Professional Competencies Selective Project Wiki Entry:
Web-based Educational Resource on the CanMEDs Health Advocate Competency for Dalhousie
Medical Students
Asha Bienkowski
March 28, 2013
Health Advocate
The CanMEDS Physician Competency Framework, a formal educational framework adopted by
the Royal College of Physicians and Surgeons of Canada, describes seven key roles, or
competencies, that all physicians must possess in order to provide patients with the highest
possible quality of care.
One such role—that of Health Advocate—is defined as follows:
“As Health Advocates, physicians responsibly use their expertise and influence to advance the
health and well-being of individual patients, communities, and populations.”
The Health Advocate competency is further defined as the physician's ability to:
“1. Respond to individual patient health needs and issues as part of patient care;
2. Respond to the health needs of the communities that they serve;
3. Identify the determinants of health of the populations that they serve;
and
4. Promote the health of individual patients, communities and populations.”
Levels of Advocacy
Individual patients need physicians to assist them in navigating the healthcare system and
accessing the appropriate health resources in a timely manner. This includes things like phone
calls to specialists to speed up referrals, helping a patient find a family physician, and advocating
for alternative treatment/coverage for alternative treatment to better meet the needs of patients in
rural areas (e.g. peritoneal dialysis over hemodialysis).
Communities need physicians to identify and address local health issues and determinants of
health in the community in which the physician practices. This includes things like advocating
for school cafeterias to serve healthier meals and snacks, promoting recruitment and
establishment of necessary specialists and health services, and working with community outreach
programs.
Populations need physicians to identify and address health needs and determinants of health of
marginalized, disadvantaged, and vulnerable populations on a local, provincial, and national
scale. This includes things like advocating for aboriginal and refugee health equity, supporting
mental health initiatives and destigmatizing mental illness, and promoting public health. Often,
this type of advocacy occurs at a political level to promote changes in policy and practice.
There is also a role for advocacy within institutions (e.g. hospitals and academic centres). This
includes things like promoting timely access to hospital services, improving the way services are
delivered, establishing policies and programs for managing conflicts, concerns, ethical dilemmas,
and moral distress, as well as supporting safe and ethical research practices.
Ethical Dilemmas and Advocacy
Health advocacy often involves balancing several ethical principles and advocating at individual,
community, population, and institutional levels may give rise to a number of ethical dilemmas.
Beneficence
Beneficence, in medicine, is the responsibility to do good for our patients and our society in
terms of health. The CMA Code of Ethics tells physicians to:
“Consider first the well-being of the patient;”
and
“Consider the well-being of society in matters affecting health.”
Physicians must find a balance between doing what is best for individual patients, the
community in which they practice, and society.
In the context of advocacy, dilemmas may arise when considering:




What constitutes the “well-being” of patients and society;
How far does the responsibility to do good or to advocate extend;
Who decides (and how does one decide) what is “good;”
Is what is good for one person/community/population good for another?
and

How does one decide which patients and community/population issues to advocate for?
Justice/Resource Allocation
The CMA Code of Ethics highlights the physician’s responsibility to “promote equitable access
to health care resources.” In an era of limited resources, this responsibility may lead to several
dilemmas:





How does one promote equitable access to healthcare?
Which inequities should one address? Which inequities can one address?
Does allocating resources to one disadvantaged population take away from or neglect
another?
Does equity mean access for everybody to the same basic medical services for or access
to any/all the medical services one needs?
How does one balance doing the best for each individual patient with responsibly
allocating scarce societal resources?
Competing/Conflicting Interests
In their careers, physicians may experience competing interests (e.g. incorporating both research
and clinical duties into their practice or balancing responsibilities to both patients and the
hospital/academic centre in which they work) and/or conflicting interests (e.g. a financial
relationship that may influence professional judgement in favour of personal gain).
In these situations, the CMA Code of Ethics instructs physicians to “manage conflicts of interest
and resolve them in favour of responsibilities to patients.”
Ethical dilemmas may arise when physicians feel that there is a conflict between their duty to
their patients and their duty to their research, institution, or employer, particularly if the latter
sees advocating for patients as disloyal behaviour or troublemaking and persecutes physicians for
representing patient interests (e.g. revoking clinical privileges or terminating employment). Fear
of institutional repercussions and unwillingness to jeopardize conflicting financial relationships
(e.g. with pharmaceutical companies) can present significant barriers to patient advocacy.
Advocacy and Social Justice
Many health advocacy efforts centre on providing services, resources, time, and knowledge to
vulnerable populations. While helpful, these “charity” based approach to advocacy are difficult
to sustain and they do not address the heart of the problem: health inequity. Health inequities
faced by disadvantaged and vulnerable populations lead to a decreased ability to protect personal
needs and interests, worse health outcomes, higher rates of morbidity, increased barriers to care,
and inappropriate use of health services. A social justice approach to health advocacy focuses on
understanding and acting to change the factors that contribute to inequity. Some of these factors
are captured in Health Canada’s determinants of health.
Determinants of Health
The World Health Organization defines health as “a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity.”
To identify health needs and advance the physical, mental, and social well-being of patients, it is
important to understand the multifaceted factors underlying and influencing health.
Health Canada has identified twelve determinants health:
1. Income and social status
2. Employment
3. Education
4. Social environments
5. Physical environments
6. Healthy child development
7. Personal health practices and coping skills
8. Health services
9. Social support networks
10. Biology and genetic endowment
11. Gender
12. Culture
To be effective, advocacy efforts must consider these determinants; many such efforts are built
around addressing and ameliorating them.
Examples of Advocacy
Three example cases from British Columbia with follow up questions, pg. 18-20
http://www.chd.ubc.ca/files/file/resources%20and%20publications/Dharamsi%20et%20al%20Ca
nMEDS%20Health%20Advocate%20Role.pdf
Government of Nova Scotia directory of family physicians accepting new patients
http://www.gov.ns.ca/health/physicians/
New Brunswick physicians call for tanning bed ban for youth under 19
http://www.nbms.nb.ca/leadership-2/public-awareness-campaigns/new-brunswick-doctors-sayban-the-tan/
Canadian Paediatric Society:


