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Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
EDUCATION
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents? Julie Hakim, MD,1 Amanda Black, MD, MPH,1,2,3 Andrée Gruslin, MD,1,3 Nathalie Fleming, MD1,2,3 1
Department of Obstetrics, Gynecology, and Newborn Care, The Ottawa Hospital, University of Ottawa, Ottawa ON
2
Division of Pediatric and Adolescent Gynecology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa ON
3
Ottawa Hospital Research Institute, Ottawa ON
Abstract
Résumé
Objectives: Health advocacy (HA) is a core competency in Canadian obstetrics and gynaecology postgraduate programs. Our objectives were to assess awareness and understanding of the health advocate role among trainees, their current HA training and exposure, and the desire and needs for future HA training.
Objectifs : La promotion de la santé (PS) est une compétence de base qui figure dans les programmes canadiens d’études supérieures en obstétrique-gynécologie. Nous avions pour objectif d’évaluer la connaissance et la compréhension du rôle de promoteur de la santé chez les stagiaires, la formation actuellement vouée à la PS et l’exposition des stagiaires à ce concept à l’heure actuelle, ainsi que les souhaits et les besoins pour ce qui est de l’avenir de la formation vouée à la PS.
Methods: An anonymous, cross-sectional, Internet-based, selfreported health advocacy questionnaire was distributed to Canadian obstetrics and gynaecology trainees. Descriptive analysis was conducted for all study variables. Chi-square tests, Cochran-Armitage trend test, and Fisher exact test were performed where appropriate. Results: Most trainees (93.9% of respondents) were aware of the CanMEDS HA role and that it is a training objective (92.9%). Only 52.4% had clear objectives while 58.4% understood the role requirements. Most trainees (95.1% of respondents) felt HA was important to address during training. Only 30.4% had HA training, and just 36.3% felt their training needs were addressed. Training included teaching sessions (11.9%), clinical teaching (4.7%), and role modelling (4.7%). Although 82.9% of respondents had HA opportunities with patients, there were fewer opportunities at community (45.1%) and societal (30.0%) levels. Awareness of community groups and activities was low (28.6%), and few (20.0%) had participated in community advocacy programs during their residency. Incorporating advocacy activities into training was valued (80.0%). Many residents supported mandatory HA training (60.0%), more training time on HA experiences (66.3%), and HA experiences during protected time (71.3%). Conclusion: Awareness of and interest in the HA role is high, but clear objectives and training are lacking or inadequate. A standardized curriculum would ensure health advocacy exposure and emphasize active participation in community and societal activities. Trainees support this training during protected time. Key Words: Health advocacy, curriculum, obstetrics and gynaecology, postgraduate medical education Competing Interests: None declared. Received on February 4, 2013 Accepted on February 27, 2013
Méthodes : Un questionnaire en ligne, transversal, autodéclaré et anonyme a été distribué aux stagiaires canadiens en obstétrique-gynécologie. Une analyse descriptive a été menée pour toutes les variables à l’étude. Des tests de chi carré, un test de tendance de Cochran-Armitage et un test exact de Fisher ont été menés, lorsque cela s’avérait approprié. Résultats : La plupart des stagiaires (93,9 % des répondants) connaissaient le rôle PS CanMEDS et savaient qu’il s’agissait d’un objectif de formation (92,9 %). Seulement 52,4 % d’entre eux disposaient d’objectifs clairs à ce sujet, tandis que 58,4 % comprenaient les exigences de ce rôle. La plupart des stagiaires (95,1 % des répondants) estimaient que la PS constituait un sujet important à aborder dans le cadre de la formation. Seulement 30,4 % des stagiaires disposaient d’une formation en PS et tout juste 36,3 % d’entre eux estimaient que leurs besoins de formation étaient satisfaits. Dans le cadre de la formation, on trouvait les sessions d’enseignement (11,9 %), l’enseignement clinique (4,7 %) et l’imitation de rôles (4,7 %). Bien que 82,9 % des répondants aient disposé d’occasions de PS auprès des patientes, les occasions de ce genre étaient moins nombreuses aux niveaux communautaire (45,1 %) et sociétal (30,0 %). La connaissance des activités et des groupes communautaires était faible (28,6 %), et peu de répondants (20,0 %) avaient participé à des programmes communautaires de promotion de la santé au cours de leur résidence. L’intégration des activités de promotion de la santé à la formation était appréciée (80,0 %). De nombreux résidents soutenaient la formation obligatoire en PS (60,0 %), l’octroi d’un plus grand nombre d’heures de formation aux expériences de PS (66,3 %) et la tenue d’expériences de PS au cours du temps réservé (71,3 %).
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Conclusion : Bien que la connaissance du rôle de PS et l’intérêt envers ce dernier soient élevés, il existe des lacunes en matière de formation et d’octroi d’objectifs clairs. Un curriculum standardisé permettrait d’assurer l’exposition des stagiaires au concept de la promotion de la santé et faciliterait leur participation active à des activités communautaires et sociétales. Les stagiaires soutiennent l’offre d’une telle formation dans le cadre du temps réservé.
J Obstet Gynaecol Can 2013;35(6):539–546
INTRODUCTION
T
he practice of health care has changed dramatically since the 1990s. In addition to being medical experts, health care professionals are expected to play a broader role in the direction and provision of care in their communities and society. The Royal College of Physicians and Surgeons of Canada was at the forefront of change in medical education with the introduction of the CanMEDS program.1 CanMEDS is an innovative framework of physician roles that has been incorporated into the objectives for residency training, examinations, and program accreditation across Canada. There are seven CanMEDS roles, each outlining key physician competencies. The central role is that of a medical expert, while the other six are the roles of communicator, collaborator, manager, health advocate, scholar, and professional. The RCPSC has defined HA as “using [physicians’] expertise and influence to advance the health and well-being of individual patients, communities, and population.”1 The four key competencies of physicians as health advocates are to be able to respond to individual patient health needs and issues as part of patient care; to respond to the health needs of the communities that they serve; to identify the determinants of health populations that they serve; and to promote the health of individual patients, communities, and populations.1 Although the role of the health advocate is one of the core competencies in the CanMEDS framework, it has long been identified as an area of weakness for residents and an area of deficiency in postgraduate training.2 Previous studies examining residents’ awareness of and attitudes towards the health advocate role have found that most residents were not adequately aware of the health advocate role, despite its being a core competency. In a 2007 study of final ABBREVIATIONS HA
health advocacy
PGY
postgraduate year
RCPSC The Royal College of Physicians and Surgeons of Canada
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year (PGY-5) residents in urology postgraduate training programs across Canada, Leveridge et al. found that 21% of surveyed residents were not aware of the existence of the health advocate role.3 Similarly, a 2005 survey of residents at Queen’s University revealed that none of the trainees knew of the health advocate role or its expectations for learners.4 Finally, a 2006 survey of recent graduates in general internal medicine at the University of British Columbia found that graduates felt inadequately prepared for the role of health advocate.5 Health advocacy is felt to be one of the more difficult roles to teach and evaluate. A 2001 RCPSC survey found that this is partly due to the lack of an “operational” curriculum framework or any parameters for assessing residents’ competency.6 Other barriers to providing adequate teaching of the health advocate role include an inadequate definition, insufficient resident and staff time, a lack of remuneration, and the broad scope of health advocacy.2 As such, this CanMEDS role has traditionally been learned through experience and role modelling. Despite the mandate from the RCPSC that the CanMEDS role of health advocate be one of the key physician competencies addressed during postgraduate training programs, no formal standardized health advocacy curriculums in Canadian obstetrics and gynaecology residency training programs have been described or evaluated in the literature. The objectives of this study were: 1. to determine the level of obstetrics and gynaecology postgraduate trainee awareness and understanding of the role of the health advocate, 2. to identify the amount and types of training and exposure to health advocacy that trainees currently have, and 3. to determine trainees’ desire for more formal training in health advocacy and the most effective format for delivering this training. METHODS
A cross-sectional survey was conducted during the 2010 to 2011 academic year. Canadian postgraduate obstetrics and gynaecology trainees at 15 of Canada’s postgraduate training sites were invited to complete an anonymous, cross-sectional, Internet-based, self-reported questionnaire on health advocacy. The survey was provided in English or French according to the preference of the respondent. A 41-question needs-assessment survey based on work by Leveridge et al.3 was designed (online eAppendix). Respondents were asked to provide demographic data.
