Advocacy Toolbox: Training for Preclinical Medical Students Interested in Surgery

For too long, status quo has taught aspiring surgeons that they have no place in public health. Medical student Max Zhu recalls, “As an undergraduate student, I confirmed my desire to go to medical school while volunteering for my school’s mobile clinic. I witnessed how the social determinants of health created health outcome disparities for those experiencing homelessness in Los Angeles. At that time, I also started to realize my interest in surgery. That doesn’t make sense, I remember my friends telling me. You can’t enjoy community health work AND be a surgeon.”

Admittedly, surgery and public health fields have not traditionally gone hand in hand. However, as surgical practice continues to evolve, many surgeons now acknowledge that the social determinants of health (SDH) are fundamental to the health outcomes of surgical patients (Robinson, 2017; Spruce, 2019). The concept of socially responsible surgery has emerged as an avenue to empower surgeons and trainees to partake in public health interventions and advocacy to address these disparities (Robinson, 2017).

Beyond realizing that SDH affect surgical outcomes, it is imperative that surgeons and aspiring surgical trainees not only learn of these health disparities, but also learn how to address and ameliorate them as physician advocates. Earnest et al. (2010) define a physician advocate as a physician who not only advocates for their patients on an individual level, but who also goes further and addresses the root causes of the health disparities their patients face. Some examples include advocating for state and national healthcare reform, improving nutrition policy for school lunches, and redistributing resources at a local hospital to better address a patient’s social needs, such as housing and environmental exposures (Earnest, 2010). Many medical schools have begun to emphasize the importance of SDH and associated advocacy efforts through class-based instruction (Doobay-Persaud, 2019). Marsh et al. (2019) have recently described an advocacy curriculum for students on their third-year pediatrics rotation. Perhaps the most well-known program is the Leadership Education Advocacy Development Scholarship (LEADS) program at the University of Colorado Denver School of Medicine: a track for medical students with exposure to advocacy training throughout their four years of medical school and an opportunity to practice advocacy through a paid internship after their first year (Long, 2011).

On an international scale, one exciting area of physician advocacy has been the expansion of global surgery initiatives within the past decade. In 2015, the World Health Organization signed World Health Assembly 68.15 recognizing surgery and anesthesia a fundamental component in building a country’s health infrastructure (Price, 2015). In 2021, the US global health appropriations bill designated the use of United States Agency of International Development funds in part to treating “neglected surgical conditions” such as cleft lip and hernias in developing countries (“Explanatory Statement,” 2021). This expansion of care for surgical diseases globally has only become possible due to the work of physician advocates within surgery such as the Global Alliance for Surgical, Obstetric, Trauma, and Anesthesia Care (the G4 Alliance): an alliance of several organizations fighting for surgical equity (“The G4 Alliance,” 2021). One member organization, the International Student Surgical Network (InciSioN), is a medical student organization that champions the expansion of global surgery (“InciSioN,” 2021). With the recent surge in global surgery support, it is imperative to train physician advocates who can have impact locally, nationally, and globally in efforts to achieve surgical equity.

Despite increasing interest in physician advocacy and a greater emphasis on SDH in surgery, very few programs have trained medical students or residents to become physician advocates in surgery. One academic center has implemented a mandatory health advocacy curriculum for its first- and second-year surgical residents, in which 76% of participants responded that they learned something meaningful from this experience (Ying, 2019). Thus, there is interest in advocacy training among surgical trainees, and earlier introduction of surgical advocacy at the medical school level can further cultivate this interest as students decide upon their career path. An obstacle to implementation of medical advocacy curricula nationally is perhaps the ambiguity of what advocacy entails. In an implementation of a health disparities course covering advocacy topics for medical students, an analysis of student reflections noted that one student thought of advocacy “as literally speaking out or speaking up for a certain cause, whereas I think that the approach… is [actually] a more encompassing [one] that includes identifying, testing, and intervening, not just raising one’s voice. I don’t have a better term for it, but ‘advocacy’ seems to somehow undersell and nebulize the work that is being done on these topics” (Press, 2015). These studies suggest that further work is required to create an optimal advocacy curriculum for medical students, especially one which encourages participation from medical students interested in surgery and recognizes the many forms that advocacy and social responsibility can take.

In Boston, the organization Socially Responsible Surgery (SRS) was founded in 2014 to introduce medical students at Boston University School of Medicine (BUSM) to how SDH affect surgical patients and provide students with the tools to advocate for change. Since its conception, SRS has expanded into a national organization which aims to bring surgical equity through research, education, service, and health advocacy to medical centers across the country (“Socially Responsible Surgery,” 2021). At BUSM, mentors within SRS have shown medical students that it is possible to balance surgery and healthcare advocacy and have demonstrated the extent to which surgical advocacy can take shape. In 2019, the SRS Advocacy Track for medical students was started to answer the questions how and what. How does one advocate for surgical patients? What are the techniques to accomplish this? Over the past year, we developed and implemented our answer: the Advocacy Toolbox.