Patient Advocacy Assessment in the Medicine Clerkship: A Qualitative Study of Definition, Context, and Impact.

BACKGROUND: Advocacy is a core value of the medical profession. However, patient advocacy (advocacy) is not uniformly assessed and there are no studies of the behaviors clinical supervisors consider when assessing advocacy. OBJECTIVE: To explore how medical students and supervisors characterize advocacy during an internal medicine clerkship, how assessment of advocacy impacted students and supervisors, and elements that support effective implementation of advocacy assessment. DESIGN: A constructivist qualitative paradigm was used to understand advocacy assessment from the perspectives of students and supervisors. PARTICIPANTS: Medical students who completed the internal medicine clerkship at UCSF during the 2018 and 2019 academic years and supervisors who evaluated students during this period. APPROACH: Supervisor comments from an advocacy assessment item in the medicine clerkship and transcripts of focus groups were used to explore which behaviors students and supervisors deem to be advocacy. Separate focus groups with both students and supervisors examined the impact that advocacy assessment had on students' and supervisors' perceptions of advocacy and what additional context was necessary to effectively implement advocacy assessment. KEY RESULTS: Students and supervisors define advocacy as identifying and addressing social determinants of health, recognizing and addressing patient wishes and concerns, navigating the health care system, conducting appropriate evaluation and treatment, and creating exceptional therapeutic alliances. Effective implementation of advocacy assessment requires the creation of non-hierarchical team environments, supervisor role modeling, and pairing assessment with teaching of advocacy skills. Inclusion of advocacy assessment reflects and dictates institutional priorities, shapes professional identity formation, and enhances advocacy skill development for students and their supervisors. CONCLUSIONS: Students and supervisors consider advocacy to be a variety of behaviors beyond identifying and addressing social determinants of health. Effectively implementing advocacy assessment shapes students' professional identity formation, underscoring the critical importance of formally focusing on this competency in the health professions education.

A is for advocacy: How introducing student advocacy assessment impacts longitudinal integrated clerkship students and clinical supervisors.

To improve health, physicians are increasingly called to advocate. Yet medical schools have only recently focused on health advocacy skill-building. Limited work to date addresses assessing medical student advocacy on behalf of patients. We describe how students and clinical supervisors (CS) in two urban longitudinal integrated clerkships (LIC) experience patient advocacy and how introducing a new advocacy assessment impacts them. Using a thematic approach, we analyzed transcripts of focus groups during 2018-2019. Seventeen of 24 (71%) students and 15 of 21 (71%) CS participated in the focus groups. We describe how students perceive their advocacy role as they accompany the patient, amplify their voice, and facilitate connection. The rationale for advocacy assessment includes that it (1) adds a novel dimension to the written and verbal assessment, (2) drives student learning, (3) aligns with the institutional goal to promote equity, and (4) impacts CS teaching and clinical practice. Challenges are the ambiguity of expectations, pressure to 'perform,' and a moral overlay to advocacy assessment. Findings demonstrate how educational alliances between students and CS and longitudinal relationships between LIC students and patients offer a constructive opportunity for advocacy assessment. We describe suggestions to hone and expand the reach of advocacy assessment.

Best Practices for Integrating Medical Students Into Telehealth Visits.

Telehealth has become an increasingly important part of health care delivery, with a dramatic rise in telehealth visits during the COVID-19 pandemic. Telehealth visits will continue to be a part of care delivery after the pandemic subsides, and it is important that medical students receive training in telehealth skills to meet emerging telehealth competencies. This paper describes strategies for successfully integrating medical students into telehealth visits in the ambulatory setting based on existing literature and the extensive experience of the authors teaching and learning in the telehealth environment.

LVAD-DT: Culture of Rescue and Liminal Experience in the Treatment of Heart Failure.

The purpose of this article is to investigate how cultural meanings associated with the left ventricular assist device (LVAD) inform acceptance and experience of this innovative technology when it is used as a destination therapy. We conducted open-ended, semistructured interviews with family caregivers and patients who had undergone LVAD-DT procedures at six U.S. hospitals. A grounded theory approach was used for the analysis. Thirty-nine patients and 42 caregivers participated. Participants described a sense of obligation to undergo the procedure because of its promise for salvation. However, once the device was implanted, patients described being placed into a liminal state of being neither sick nor healthy, with no culturally scripted role. Consideration of end-of-life decisions was complicated by the uncertainties about how patients with LVADs die. Pre-implantation communications among patient, family, and clinicians should take into account the impact of the technology on meaning, identity, and patient experience.

"No One Ever Even Asked Me that Before": Autobiographical Power, Social Defeat, and Recovery among African Americans with Lived Experiences of Psychosis.

Our article draws on ethnographic research with African American males diagnosed with a psychotic disorder in a high-poverty urban area of the northeastern United States. Our participants frequently described the ways public mental health services led them to experience a paralyzing erosion of autobiographical power, which we define as the ability to tell one's own story and be the editor of one's own life. We identified three important points when the loss of autobiographical power seemed to perpetuate social defeat or a sense of social powerlessness (Luhrmann 2007) for our participants during their interactions with public mental health care. We invite further inquiry into the loss of autobiographical power in settings of public mental health care, the sense of social defeat it seems to perpetuate, and the impact of these on mental health recovery, especially for people living in contexts of persistent social adversity.