What Is Taught Versus What Is Learned: Health Advocacy in Specialist Graduate Medical Education

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Abstract
Purpose: Health advocacy (HA) is a key component of competency frameworks in many global jurisdictions, yet how HA is taught is not well defined, particularly in specialty graduate medical education. This study explored how residents in these programs came to understand what HA is, what activities it entails, and what importance it carries. Method: This qualitative study conducted semistructured interviews of 39 specialty residents from 2 universities (University of Toronto and University of Ottawa) from July 2019 to June 2023. A reflexive thematic analysis was used, with sensitizing concepts of the formal, informal, and hidden curricula and the CanMEDS health advocate role to construct themes from this data set. Results: Most trainees struggled to define what HA means, what good HA should look like, and which kinds of activities it signifies. The lack of definitional clarity meant that many non-HA activities became conflated with HA, particularly research and quality improvement. Few could recall clear formal curricular content, whereas exposure in clinical training environments was highly variable. Many perceived HA activities as threats to clinical efficiency, of little interest to residency program leadership, and of minimal currency in being competitive for eventual staff positions. Self-identified advocates frequently engaged in self-censoring behaviors because they thought their programs and leaders were often not supportive of this kind of work. Conclusions: Trainees struggled to understand what activities comprise HA because it was not prioritized in their programs or they encountered highly variable role modeling. Trainees who participated in HA activities experienced difficulties integrating HA into their overall clinical skill set due to a lack of institutional support. Health advocacy training requires consideration of structural and cultural reinforcements, including the adoption of curricula that integrate it with daily clinical care and address hidden curriculum effects.

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