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
In addition, five main themes were assessed, including awareness of the health advocate role, past exposure to HA, the importance of HA in training and practice, participation in HA activities (individual/community/society), and HA training during residency and in the future. A five-point Likert response scale was used to determine degrees of familiarity with the health advocate role, the perceived importance of HA, and the desire for HA training. Before the survey was administered it was pilot tested for comprehensibility and response burden. An introductory letter was distributed to all 16 Canadian obstetrics and gynaecology program directors asking them to take part in the survey. Program directors who agreed to participate would then distribute a letter of invitation with the online survey link to all of their obstetrics and gynaecology residents. Respondents were able to access the survey on an online survey site (www.surveymonkey.com). A reminder follow-up letter was sent to all program directors six months later. Participants provided informed consent on the first page before entering the actual questionnaire. Descriptive analysis was conducted for all study variables. Chisquare tests were used to explore within-group differences for awareness of the health advocacy role, importance of health advocacy, and desire for future training. CochranArmitage trend test was performed to test if there was any trend with an increase in postgraduate year training level or with past exposure to health advocacy activities. Fisher exact test was used when expected cell counts of < 5 made up 25% or more of a table. Statistical significance was set at an alpha level of 0.05. All analyses were performed using SAS-PC statistical software version 9.2 (SAS Institute Inc., Cary NC). The survey was approved by The Ottawa Hospital Research Ethics Board and the University of British Columbia Research Ethics Board.
Table 1. Demographic characteristics of resident respondents N = 84 n (%)
Demographic characteristic PGY 1
29 (34.5)
2
17 (20.2)
3
12 (14.3)
4
18 (21.4)
5
7 (8.3)
7
1 (1.2)
Gender Male
8 (9.5)
Female
76 (90.5)
Age, years 18 to 25
5 (6.9)
26 to 30
52 (72.2)
31 to 35
11 (15.3)
36 to 40
2 (2.8)
> 41
2 (2.8)
Country of medical school training Canada
81 (96.4)
United States
1 (1.2)
Other
2 (2.4)
Degree MD
69 (82.1)
MD and higher (MPH, MSc, MA, PhD)
15 (17.9)
School University of Ottawa
36 (42.8)
University of Toronto
13 (15.5)
University of Saskatchewan
7 (8.3)
Université de Laval
7 (8.3)
Université de Montréal
5 (5.9)
University of Western Ontario
4 (4.7)
University of British Columbia
4 (4.7)
McGill University
3 (3.5)
Other (Memorial University, Queen’s University, University of Manitoba)
5 (5.9)
RESULTS
Fifteen of the 16 Canadian obstetrics and gynaecology postgraduate training programs agreed to take part in the study. Responses were received from participants at 12 of the 15 programs that agreed to participate. Of the 470 eligible participants at the 15 sites, 84 completed the online survey (68 English, 16 French; total response rate = 17.8%). The demographic characteristics of the 84 respondents who completed the survey are shown in Table 1. Sixty-nine percent of the respondents were junior level residents (PGY1, 2, or 3), and the majority were Canadian medical graduates.
Awareness of the Health Advocate Role
The majority (93.9%) of respondents stated that they were aware of the health advocate role as defined by CanMEDS (Table 2). Awareness did not vary by year of residency training (P = 0.93), gender (P = 0.28), age (P = 0.11), or country of medical school graduation (P = 0.90). Most respondents (95.7%) correctly identified the key components of the health advocate role. Although 92.9% were aware that HA was an objective of their residency training, only 52.4% agreed that the role of HA had been defined with clear objectives during their JUNE JOGC JUIN 2013 l 541
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Table 2. Attitudes of respondents towards health advocacy Agree n (%)
Disagree n (%)
Not sure n (%)
Aware of the HA role as defined by CanMEDS
77 (93.9)
1 (1.2)
4 (4.8)
The role of HA has been defined with clear objectives
43 (52.4)
16 (19.5)
23 (28.0)
Understand what is required to fulfill HA role
48 (58.5)
10 (12.2)
24 (29.3)
Health advocate is an important CanMEDS role to address
78 (95.1)
0 (0.0)
4 (4.9)
Formal HA training would be valuable in future practice
66 (80.5)
3 (3.6)
12 (14.6)
I feel a personal obligation to advancing the practice of my specialty through HA
73 (89.0)
1 (1.22)
7 (8.54)
Health promotion will play a substantial role in my future practice
70 (85.4)
2 (2.44)
9 (10.9)
Disease prevention will play a substantial role in my practice
67 (97.1)
0 (0.0)
2 (2.9)
Question
residency. There was no significant increase in having clear objectives with increasing level of postgraduate training (P = 0.14). Many (41.5%) did not understand what was required of them as a health advocate in obstetrics and gynaecology. Importance of Health Advocacy in Training and Practice
Most respondents (95.1%) agreed that it was important to address the CanMEDS health advocate role during residency training, and 80.5% agreed that formal HA training would be valuable when they eventually begin practice. Many (89.0%) felt a personal obligation to advancing their specialty through HA. Most agreed that disease prevention and health promotion would be significant in their future practice (97.1% and 85.4%, respectively). The significance of the role of disease prevention in future practice did not vary by age or level of training. Similarly, the perceived role of health promotion in future practice did not vary significantly with age (P = 0.26) or year of training (P = 0.78). Participation in and Exposure to Health Advocacy Activities
Before starting residency, 57.1% of resident respondents had participated in HA programs; of these, 43.0% were at the local level, 7.0% at the national level, and 11.0% international level. There was no significant difference in previous health advocacy experience by postgraduate training level (P = 0.67). Many (80.5%) agreed that they would be more likely to engage in HA activities after residency if they had the opportunity to participate in HA activities during residency training. Most respondents (82.9%) agreed that within their training program there were opportunities for HA and health promotion at the patient level, while 45.1% agreed there were opportunities at the community level, and 30.0% felt there were opportunities at the societal level. Many 542 l JUNE JOGC JUIN 2013
(71.4%) were not aware of HA groups or activities related to obstetrics and gynaecology in their communities, and 80.0% of respondents had not participated in any community HA groups or activities during their residency. There was no significant difference in awareness of HA opportunities in the community between residents who had formal training from their university or department and those who did not. Training in Health Advocacy
Only 27.5% of respondents agreed that there was formal HA training available at their university, and only 30.4% agreed that there was formal training available in their obstetrics and gynaecology department (Table 3). Training occurred in dedicated teaching seminars (11.9%), during clinical teaching encounters (4.7%), through participation in advocacy projects (4.7%), and through role modelling (4.7%). Evaluations of the health advocate role occurred through objective structured clinical examinations (29.8%), in-training evaluation reports (32.1%), written assignments (7.1%), and oral presentations (9.5%). No respondents were evaluated as part of a community intervention. With respect to faculty, only 38.8% of respondents agreed that faculty frequently addressed health advocacy issues. Faculty members were perceived to address HA issues during clinical teaching experiences (54.4%), during dedicated teaching sessions (40.0%), or through role modelling (62.3%). Most respondents (80.5%) agreed that more formal training and exposure to HA would be a valuable addition to their residency program, and 60.0% felt this should be a mandatory part of training. Only 36.3% of respondents agreed that their program was adequately addressing their HA training needs. The perceived adequacy of HA training did not vary significantly by training level (P = 0.95). Whereas 66.3% of respondents agreed that they would
