key: cord-0748108-8l37r84q
authors: Yu, Zizi; Moustafa, Danna; Kwak, Ruby; O'Connor, Daniel M; Cavanaugh-Hussey, Margaret W; Huang, Jennifer T; LaChance, Avery H
title: Engaging in advocacy during medical training: assessing the impact of a virtual COVID-19-focused state advocacy day
date: 2021-01-13
journal: Postgrad Med J
DOI: 10.1136/postgradmedj-2020-139362
sha: 760c1e66a798a9e60999e17eec623f5bd2885dea
doc_id: 748108
cord_uid: 8l37r84q

PURPOSE: The physician voice is crucial to shaping health policy and public health guidelines, particularly during COVID-19. However, there are gaps in health policy and advocacy education within graduate medical education. This study sought to characterise the impact of a virtual COVID-19 focused advocacy day among medical trainees in Massachusetts. STUDY DESIGN: The half-day event featured speakers drawn from government relations experts, physician advocates, and state and federal legislators as well as breakout discussions among attendees. A 25-question Redcap survey and list of resources/opportunities for continued advocacy was administered to all participants at event’s conclusion on 19 May 2020. RESULTS: There were 60 responses from 141 participants (43% response rate). One-third reported no prior formal health policy instruction, and over half reported getting information from news publications, social media and peers. 58% believed physician involvement in advocacy to be ‘extremely important’ prior to COVID-19; 83% believed the same after onset of COVID-19 (p<0.0001). The most common barriers to advocacy engagement were lack of time and knowledge. Most attendees felt participation increased their knowledge and likelihood to engage in the COVID-19 response, imparted useful skills/knowledge for continued advocacy, increased their interest in future similar events, and that such events should be available to all trainees. CONCLUSIONS: Trainees recognise the importance of health policy and advocacy and value opportunities to gain the necessary skills/knowledge to effect tangible change. Virtual advocacy days can be replicated nationwide to help trainees learn about advocacy efforts and find their legislative voices during COVID-19 and beyond.

The COVID-19 crisis has significantly altered both the delivery of healthcare and undergraduate and graduate medical education worldwide. In confronting these unprecedented challenges, the physician voice is crucial to shaping health policy and public health guidelines for the well-being of our communities. However, health policy and advocacy education have traditionally been lacking within US graduate medical education, with most non-medical educational efforts focusing on business preparedness and practice management among residents and recent graduates across many medical specialties. [1] [2] [3] [4] These gaps in health policy and advocacy education can leave trainees feeling frustrated and paralysed; while trainees feel it is essential for physicians to participate in advocacy efforts to shape health policy, their perceived ability to do so is curtailed by a lack of knowledge surrounding these areas. 5 6 Further, lack of health policy and advocacy awareness can also be detrimental to the quality and equity of patient care provided, prompting calls to address this critical training gap. [7] [8] [9] [10] [11] [12] [13] [14] In order to meet the need for increased advocacy education, a group of medical students, residents and faculty in the Harvard Combined Dermatology Residency Training Programme organised a cross-specialty virtual COVID-19 advocacy day for medical trainees across the state of Massachusetts. The goals of the event were to (1) discuss ways in which physicians and medical trainees can play a role in advocacy; (2) learn about local, state and federal COVID-19 advocacy efforts; (3) brainstorm potential advocacy opportunities following the event; and (4) empower trainees to find their legislative voice during COVID-19 and beyond. This study characterises participants' experiences and attitudes towards advocacy engagement as well as the impact of the advocacy day.

The half-day virtual event was hosted on Zoom and took place on 19 May 2020 (table 1) . The event featured speakers drawn from government relations experts in the Massachusetts Medical Society, physician advocates, and state and federal legislators. Each of the four speakers addressed the group in a 35-45 min large group session. Topics discussed in these sessions included an overview of physician engagement in advocacy, the impact of COVID-19 on the 2020 legislative cycle in Massachusetts, physician advocacy through task force participation and development of an international COVID-19 patient registry, tips for media interviews and general communication skills, the importance of addressing health disparities during the COVID-19 pandemic, and updates on specific local, state, and national COVID-19 legislative actions. Each of the four talks was followed by a 15 min breakout group discussion among attendees at similar levels of training. Breakout rooms were preassigned prior to the event, in order to kickstart ongoing conversation and brainstorm potential advocacy action items. Publicity of the event and Original research recruitment of participants was conducted by email through listservs of trainees and medical students maintained by Massachusetts area hospitals, medical school student affairs offices and student-run Dermatology Interest Groups.

A 25-question Redcap survey was administered to all participants through the Zoom chat feature at the conclusion of the event on 19 May 2020, as well as in follow-up emails in order to assess participants' experiences and attitudes towards health policy and advocacy engagement generally, COVID-19specific issues, and impact of the event itself. Question formats included binary yes-no questions as well as multiple choice questions in which responses were rated across a spectrum of 3-5 choices (including a neutral option). Following the event, we also distributed (1) a 'how-to' primer for advocating at the local, state and federal level (2) a list of advocacy resources and opportunities, and (3) concrete advocacy action items moving forward, ranging from improving health equity for our vulnerable populations to maintaining ongoing access to telehealth for our patients. A Slack community was additionally created with individual channels for specific issues to facilitate continued conversation. Statistical analyses were completed using Stata/SE V.15.1.

