Mobilization of Professional Organizations, and 4) Health Journalism. A one-hour didactic session is devoted to each of these topics, led by speakers working actively with each. Didactic sessions are carried out throughout the fall semester. Legislative Advocacy aims to familiarize medical students with the structure of the American legislative system and how they can contribute to health policy efforts, including speaking to lawmakers, encouraging sponsorship of bills, and providing testimony. It has a special focus on local government and accessible routes of involvement. Research as Advocacy focuses on how research can bring light to health disparities and demonstrates the efficacy of existing interventions that can be used as a call to action for policy change at a hospital, local, state, or national level. Engagement and Mobilization of Professional Organizations introduces students to medical associations and societies. It illuminates how medical students, as members, have a voice in determining the positions of these organizations and how they can use levers such as writing resolutions to affect healthcare policy. Health Journalism discusses the use of writing and social media tools to increase health literacy and information sharing. Table 1 summarizes the learning objectives for each topic.
The didactics covered in the fall semester lay the groundwork for a longitudinal project during the spring semester, where students select an area of healthcare advocacy about which they are passionate and pursue a project via an advocacy technique they find interesting. Advocacy projects need not be limited to surgery, but students are encouraged to pick a surgical topic if interested. Over the course of the spring semester, students practice applying their chosen advocacy technique to their topic. During this time, students are supported by leaders of the Advocacy Toolbox curriculum and faculty mentorship through several check-in meetings where students share their work with one another and discuss any roadblocks they encounter.
Of the 15 medical students who participated in our inaugural implementation of the Advocacy Toolbox, 12 students continued to pursue longitudinal projects during the second semester of the curriculum. These projects ranged from enacting local change at the medical school level to researching national level reforms related to surgical disease. For example, one student started working with the School of Medicine’s Vertical Integration Group to integrate more training on transgender patient care and gender-affirming surgery into the pre-clinical curriculum. Another student was interested in using research as a tool for advocacy and began investigating if open hemodialysis ports increased the risk for post-operative infection amongst patients experiencing homelessness. One student partnered with a Boston organization working to expand clinical trial access in a more equitable way. Other students engaged with the community creating infographics to combat Covid-19 vaccine hesitancy for local community health centers, and contacting state government officials to work on illicit substance decriminalization in Massachusetts. Students agreed that participation in these longitudinal projects helped shape their understanding of what it means to be a physician advocate.
1. How legislature works
2. Brief overview of US civics
3. How to advocate as a medical student
-Going to the State House
Research as Advocacy
1. Review of social determinants
2. What are examples of this kind of research
3. How do you translate research into advocacy
4. What are active projects at your local institution
Mobilization of Professional Organizations
1. What role do medical societies play in health advocacy
2. Examples of policy changes brought about by organizational advocacy
3. Medical societies as a funding source for advocacy and professional lobbying
4. How to write a resolution for national, state, or institutional professional organizations
1. What is an op-ed and how do you write one
2. How to explain science to a general audience
3. How to leverage social media and technology for information sharing
4. Journalism in the digital world and its impacts on health
5. How do you tell a compelling story to promote change
Table 1. Learning objectives for each didactic session of the Advocacy Toolbox.
For many students who are interested in both public health and surgery, SRS aims to provide validation that there are surgeons who are actively involved in advocacy efforts and to push for greater emphasis on advocacy training for medical students interested in surgery. To formalize this, the leaders of the SRS Advocacy Track have created the Advocacy Toolbox, a curriculum designed to expose first year medical students to the techniques by which they can advocate for their patients and their communities within the field of surgery. With expansion and evaluation of the Advocacy Toolbox curriculum, we hope to increase the number of future surgeons who have a passion for social responsibility and reify the role of the surgeon as a health advocate. By doing so, we can ensure that surgical involvement in public health efforts is the norm and not the exception.
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The authors have no conflicts of interest to disclose. Miriam Y Neufeld is supported, in part, by a T32 training grant (GM86308).
Max Zhu is with Boston University School of Medicine.
Miriam Y. Neufeld, MD, MPH is a Surgical Resident and Researcher advocating for violence prevention, sensible firearm policy, and surgical equity.
Sarah G. Keller, BFA is a third-year medical student at Boston University School of Medicine. At BUSM she was a leader of the student groups SRS (Socially Responsibly Surgery) and CLEAR (Creating Leadership and Education to Address Racism).
Alexandra Leigh Boden earned their BS in Biology and Anthropology at Tufts University and is now a current medical student at the Boston University School of Medicine. They served as a student leader of Socially Responsibly Surgery at BUSM, and plan to continue pursuing work in advocacy, education, and LGBTQ+ issues.
Megan G. Janeway, MD is with Boston University School of Medicine and Boston Medical Center.
Lisa Allee, MSW, LICSW is the Director of the Community Violence Response Team and Injury Prevention at Boston Medical Center in the Department of Surgery, Section of Trauma. She is on faculty as an Assistant Professor of Surgery at Boston University Medical School and is the Faculty lead for Advocacy in the Socially Responsible Surgery group. In her role, Lisa engages in research, advocacy, education and service.
Tracey Dechert, MD, FACS, Associate Professor of Surgery at Boston University School of Medicine, created Socially Responsible Surgery (SRS) which advocates for the concept of social responsibility as a core value in surgical practice and surgery as an essential component of health