Advocacy Curriculum Planning Among Internal Medicine Residency Programs: Results from a National Survey of Program Directors

Background Accreditation Council for Graduate Medical Education (ACGME) program requirements for all medical specialties state that resident physicians including internal medicine (IM) residents must demonstrate competence in advocacy as part of delivering quality patient care and creating optimal patient care systems, being responsive to the larger context and system of health care including the structural and social determinants of health, and considering equity in patient and population-based care. Moreover, it is known that practicing IM physicians and trainees view population-level advocacy as a professional obligation. However, fewer than half of U.S.-based IM residencies currently offer a formal advocacy curriculum. Rationale Efforts to identify specific barriers to implementing population-level advocacy curricula among IM residency programs without one, and the prevalence of programs who are planning to offer one as well as their proposed methods and content, can provide IM residency programs with key data to help inform population-level advocacy curriculum planning and implementation. Methods In this nationally-representative, web-based, cross-sectional study, we surveyed 456 IM program directors (PDs) with membership in an academic professional association between August and December 2022. Descriptive statistics and sub-group comparative analyses were performed. Results PDs from 276 (61.0%) eligible U.S.-based IM programs completed the survey, with 148 of 276 (53.6%) reporting no population-level advocacy curriculum. Among programs without such an advocacy curriculum, 33/148 (22.3%) reported planning to incorporate one. The most frequently reported proposed methods of instruction among planners were didactics (64%), experiential learning (51%), and advocacy projects (43%). The most frequently reported topics to be covered included foundational concepts of physician advocacy (e.g., definitions, professional code of ethics, general principles, social determinants of health) (74%) and health policy (64%); community organizing and legislative advocacy, which more directly reflect population-level advocacy, were reported at 36% and 27%, respectively. Commonly reported barriers to implementing a population-level advocacy curriculum, including lack of faculty expertise, faculty time, and time in the existing curriculum, were comparable between advocacy curriculum planners and non-planners. Programs with initial ACGME accreditation were more likely to report planning advocacy curricula compared to programs with continued accreditation (18.2% vs 3.5%, p=0.01). Conclusions Among U.S.-based IM residency programs without formal advocacy curricula, few were planning to offer a population-level advocacy curriculum. All IM residencies without advocacy curricula faced significant barriers to implementing such curricula regardless of planning status. Overcoming barriers to implementing population-level advocacy curricula, including lack of expertise and time in the curriculum, will be critical to providing effective population-level advocacy training. Further, some IM program leaders expressed uncertainty about how and what to teach in population-level advocacy curricula, suggesting that guidance and support for curriculum planning may be needed. Integrating some evidence-based best practices as well as exploring partnerships with faculty in other specialties and leaders of community-based advocacy organizations could help IM residency programs without advocacy curricula develop an effective population-level advocacy curriculum to help train the next generation of health advocates to improve health outcomes for patients, families, and communities.