There were 60 responses from 141 participants (43% response rate). Most participants were women (75%) with roughly equal distribution of medical students, residents and faculty members (table 2). Over half of participants were dermatologists or medical students intending to pursue dermatology. One-third of participants reported no prior formal health policy instruction, and over half reported getting their health policy information from news publications, social media and peer discussions. Fiftyeight per cent of participants believed physician involvement in advocacy to be 'extremely important' prior to COVID-19, while 83% believed the same after onset of COVID-19 (p<0.0001).

The most commonly cited barriers to engaging in advocacy were lack of time and knowledge, both for participants themselves and what participants believed to be true for physicians more generally. However, significantly more participants indicated lack of interest (p<0.0001), lack of knowledge (p=0.017) and belief that advocacy is unimportant (p=0.0001) as general physician barriers rather than their own personal barriers to advocacy engagement. The vast majority of attendees felt that participating in the event increased their knowledge and likelihood to become involved in issues related to the COVID-19 response, imparted useful skills and knowledge for continued advocacy in their future careers, increased their interest in participating in future similar events, and that an event like this should be made available to all medical trainees (figure 1).

Our study demonstrates that medical trainees recognise the importance of health policy and advocacy and highly value educational opportunities to gain the skills/knowledge necessary to effect tangible change. The COVID-19 pandemic has magnified the importance of physician involvement in shaping public health policies and guidelines, and the need to train physicians to effectively advocate on behalf of their patients and communities has never been more critical. While some participants reported significant education and work experiences in the advocacy sphere, the majority indicated a lack of both knowledge and time to engage in this work. In particular, many participants expressed difficulty finding suitable mentors and opportunities in this arena. We believe that an event similar to this can be replicated in many settings nationwide and worldwide, serving as valuable means to learn about local, state and federal advocacy efforts; network with like-minded people with similar interests and goals; and find one's legislative voice during COVID-19 and beyond. Study limitations include regional bias given the single state nature of the event. The views represented among participants of this event may not be reflective of those of medical trainees nationwide. Reporting bias and selection bias, in which the more engaged or interested individuals were more likely to complete a voluntary survey, may also play a role in our results. However, the latter suggests that our results may over-capture the current state of trainees engagement and knowledge, in which case even more efforts to educate the trainee population are warranted.

In the future, we hope to more closely examine the range of policy and advocacy focused curricular, elective, research and enrichment opportunities provided to medical trainees, given the need for and benefits of sustained, longitudinal education and involvement in this arena. Nevertheless, the positive feedback and high number of participants, particularly among 

► The COVID-19 pandemic presents a unique opportunity for physicians to help shape public health policies and guidelines, and health policy and advocacy training has never been more crucial. ► While some medical trainees report significant education and work experiences in the policy and advocacy sphere, there remains a gap in educational opportunities for them to gain the skills and knowledge necessary to effect tangible change. ► Virtual health policy and advocacy events can be easily replicated and are a powerful means to help medical trainees find their legislative voice during COVID-19 and beyond.

► Given the current lack of and demonstrated benefits of sustained, longitudinal health policy and advocacy education, there is a need to closely examine the range of curricular, elective, research and enrichment opportunities in these areas currently available to medical trainees. ► There is a need to better understand the barriers to engaging in health policy and advocacy during medical training and beyond in order to be able to address and overcome these barriers. ► There is additionally a need to develop and explore alternative innovative educational platforms, strategies and events in order to better deliver important knowledge and experiences in health policy and advocacy, particularly in light of increasing curricular and time constraints. What is already known on the subject ► Medical trainees feel it is essential for physicians to participate in advocacy efforts to shape health policy. ► Health policy and advocacy education have traditionally been lacking within US graduate medical education.

Original research student trainees, supports the demand for this type of experience and highlights the vital role that medical students and future physicians can play in leading the effort to make meaningful, evidence-based improvements in our healthcare system and society.

Trainees recognise the importance of health policy and advocacy and value opportunities to gain the necessary skills and knowledge to effect tangible change. A virtual advocacy day like this can be widely replicated to help trainees learn about advocacy efforts and find their legislative voices during COVID-19 and beyond.

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The authors would like to acknowledge the remainder of the advocacy day planning committee, including Elena Hawryluk, MD, PhD, Sadaf Hussain, MD, Julia Benedetti, MD and Andrea Hinton, MD whose hard work and thoughtful input helped make the event a success. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Patient consent for publication Not required.

The Partners Healthcare IRB approved this study.Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. Not applicable.This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

Zizi Yu http:// orcid. org/ 0000-0001-8566-0777