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
Table 3. Amount and types of HA training and evaluation Question
n (%)
Formal training in HA is available at my university Agree
19 (27.5)
Disagree
3 (4.3)
Not sure
47 (68.1)
Formal training in HA is available in my department Agree
21 (30.4)
Disagree
10 (14.5)
Not sure
38 (55.1)
HA training occurs in my university or department by* Clear objectives
15 (17.8)
Dedicated teaching seminars
10 (11.9)
Clinical teaching encounters
4 (4.7)
Advocacy projects
4 (4.7)
Role modelling
4 (4.7)
Other (unsure)
5 (5.9)
No formal training in HA
22 (26.1)
Evaluation of the HA role occurred by* OSCE
25 (29.8)
ITER
27 (32.1)
Written assignments
6 (7.1)
Oral presentations
8 (9.5)
Community interventions
0 (0.0)
No formal evaluation occurs
11 (13.1)
Unsure of method of evaluation
21 (25.0)
Other (unsure, clinical assessments)
5 (5.9)
*Subjects could choose more than one response ITER: in-training evaluation reports.
support spending additional time during their residency on rotations concentrating on HA experiences, 71.3% stated they would do this only if the time were protected. Senior residents were significantly less likely to support spending additional time on HA activities than junior residents (P = 0.01). Overall, 67.5% agreed that a formal HA curriculum would allow them to better respond to the needs of their patients and community in the future. DISCUSSION
While there have been calls for reform to medical education related to health advocacy training for years, this is the first study to assess the level of awareness and understanding of the health advocate role in Canadian obstetrics and gynaecology training programs. In addition, we have identified the types of HA training currently provided and the desire for opportunities to improve HA educational experiences.
This study demonstrates that while awareness of the role of the health advocate is high among residents in obstetrics and gynaecology across Canada, there remains a lack of clearly defined objectives for the role. Unfortunately, the observed need for definition and clarity with regard to the objectives and expectations of the role of the health advocate at the different levels of training is not new; other studies have reported similar findings.4,5,7 In one of the first health advocacy studies published in 2005, Verma et al. held a series of focus groups on health advocacy for residents and staff at Queens University.4 All four focus groups, particularly the faculty groups, felt that the definition of a health advocate required clarity, especially patient-level advocacy versus advocacy at the broader and more complex community and society levels. The study concluded that “little [was] known about how to teach and evaluate the role of the health advocate.”4 A 2006 study of Canadian general internal medicine training program graduates also concluded that the broad scope of “advocacy” contributed JUNE JOGC JUIN 2013 l 543
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to the lack of clarity on expectations by its teachers and learners.5 In 2008, Flynn and Verma suggested that a major barrier to effectively teaching this competency stemmed from the “lack of an ‘operational’ curriculum framework.”8 Despite the lack of clearly defined objectives and expectations for the role of the health advocate, 95.1% of residents surveyed in our study still felt that HA was an important issue to address during training regardless of age, training level, or previous HA exposure. Formal training in HA is still suboptimal, with only about 30.5% of residents receiving any kind of formal instruction on this core competency. Many postgraduate programs still rely heavily on “role modelling”; only 15.6% of residents who responded received teaching sessions as part of their formal training in HA. This is consistent with the findings of the study by Verma et al., which found that most participants learned from role models, from their innate sense of values, or from their parents.4 Residents in that study also reported that the interest and personal skills of faculty determined whether advocacy was taught and evaluated.4 Though role modelling is an invaluable adjunct to formal teaching and engagement in HA activities, it should not replace sound curriculum and a formal teaching process. Not surprisingly, almost two thirds of residents surveyed did not feel their needs with regard to HA training were being adequately addressed. In fact, 60.5% agreed that HA training should be a mandatory part of their residency training curriculum, and this did not vary by age or training level. More than 80.5% felt that incorporating advocacy activities into their postgraduate training would provide valuable experiences, although most agreed with incorporating this training only if it could be done within protected time away from clinical and other residency duties. This is consistent with previous study findings that have highlighted residency time constraints, too many other learning requirements, and residency stress as factors preventing engagement in HA activities.2,4,7 Interestingly, our study found that senior residents were significantly less likely to support spending additional time on HA activities, regardless of whether these were within protected time. This sentiment might be related to the focus that senior residents have on developing the medical expert role as they prepare for licensing examinations and independent practice. Whether or not there is an optimal time during residency training to provide opportunities for engagement in HA training and activities remains to be seen; however, the focus of HA activity engagement should likely begin at the junior level when residents may be more receptive to the experience. 544 l JUNE JOGC JUIN 2013
Although residents may engage in health advocacy activities as medical students, their engagement in these activities during postgraduate training is often lower. This study found that the majority of residents (61.5%) who had previously participated in HA programs or activities were within one year of graduating from medical school. This is a similar finding to Card’s survey of graduating general internal medicine residents, in which 74% of residents stated that they were not currently engaging in health advocacy activities; yet more than 80% had participated in these activities during medical school.5 Perceived barriers to health advocacy engagement in this group included lack of time, insufficient rest, and the high-stress environment of residency. This was similar to the findings of the focus groups conducted by Verma et al. that faculty did not have the time to teach advocacy and that residents were constrained by the need to get “everything else done.”4 Thus, adequate protected time is clearly a necessary component to fostering involvement in HA activities. Card et al. even suggested performing a “time audit” to minimize the time required for engagement so that it would be perceived to be less of a barrier.5 Hufford et al. described a novel training program in community health advocacy for pediatric residents at the University of California called “Communities and Physicians Together.” 9 Those authors stated that “Communities and Physicians Together” blocks should be treated with the same importance as any other component of the residency curriculum. In general, our study found that resident engagement in health advocacy is largely limited to patient-level interactions. While almost 82.9% of residents surveyed engaged in health advocacy and promotion with patients, many felt there were few opportunities for similar engagement at community and societal levels. Unfortunately, awareness of health advocacy community groups and activities in obstetrics and gynaecology was extremely low; this likely contributes to the low rates of health advocacy participation (20.0%) at these levels. Even in residents who had formal HA training available at their university or department, there were low rates of awareness of HA opportunities in their community. As in the study by Card et al.,5 many of the obstetrics and gynaecology residents surveyed revealed high levels of engagement in advocacy groups and activities before entering residency training. Thus a marked drop-off in health advocacy participation during residency seems to be consistent across medical disciplines and appears to reflect disengagement by postgraduate trainees. However, it could also represent a lack of promotion of available opportunities for engagement beyond patient-level interactions by the community and societal-level groups in question or by those providing the HA training. In order to
