INTRODUCTION

Physicians and professional organizations endorse the value of community and legislative health advocacy,1 but community health advocacy training is often neglected in medical training. To address this, in 2000, we implemented a Liberation Medicine (LM) curriculum for Montefiore’s Primary Care/Social Medicine (PC/SM) residents. Defined as the conscious, conscientious use of healthcare to promote social justice and human dignity,2 LM provides a framework to support community efforts to address social arrangements that disproportionately impact health and well-being among poor and marginalized persons. We describe the evolution of our LM curriculum from 2000 to 2017 and present preliminary evaluation results from 2016 to 2017.

METHODS

In 2015, we performed a rigorous exercise to enhance our existing LM curriculum. We invited third-year PC/SM residents who had completed the curriculum to a focus group, then used their feedback to create four curricular aims aligned with ACGME milestones for systems-based practice (Table 1): (1) define and contextualize LM, (2) promote community engagement, (3) foster mentoring relationships with faculty physician advocates, and (4) improve resident advocacy skills.

Table 1 Original (2000) and Current (2016–2018) Liberation Medicine Seminars, and Participating Community Partners
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To achieve aim (1), we developed two sessions to introduce LM. To achieve aims (2) and (3), faculty physician advocates and/or leaders of community-based organizations (CBOs) lead/co-lead sessions on local community issues; these sessions also describe strategies for and challenges to successful partnerships, as well as for career development in community health advocacy. To achieve aim (4), we developed an advocacy writing series for residents to learn about written advocacy, draft and workshop social media posts, and submit advocacy writing to media outlets. Our revised LM curriculum was instituted in 2016.

To evaluate our revised LM curriculum, we developed a 20-item pre/post survey to assess impact on residents’ confidence in their health advocacy knowledge and skills. Survey items were grouped into four domains: ability to define LM, individual advocacy, community advocacy, and public health advocacy. Residents rated agreement with each item on a 6-point Likert scale (1=strongly disagree, 6=strongly agree); survey completion was optional. Results were analyzed continuously using nonparametric paired t tests. We also queried graduating PC/SM residents regarding involvement in health advocacy and community partnerships. Einstein’s IRB approved the protocol.

RESULTS

Ten PC/SM residents completed the revised LM curriculum in both 2016 and 2017; surveys were administered to all 20 residents. Both pre- and post-curriculum surveys were completed by 17/20 residents (85%). We observed significant improvements in self-reported confidence in two domains: ability to define LM and public health advocacy (Table 2). Of 20 residents, three published op-eds, 16 used social media for health advocacy, nine participated in advocacy through professional organizations, and 12 collaborated with CBOs. Graduating residents reported that the curriculum supported their physician identity: “Liberation Medicine fought burnout. I didn’t just [become a physician] to fill out prior authorizations.” Some described challenges engaging in advocacy during residency, but hoped to later: “I can’t keep up a commitment during residency. I think this [training] will be valuable in the future.” “One of my goals for fellowship is to be more engaged with community partnerships.”

Table 2 Results of Pre/Post Survey of Residents’ Liberation Medicine Knowledge and Skills (N = 17)
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DISCUSSION

Our preliminary results demonstrate that a community partnership and health advocacy curriculum enhances residents’ confidence in health advocacy knowledge and skills. After curriculum completion, residents partnered with CBOs and used social media for health advocacy. Specific strengths of our LM curriculum include faculty physicians’ role modeling community engagement, and practical experience with advocacy writing.

Our curriculum adds to a modest but growing literature on advocacy training during residency. Surveys of established physician advocates demonstrate that mentorship and training facilitate engagement in health advocacy,3 but few studies describe efforts to mentor residents to incorporate advocacy into their careers. Existing studies include descriptions of health policy and legislative advocacy training,4 and of a research-based health advocacy curriculum,5 but we found no descriptions of skills-based community health advocacy curricula for residents. Studies also report course satisfaction and perceived confidence, rather than skill development.6

Our preliminary evaluation utilized a pre/post survey of residents’ confidence in their knowledge and skills, which is a limitation. Additionally, the strong mission of Montefiore’s PC/SM program attracts residents who value community engagement and health advocacy; two-thirds of surveyed residents reported prior experience with advocacy. Further research is needed to replicate our results in other IM residency programs and to understand the impact of our curriculum on local community health.