Calling for provinces to ban children under 16 years old from operating all-terrain
vehicles
http://www.cps.ca/documents/position/preventing-injury-from-atvs
Recommends delaying body checking in hockey until bantam league play
http://www.cps.ca/documents/position/bodychecking-ice-hockey
Code Red
http://www.thespec.com/topic/codered
Health Advocacy in Emergency Medicine
http://www.cjem-online.ca/v11/n1/p99
Dr. Jeffrey Brenner, an American physician, tackles health care delivery for the most difficult,
complicated patients in Camden, New Jersey
http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande
Links
Physician Advocacy: What Is It and How Do We Do It?
http://libportal.medilam.ac.ir/documents/10129/34031/Physician+Advocacy.pdf
The Health Advocate Role: Preparing Future Physicians for Socially Responsive Practice
http://www.chd.ubc.ca/files/file/resources%20and%20publications/Dharamsi%20et%20al%20Ca
nMEDS%20Health%20Advocate%20Role.pdf
Promoting Health: Advocacy Guide for Health Professionals
http://www.whpa.org/PPE_Advocacy_Guide.pdf
Physician-Citizens—Public Roles and Professional Obligations
http://cmsc.uicmed.net/filestore/2%20-%20JAMA%20Article.pdf
CBC’s Sick People or Sick Societies?
http://canadiandimension.com/articles/4797/
References
Banack, J. Literature Review Health Advocate Role. Accessed Feb 28, 2013 at
http://medicine.ucalgary.ca/files/med/Assessing%20Health%20Advocate.pdf.
Canadian Medical Association. CMA Code of Ethics. Accessed Mar 25, 2013 at
http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf.
Frank, JR. (Ed). 2005. The CanMEDS 2005 physician competency framework. Better standards.
Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of
Canada.
Frank, J. R., Jabbour, M., Tugwell, P., et al. 1996. Skills for the new millennium: Report of the
societal needs working group, CanMEDS 2000 Project. Annals Royal College of Physicians and
Surgeons of Canada, 29:206–216.
Huntoon, KM. McCluney, CJ., Wiley, EA., Scannell, CA., Bruno, R., Stull, MJ. 2012. Selfreported evaluation of competencies and attitudes by physicians-in-training before and after a
single day legislative advocacy experience. BMC Medical Education, 12(47).
Long, JA., Lee, RS., Federico, S., Battaglia, C., Wong, S., Earnest, M. 2011. Lippincott Williams
& Wilkins.
Parent, F. Jouquan, J., Ketele, J-MD. 2012. CanMEDS and other ‘‘competency and outcomebased approaches’’ in medical education: clarifying the ongoing ambiguity. Adv in Health Sci
Educ. (Commentary).
Preamble to the Constitution of the World Health Organization as adopted by the International
Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives
of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into
force on 7 April 1948. The Definition has not been amended since 1948. Accessed Feb. 22, 2013
at http://www.who.int/about/definition/en/print.html.
Public Health Agency of Canada. 2011. What Determines Health? Key Determinants. Accessed
Feb. 22, 2013 at http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php#determinants.
Verma, S., Flynn, L., Seguin, R. 2005. Faculty’s and Residents’ Perceptions of Teaching and
Evaluating the Role of Health Advocate: A Study at One Canadian University. Academic
Medicine, 80(1):103-108.
WHO Closing the Gap: Commission on Social Determinants of Health-final report accessed
March 3, 2013 at www.who.int/social_determinants/thecommission/finalreport/en/index.html.