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
re-engage residents in the health advocate role, increasing awareness of health advocacy opportunities and improved training should be a part of training programs. Physicians have a role as leaders in the health care community, and most residents stated that they would be more likely to engage in HA activities after completion of their residency if they had had the opportunity to participate in similar activities during residency training. It is unclear whether the lack of awareness of community and societal-level advocacy initiatives is due to a lack of publicity from these groups or to the systemic factors inherent in a busy residency program that serve to limit a trainee’s ability to be more engaged (which seems more likely). However, if training in health advocacy is to move beyond patient-level engagement and produce physicians who are willing, passionate, and trained to engage in health advocacy activities on a broader scale, then these systemic factors must be addressed. It is now important to develop a standardized curriculum in health advocacy at the postgraduate medical education level that will expose residents, especially those in their junior years, to health advocacy concepts and applications in a more rigorous and deliberate way during their training. Resident-led local and national projects in our discipline include collaborating with high schools in their sexual health curriculum, establishing a human papillomavirus catch-up vaccination program in the community, participating in the national Papanicolaou smear campaign, and collaborating on national and international initiatives to improve maternalnewborn health. As well, a more objective method of assessment and evaluation of residents’ competency and engagement in HA must be developed and standardized. There have been some modest successes in producing health advocacy curricula in both pediatrics and general internal medicine that could be translated into curricula for postgraduate training in obstetrics and gynaecology.2,10 Both of these successful programs have combined didactic teaching programs with a longitudinal community-based engagement component that have been implemented during residents’ protected time away from clinical duties. With renewed debates on health care reforms, the face of health care service provision will certainly change. There has also been a rapid increase in immigration, with effects on diversity in community makeup and citizens’ health backgrounds. These changes, coupled with the growing involvement of residents on the local, national, and international health care arenas, have required postgraduate medical education programs to ensure that their residents are competent in all aspects of health care provision and that they are prepared and able to influence health policy at the system level, to promote health and access to health
care in their communities, and to adequately serve the individuals they are to treat. Although our study is the first to measure obstetrics and gynaecology residents’ attitudes and exposures to health advocacy training in Canada, it has several limitations. The overall response rate was low, although responses were received from a majority of Canadian residency programs. Participants were self-selected by their willingness to take part in this particular survey and by their comfort with the survey material. This type of self-selection may skew normative data. Voluntary participation may select for residents already passionate about or interested in health advocacy, or those who already had health advocacy training at their university. Another study limitation is that although we received responses from residents in 12 of the country’s 16 training programs, we do not have data on health advocacy training and awareness in the programs that did not respond. Other biases may be related to recall, reporting, or perceived desirability. Resident reflections on teaching and exposures to health advocacy were potentially limited by recall bias. Finally, although the survey was pilot tested, the validation of this questionnaire was minimal; this may have led to response errors by participants who may not have correctly interpreted the questions. CONCLUSION
According to the Royal College of Physicians and Surgeons of Canada, health advocacy is a core competency for physicians; however, there are currently no national standardized health advocacy curricula for Canadian obstetrics and gynaecology postgraduate training programs, and there have been no previous publications describing the current training and desire for future health advocacy training and activities among Canadian obstetrics and gynaecology trainees. Postgraduate trainees are aware of the health advocate role and recognize that health promotion and disease prevention will be an important aspect of their future practice, but they are often unaware of opportunities to engage in health advocacy activities. The current HA training needs of Canadian obstetrics and gynaecology residents may be inadequate to prepare them for practice and for their role as a health advocate. Trainees appear open to the opportunity to obtain further HA training and exposure during residency. The development and evaluation of a standardized national curriculum that exposes trainees to HA in a more rigorous and deliberate way during their training and that emphasizes active participation in community and societal level activities relating to HA should be considered to meet the requirements for this important CanMEDS role. JUNE JOGC JUIN 2013 l 545
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ACKNOWLEDGMENTS
The authors received funding from The Educational Initiatives in Residency Education Fund, University of Ottawa, Ottawa, Ontario The authors would like to acknowledge the contributions of Dr Yanfang Guo, of the OMNI Research Group, Ottawa Ontario, who performed the data analysis for this study. They also wish to thank Dr Jamie Brehauf of The Ottawa Hospital Research Institute Methods Centre who assisted with the development of the questionnaire. REFERENCES 1. The Royal College of Physicians and Surgeons of Canada. The CanMEDS 2005 Physician Competency Framework. Better standards. Better physicians. Better care. Ottawa ON: RCPSC; 2005.
4. Verma S, Flynn L, Seguin R. Faculty’s and residents’ perceptions of teaching and evaluating the role of health advocate: a study at one Canadian university. Acad Med 2005;80(1):103–8. 5. Card SE, Snell L, O’Brien B. Are Canadian general internal medicine training program graduates well prepared for their future careers? BMC Med Educ 2006;6:56. doi:10.1186/1472–6920–6–56 6. Frank JR, Cole G, Lee C, Mikhael N, Jabbour M. Progress in paradigm shift: the RCPSC CanMEDS Implementation Survey. Office of Education, Royal College of Physicians and Surgeons of Canada, University of Ottawa, Ottawa, Canada. Paper presented at the Annual Meeting of the Association of Canadian Medical Colleges; 2003; Quebec City, Quebec. 7. Stafford S, Sedlack T, Fok M, Wong R. Evaluation of resident attitudes and self-reported competencies in health advocacy. BMC Med Educ 2010;10:82–9. 8. Flynn L, Verma S. Fundamental components of a curriculum for residents in health advocacy. Med Teach 2008;30:7,e178–e183.
2. Sohi D, Li A, Wong R. Development and implementation of a CanMEDS health advocacy curriculum for internal medicine residents. Can J Gen Int Med 2010;5(4):164–7.
9. Hufford L, West DC, Paterniti DA, Pan RJ. Community-based advocacy training: applying asset-based community development in resident education. Acad Med 2009; 84:765–70.
3. Leveridge M, Beiko D, Wilson JW, Siemens R. Health advocacy training in urology: a Canadian survey on attitudes and experience in residency. Can Urol Assoc J 2007;1(4):363–9.
10. Chamberlain LJ, Sanders LM, Takayama JI. Child advocacy training curriculum outcomes and resident satisfaction. Arch Pediatr Adolesc Med 2005;159:842–7.
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Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents? Julie Hakim, MD,1 Amanda Black, MD, MPH,1,2,3 Andrée Gruslin, MD,1,3 Nathalie Fleming, MD1,2,3 1
Department of Obstetrics, Gynecology, and Newborn Care, The Ottawa Hospital, University of Ottawa, Ottawa ON
2
Division of Pediatric and Adolescent Gynecology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa ON
3
Ottawa Hospital Research Institute, Ottawa ON
Abstract
Résumé
Objectives: Health advocacy (HA) is a core competency in Canadian obstetrics and gynaecology postgraduate programs. Our objectives were to assess awareness and understanding of the health advocate role among trainees, their current HA training and exposure, and the desire and needs for future HA training.
Objectifs : La promotion de la santé (PS) est une compétence de base qui figure dans les programmes canadiens d’études supérieures en obstétrique-gynécologie. Nous avions pour objectif d’évaluer la connaissance et la compréhension du rôle de promoteur de la santé chez les stagiaires, la formation actuellement vouée à la PS et l’exposition des stagiaires à ce concept à l’heure actuelle, ainsi que les souhaits et les besoins pour ce qui est de l’avenir de la formation vouée à la PS.
Methods: An anonymous, cross-sectional, Internet-based, selfreported health advocacy questionnaire was distributed to Canadian obstetrics and gynaecology trainees. Descriptive analysis was conducted for all study variables. Chi-square tests, Cochran-Armitage trend test, and Fisher exact test were performed where appropriate. Results: Most trainees (93.9% of respondents) were aware of the CanMEDS HA role and that it is a training objective (92.9%). Only 52.4% had clear objectives while 58.4% understood the role requirements. Most trainees (95.1% of respondents) felt HA was important to address during training. Only 30.4% had HA training, and just 36.3% felt their training needs were addressed. Training included teaching sessions (11.9%), clinical teaching (4.7%), and role modelling (4.7%). Although 82.9% of respondents had HA opportunities with patients, there were fewer opportunities at community (45.1%) and societal (30.0%) levels. Awareness of community groups and activities was low (28.6%), and few (20.0%) had participated in community advocacy programs during their residency. Incorporating advocacy activities into training was valued (80.0%). Many residents supported mandatory HA training (60.0%), more training time on HA experiences (66.3%), and HA experiences during protected time (71.3%). Conclusion: Awareness of and interest in the HA role is high, but clear objectives and training are lacking or inadequate. A standardized curriculum would ensure health advocacy exposure and emphasize active participation in community and societal activities. Trainees support this training during protected time. Key Words: Health advocacy, curriculum, obstetrics and gynaecology, postgraduate medical education Competing Interests: None declared. Received on February 4, 2013 Accepted on February 27, 2013
Méthodes : Un questionnaire en ligne, transversal, autodéclaré et anonyme a été distribué aux stagiaires canadiens en obstétrique-gynécologie. Une analyse descriptive a été menée pour toutes les variables à l’étude. Des tests de chi carré, un test de tendance de Cochran-Armitage et un test exact de Fisher ont été menés, lorsque cela s’avérait approprié. Résultats : La plupart des stagiaires (93,9 % des répondants) connaissaient le rôle PS CanMEDS et savaient qu’il s’agissait d’un objectif de formation (92,9 %). Seulement 52,4 % d’entre eux disposaient d’objectifs clairs à ce sujet, tandis que 58,4 % comprenaient les exigences de ce rôle. La plupart des stagiaires (95,1 % des répondants) estimaient que la PS constituait un sujet important à aborder dans le cadre de la formation. Seulement 30,4 % des stagiaires disposaient d’une formation en PS et tout juste 36,3 % d’entre eux estimaient que leurs besoins de formation étaient satisfaits. Dans le cadre de la formation, on trouvait les sessions d’enseignement (11,9 %), l’enseignement clinique (4,7 %) et l’imitation de rôles (4,7 %). Bien que 82,9 % des répondants aient disposé d’occasions de PS auprès des patientes, les occasions de ce genre étaient moins nombreuses aux niveaux communautaire (45,1 %) et sociétal (30,0 %). La connaissance des activités et des groupes communautaires était faible (28,6 %), et peu de répondants (20,0 %) avaient participé à des programmes communautaires de promotion de la santé au cours de leur résidence. L’intégration des activités de promotion de la santé à la formation était appréciée (80,0 %). De nombreux résidents soutenaient la formation obligatoire en PS (60,0 %), l’octroi d’un plus grand nombre d’heures de formation aux expériences de PS (66,3 %) et la tenue d’expériences de PS au cours du temps réservé (71,3 %).
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Conclusion : Bien que la connaissance du rôle de PS et l’intérêt envers ce dernier soient élevés, il existe des lacunes en matière de formation et d’octroi d’objectifs clairs. Un curriculum standardisé permettrait d’assurer l’exposition des stagiaires au concept de la promotion de la santé et faciliterait leur participation active à des activités communautaires et sociétales. Les stagiaires soutiennent l’offre d’une telle formation dans le cadre du temps réservé.
J Obstet Gynaecol Can 2013;35(6):539–546
INTRODUCTION
T
he practice of health care has changed dramatically since the 1990s. In addition to being medical experts, health care professionals are expected to play a broader role in the direction and provision of care in their communities and society. The Royal College of Physicians and Surgeons of Canada was at the forefront of change in medical education with the introduction of the CanMEDS program.1 CanMEDS is an innovative framework of physician roles that has been incorporated into the objectives for residency training, examinations, and program accreditation across Canada. There are seven CanMEDS roles, each outlining key physician competencies. The central role is that of a medical expert, while the other six are the roles of communicator, collaborator, manager, health advocate, scholar, and professional. The RCPSC has defined HA as “using [physicians’] expertise and influence to advance the health and well-being of individual patients, communities, and population.”1 The four key competencies of physicians as health advocates are to be able to respond to individual patient health needs and issues as part of patient care; to respond to the health needs of the communities that they serve; to identify the determinants of health populations that they serve; and to promote the health of individual patients, communities, and populations.1 Although the role of the health advocate is one of the core competencies in the CanMEDS framework, it has long been identified as an area of weakness for residents and an area of deficiency in postgraduate training.2 Previous studies examining residents’ awareness of and attitudes towards the health advocate role have found that most residents were not adequately aware of the health advocate role, despite its being a core competency. In a 2007 study of final ABBREVIATIONS HA
health advocacy
PGY
postgraduate year
RCPSC The Royal College of Physicians and Surgeons of Canada
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year (PGY-5) residents in urology postgraduate training programs across Canada, Leveridge et al. found that 21% of surveyed residents were not aware of the existence of the health advocate role.3 Similarly, a 2005 survey of residents at Queen’s University revealed that none of the trainees knew of the health advocate role or its expectations for learners.4 Finally, a 2006 survey of recent graduates in general internal medicine at the University of British Columbia found that graduates felt inadequately prepared for the role of health advocate.5 Health advocacy is felt to be one of the more difficult roles to teach and evaluate. A 2001 RCPSC survey found that this is partly due to the lack of an “operational” curriculum framework or any parameters for assessing residents’ competency.6 Other barriers to providing adequate teaching of the health advocate role include an inadequate definition, insufficient resident and staff time, a lack of remuneration, and the broad scope of health advocacy.2 As such, this CanMEDS role has traditionally been learned through experience and role modelling. Despite the mandate from the RCPSC that the CanMEDS role of health advocate be one of the key physician competencies addressed during postgraduate training programs, no formal standardized health advocacy curriculums in Canadian obstetrics and gynaecology residency training programs have been described or evaluated in the literature. The objectives of this study were: 1. to determine the level of obstetrics and gynaecology postgraduate trainee awareness and understanding of the role of the health advocate, 2. to identify the amount and types of training and exposure to health advocacy that trainees currently have, and 3. to determine trainees’ desire for more formal training in health advocacy and the most effective format for delivering this training. METHODS
A cross-sectional survey was conducted during the 2010 to 2011 academic year. Canadian postgraduate obstetrics and gynaecology trainees at 15 of Canada’s postgraduate training sites were invited to complete an anonymous, cross-sectional, Internet-based, self-reported questionnaire on health advocacy. The survey was provided in English or French according to the preference of the respondent. A 41-question needs-assessment survey based on work by Leveridge et al.3 was designed (online eAppendix). Respondents were asked to provide demographic data.
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
In addition, five main themes were assessed, including awareness of the health advocate role, past exposure to HA, the importance of HA in training and practice, participation in HA activities (individual/community/society), and HA training during residency and in the future. A five-point Likert response scale was used to determine degrees of familiarity with the health advocate role, the perceived importance of HA, and the desire for HA training. Before the survey was administered it was pilot tested for comprehensibility and response burden. An introductory letter was distributed to all 16 Canadian obstetrics and gynaecology program directors asking them to take part in the survey. Program directors who agreed to participate would then distribute a letter of invitation with the online survey link to all of their obstetrics and gynaecology residents. Respondents were able to access the survey on an online survey site (www.surveymonkey.com). A reminder follow-up letter was sent to all program directors six months later. Participants provided informed consent on the first page before entering the actual questionnaire. Descriptive analysis was conducted for all study variables. Chisquare tests were used to explore within-group differences for awareness of the health advocacy role, importance of health advocacy, and desire for future training. CochranArmitage trend test was performed to test if there was any trend with an increase in postgraduate year training level or with past exposure to health advocacy activities. Fisher exact test was used when expected cell counts of < 5 made up 25% or more of a table. Statistical significance was set at an alpha level of 0.05. All analyses were performed using SAS-PC statistical software version 9.2 (SAS Institute Inc., Cary NC). The survey was approved by The Ottawa Hospital Research Ethics Board and the University of British Columbia Research Ethics Board.
Table 1. Demographic characteristics of resident respondents N = 84 n (%)
Demographic characteristic PGY 1
29 (34.5)
2
17 (20.2)
3
12 (14.3)
4
18 (21.4)
5
7 (8.3)
7
1 (1.2)
Gender Male
8 (9.5)
Female
76 (90.5)
Age, years 18 to 25
5 (6.9)
26 to 30
52 (72.2)
31 to 35
11 (15.3)
36 to 40
2 (2.8)
> 41
2 (2.8)
Country of medical school training Canada
81 (96.4)
United States
1 (1.2)
Other
2 (2.4)
Degree MD
69 (82.1)
MD and higher (MPH, MSc, MA, PhD)
15 (17.9)
School University of Ottawa
36 (42.8)
University of Toronto
13 (15.5)
University of Saskatchewan
7 (8.3)
Université de Laval
7 (8.3)
Université de Montréal
5 (5.9)
University of Western Ontario
4 (4.7)
University of British Columbia
4 (4.7)
McGill University
3 (3.5)
Other (Memorial University, Queen’s University, University of Manitoba)
5 (5.9)
RESULTS
Fifteen of the 16 Canadian obstetrics and gynaecology postgraduate training programs agreed to take part in the study. Responses were received from participants at 12 of the 15 programs that agreed to participate. Of the 470 eligible participants at the 15 sites, 84 completed the online survey (68 English, 16 French; total response rate = 17.8%). The demographic characteristics of the 84 respondents who completed the survey are shown in Table 1. Sixty-nine percent of the respondents were junior level residents (PGY1, 2, or 3), and the majority were Canadian medical graduates.
Awareness of the Health Advocate Role
The majority (93.9%) of respondents stated that they were aware of the health advocate role as defined by CanMEDS (Table 2). Awareness did not vary by year of residency training (P = 0.93), gender (P = 0.28), age (P = 0.11), or country of medical school graduation (P = 0.90). Most respondents (95.7%) correctly identified the key components of the health advocate role. Although 92.9% were aware that HA was an objective of their residency training, only 52.4% agreed that the role of HA had been defined with clear objectives during their JUNE JOGC JUIN 2013 l 541
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Table 2. Attitudes of respondents towards health advocacy Agree n (%)
Disagree n (%)
Not sure n (%)
Aware of the HA role as defined by CanMEDS
77 (93.9)
1 (1.2)
4 (4.8)
The role of HA has been defined with clear objectives
43 (52.4)
16 (19.5)
23 (28.0)
Understand what is required to fulfill HA role
48 (58.5)
10 (12.2)
24 (29.3)
Health advocate is an important CanMEDS role to address
78 (95.1)
0 (0.0)
4 (4.9)
Formal HA training would be valuable in future practice
66 (80.5)
3 (3.6)
12 (14.6)
I feel a personal obligation to advancing the practice of my specialty through HA
73 (89.0)
1 (1.22)
7 (8.54)
Health promotion will play a substantial role in my future practice
70 (85.4)
2 (2.44)
9 (10.9)
Disease prevention will play a substantial role in my practice
67 (97.1)
0 (0.0)
2 (2.9)
Question
residency. There was no significant increase in having clear objectives with increasing level of postgraduate training (P = 0.14). Many (41.5%) did not understand what was required of them as a health advocate in obstetrics and gynaecology. Importance of Health Advocacy in Training and Practice
Most respondents (95.1%) agreed that it was important to address the CanMEDS health advocate role during residency training, and 80.5% agreed that formal HA training would be valuable when they eventually begin practice. Many (89.0%) felt a personal obligation to advancing their specialty through HA. Most agreed that disease prevention and health promotion would be significant in their future practice (97.1% and 85.4%, respectively). The significance of the role of disease prevention in future practice did not vary by age or level of training. Similarly, the perceived role of health promotion in future practice did not vary significantly with age (P = 0.26) or year of training (P = 0.78). Participation in and Exposure to Health Advocacy Activities
Before starting residency, 57.1% of resident respondents had participated in HA programs; of these, 43.0% were at the local level, 7.0% at the national level, and 11.0% international level. There was no significant difference in previous health advocacy experience by postgraduate training level (P = 0.67). Many (80.5%) agreed that they would be more likely to engage in HA activities after residency if they had the opportunity to participate in HA activities during residency training. Most respondents (82.9%) agreed that within their training program there were opportunities for HA and health promotion at the patient level, while 45.1% agreed there were opportunities at the community level, and 30.0% felt there were opportunities at the societal level. Many 542 l JUNE JOGC JUIN 2013
(71.4%) were not aware of HA groups or activities related to obstetrics and gynaecology in their communities, and 80.0% of respondents had not participated in any community HA groups or activities during their residency. There was no significant difference in awareness of HA opportunities in the community between residents who had formal training from their university or department and those who did not. Training in Health Advocacy
Only 27.5% of respondents agreed that there was formal HA training available at their university, and only 30.4% agreed that there was formal training available in their obstetrics and gynaecology department (Table 3). Training occurred in dedicated teaching seminars (11.9%), during clinical teaching encounters (4.7%), through participation in advocacy projects (4.7%), and through role modelling (4.7%). Evaluations of the health advocate role occurred through objective structured clinical examinations (29.8%), in-training evaluation reports (32.1%), written assignments (7.1%), and oral presentations (9.5%). No respondents were evaluated as part of a community intervention. With respect to faculty, only 38.8% of respondents agreed that faculty frequently addressed health advocacy issues. Faculty members were perceived to address HA issues during clinical teaching experiences (54.4%), during dedicated teaching sessions (40.0%), or through role modelling (62.3%). Most respondents (80.5%) agreed that more formal training and exposure to HA would be a valuable addition to their residency program, and 60.0% felt this should be a mandatory part of training. Only 36.3% of respondents agreed that their program was adequately addressing their HA training needs. The perceived adequacy of HA training did not vary significantly by training level (P = 0.95). Whereas 66.3% of respondents agreed that they would
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
Table 3. Amount and types of HA training and evaluation Question
n (%)
Formal training in HA is available at my university Agree
19 (27.5)
Disagree
3 (4.3)
Not sure
47 (68.1)
Formal training in HA is available in my department Agree
21 (30.4)
Disagree
10 (14.5)
Not sure
38 (55.1)
HA training occurs in my university or department by* Clear objectives
15 (17.8)
Dedicated teaching seminars
10 (11.9)
Clinical teaching encounters
4 (4.7)
Advocacy projects
4 (4.7)
Role modelling
4 (4.7)
Other (unsure)
5 (5.9)
No formal training in HA
22 (26.1)
Evaluation of the HA role occurred by* OSCE
25 (29.8)
ITER
27 (32.1)
Written assignments
6 (7.1)
Oral presentations
8 (9.5)
Community interventions
0 (0.0)
No formal evaluation occurs
11 (13.1)
Unsure of method of evaluation
21 (25.0)
Other (unsure, clinical assessments)
5 (5.9)
*Subjects could choose more than one response ITER: in-training evaluation reports.
support spending additional time during their residency on rotations concentrating on HA experiences, 71.3% stated they would do this only if the time were protected. Senior residents were significantly less likely to support spending additional time on HA activities than junior residents (P = 0.01). Overall, 67.5% agreed that a formal HA curriculum would allow them to better respond to the needs of their patients and community in the future. DISCUSSION
While there have been calls for reform to medical education related to health advocacy training for years, this is the first study to assess the level of awareness and understanding of the health advocate role in Canadian obstetrics and gynaecology training programs. In addition, we have identified the types of HA training currently provided and the desire for opportunities to improve HA educational experiences.
This study demonstrates that while awareness of the role of the health advocate is high among residents in obstetrics and gynaecology across Canada, there remains a lack of clearly defined objectives for the role. Unfortunately, the observed need for definition and clarity with regard to the objectives and expectations of the role of the health advocate at the different levels of training is not new; other studies have reported similar findings.4,5,7 In one of the first health advocacy studies published in 2005, Verma et al. held a series of focus groups on health advocacy for residents and staff at Queens University.4 All four focus groups, particularly the faculty groups, felt that the definition of a health advocate required clarity, especially patient-level advocacy versus advocacy at the broader and more complex community and society levels. The study concluded that “little [was] known about how to teach and evaluate the role of the health advocate.”4 A 2006 study of Canadian general internal medicine training program graduates also concluded that the broad scope of “advocacy” contributed JUNE JOGC JUIN 2013 l 543
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to the lack of clarity on expectations by its teachers and learners.5 In 2008, Flynn and Verma suggested that a major barrier to effectively teaching this competency stemmed from the “lack of an ‘operational’ curriculum framework.”8 Despite the lack of clearly defined objectives and expectations for the role of the health advocate, 95.1% of residents surveyed in our study still felt that HA was an important issue to address during training regardless of age, training level, or previous HA exposure. Formal training in HA is still suboptimal, with only about 30.5% of residents receiving any kind of formal instruction on this core competency. Many postgraduate programs still rely heavily on “role modelling”; only 15.6% of residents who responded received teaching sessions as part of their formal training in HA. This is consistent with the findings of the study by Verma et al., which found that most participants learned from role models, from their innate sense of values, or from their parents.4 Residents in that study also reported that the interest and personal skills of faculty determined whether advocacy was taught and evaluated.4 Though role modelling is an invaluable adjunct to formal teaching and engagement in HA activities, it should not replace sound curriculum and a formal teaching process. Not surprisingly, almost two thirds of residents surveyed did not feel their needs with regard to HA training were being adequately addressed. In fact, 60.5% agreed that HA training should be a mandatory part of their residency training curriculum, and this did not vary by age or training level. More than 80.5% felt that incorporating advocacy activities into their postgraduate training would provide valuable experiences, although most agreed with incorporating this training only if it could be done within protected time away from clinical and other residency duties. This is consistent with previous study findings that have highlighted residency time constraints, too many other learning requirements, and residency stress as factors preventing engagement in HA activities.2,4,7 Interestingly, our study found that senior residents were significantly less likely to support spending additional time on HA activities, regardless of whether these were within protected time. This sentiment might be related to the focus that senior residents have on developing the medical expert role as they prepare for licensing examinations and independent practice. Whether or not there is an optimal time during residency training to provide opportunities for engagement in HA training and activities remains to be seen; however, the focus of HA activity engagement should likely begin at the junior level when residents may be more receptive to the experience. 544 l JUNE JOGC JUIN 2013
Although residents may engage in health advocacy activities as medical students, their engagement in these activities during postgraduate training is often lower. This study found that the majority of residents (61.5%) who had previously participated in HA programs or activities were within one year of graduating from medical school. This is a similar finding to Card’s survey of graduating general internal medicine residents, in which 74% of residents stated that they were not currently engaging in health advocacy activities; yet more than 80% had participated in these activities during medical school.5 Perceived barriers to health advocacy engagement in this group included lack of time, insufficient rest, and the high-stress environment of residency. This was similar to the findings of the focus groups conducted by Verma et al. that faculty did not have the time to teach advocacy and that residents were constrained by the need to get “everything else done.”4 Thus, adequate protected time is clearly a necessary component to fostering involvement in HA activities. Card et al. even suggested performing a “time audit” to minimize the time required for engagement so that it would be perceived to be less of a barrier.5 Hufford et al. described a novel training program in community health advocacy for pediatric residents at the University of California called “Communities and Physicians Together.” 9 Those authors stated that “Communities and Physicians Together” blocks should be treated with the same importance as any other component of the residency curriculum. In general, our study found that resident engagement in health advocacy is largely limited to patient-level interactions. While almost 82.9% of residents surveyed engaged in health advocacy and promotion with patients, many felt there were few opportunities for similar engagement at community and societal levels. Unfortunately, awareness of health advocacy community groups and activities in obstetrics and gynaecology was extremely low; this likely contributes to the low rates of health advocacy participation (20.0%) at these levels. Even in residents who had formal HA training available at their university or department, there were low rates of awareness of HA opportunities in their community. As in the study by Card et al.,5 many of the obstetrics and gynaecology residents surveyed revealed high levels of engagement in advocacy groups and activities before entering residency training. Thus a marked drop-off in health advocacy participation during residency seems to be consistent across medical disciplines and appears to reflect disengagement by postgraduate trainees. However, it could also represent a lack of promotion of available opportunities for engagement beyond patient-level interactions by the community and societal-level groups in question or by those providing the HA training. In order to
Are Canadian Postgraduate Training Programs Meeting the Health Advocacy Needs of Obstetrics and Gynaecology Residents?
re-engage residents in the health advocate role, increasing awareness of health advocacy opportunities and improved training should be a part of training programs. Physicians have a role as leaders in the health care community, and most residents stated that they would be more likely to engage in HA activities after completion of their residency if they had had the opportunity to participate in similar activities during residency training. It is unclear whether the lack of awareness of community and societal-level advocacy initiatives is due to a lack of publicity from these groups or to the systemic factors inherent in a busy residency program that serve to limit a trainee’s ability to be more engaged (which seems more likely). However, if training in health advocacy is to move beyond patient-level engagement and produce physicians who are willing, passionate, and trained to engage in health advocacy activities on a broader scale, then these systemic factors must be addressed. It is now important to develop a standardized curriculum in health advocacy at the postgraduate medical education level that will expose residents, especially those in their junior years, to health advocacy concepts and applications in a more rigorous and deliberate way during their training. Resident-led local and national projects in our discipline include collaborating with high schools in their sexual health curriculum, establishing a human papillomavirus catch-up vaccination program in the community, participating in the national Papanicolaou smear campaign, and collaborating on national and international initiatives to improve maternalnewborn health. As well, a more objective method of assessment and evaluation of residents’ competency and engagement in HA must be developed and standardized. There have been some modest successes in producing health advocacy curricula in both pediatrics and general internal medicine that could be translated into curricula for postgraduate training in obstetrics and gynaecology.2,10 Both of these successful programs have combined didactic teaching programs with a longitudinal community-based engagement component that have been implemented during residents’ protected time away from clinical duties. With renewed debates on health care reforms, the face of health care service provision will certainly change. There has also been a rapid increase in immigration, with effects on diversity in community makeup and citizens’ health backgrounds. These changes, coupled with the growing involvement of residents on the local, national, and international health care arenas, have required postgraduate medical education programs to ensure that their residents are competent in all aspects of health care provision and that they are prepared and able to influence health policy at the system level, to promote health and access to health
care in their communities, and to adequately serve the individuals they are to treat. Although our study is the first to measure obstetrics and gynaecology residents’ attitudes and exposures to health advocacy training in Canada, it has several limitations. The overall response rate was low, although responses were received from a majority of Canadian residency programs. Participants were self-selected by their willingness to take part in this particular survey and by their comfort with the survey material. This type of self-selection may skew normative data. Voluntary participation may select for residents already passionate about or interested in health advocacy, or those who already had health advocacy training at their university. Another study limitation is that although we received responses from residents in 12 of the country’s 16 training programs, we do not have data on health advocacy training and awareness in the programs that did not respond. Other biases may be related to recall, reporting, or perceived desirability. Resident reflections on teaching and exposures to health advocacy were potentially limited by recall bias. Finally, although the survey was pilot tested, the validation of this questionnaire was minimal; this may have led to response errors by participants who may not have correctly interpreted the questions. CONCLUSION
According to the Royal College of Physicians and Surgeons of Canada, health advocacy is a core competency for physicians; however, there are currently no national standardized health advocacy curricula for Canadian obstetrics and gynaecology postgraduate training programs, and there have been no previous publications describing the current training and desire for future health advocacy training and activities among Canadian obstetrics and gynaecology trainees. Postgraduate trainees are aware of the health advocate role and recognize that health promotion and disease prevention will be an important aspect of their future practice, but they are often unaware of opportunities to engage in health advocacy activities. The current HA training needs of Canadian obstetrics and gynaecology residents may be inadequate to prepare them for practice and for their role as a health advocate. Trainees appear open to the opportunity to obtain further HA training and exposure during residency. The development and evaluation of a standardized national curriculum that exposes trainees to HA in a more rigorous and deliberate way during their training and that emphasizes active participation in community and societal level activities relating to HA should be considered to meet the requirements for this important CanMEDS role. JUNE JOGC JUIN 2013 l 545
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ACKNOWLEDGMENTS
The authors received funding from The Educational Initiatives in Residency Education Fund, University of Ottawa, Ottawa, Ontario The authors would like to acknowledge the contributions of Dr Yanfang Guo, of the OMNI Research Group, Ottawa Ontario, who performed the data analysis for this study. They also wish to thank Dr Jamie Brehauf of The Ottawa Hospital Research Institute Methods Centre who assisted with the development of the questionnaire. REFERENCES 1. The Royal College of Physicians and Surgeons of Canada. The CanMEDS 2005 Physician Competency Framework. Better standards. Better physicians. Better care. Ottawa ON: RCPSC; 2005.
4. Verma S, Flynn L, Seguin R. Faculty’s and residents’ perceptions of teaching and evaluating the role of health advocate: a study at one Canadian university. Acad Med 2005;80(1):103–8. 5. Card SE, Snell L, O’Brien B. Are Canadian general internal medicine training program graduates well prepared for their future careers? BMC Med Educ 2006;6:56. doi:10.1186/1472–6920–6–56 6. Frank JR, Cole G, Lee C, Mikhael N, Jabbour M. Progress in paradigm shift: the RCPSC CanMEDS Implementation Survey. Office of Education, Royal College of Physicians and Surgeons of Canada, University of Ottawa, Ottawa, Canada. Paper presented at the Annual Meeting of the Association of Canadian Medical Colleges; 2003; Quebec City, Quebec. 7. Stafford S, Sedlack T, Fok M, Wong R. Evaluation of resident attitudes and self-reported competencies in health advocacy. BMC Med Educ 2010;10:82–9. 8. Flynn L, Verma S. Fundamental components of a curriculum for residents in health advocacy. Med Teach 2008;30:7,e178–e183.
2. Sohi D, Li A, Wong R. Development and implementation of a CanMEDS health advocacy curriculum for internal medicine residents. Can J Gen Int Med 2010;5(4):164–7.
9. Hufford L, West DC, Paterniti DA, Pan RJ. Community-based advocacy training: applying asset-based community development in resident education. Acad Med 2009; 84:765–70.
3. Leveridge M, Beiko D, Wilson JW, Siemens R. Health advocacy training in urology: a Canadian survey on attitudes and experience in residency. Can Urol Assoc J 2007;1(4):363–9.
10. Chamberlain LJ, Sanders LM, Takayama JI. Child advocacy training curriculum outcomes and resident satisfaction. Arch Pediatr Adolesc Med 2005;159:842–7.
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