Advocacy Isn’t Enough: A Call for More Activism in Pediatric Training

The shortcoming of conventional advocacy in pediatrics from the perspective of two pediatric residents.

Thomas J. Agostini, MD (1)

Kanwarabijit Thind, MD, MPH (2)

(1) Fellow, Medical University of South Carolina, 2022; PGY-3 on the Health Equity Track with particular interest in harm reduction and LGBTQ+ health, University of Washington Pediatrics Residency Program

 (2) Executive resident and acting instructor (formerly known as chief resident), University of Washington Pediatrics Residency Program

Advocacy Work in Pediatrics

Advocacy is a mainstay of pediatric medicine. Many of us came into the field of pediatrics to protect vulnerable youth and be the active agents of change for kids facing systems of oppression. Making a difference is at the heart of pediatrics, and growing inequities make this work more crucial than ever.¹ What's more meaningful than advocating for patients who can’t speak for themselves? Advocacy is an important tool, but we believe it needs to be paired with activism to create equitable social change.

Pioneers for advocacy in modern pediatrics call for an “all-hands-on-deck” approach, enlisting pediatricians in community settings and academic medical centers to leverage their resources to speak up for their surrounding communities.^2,3 Crucial subsects like community health and engagement, graduate medical education, and scholarly activity can all be used as tools to advance health equity.⁴

Recent updates in Accreditation Council for Graduate Medical Education (ACGME) guidelines require advocacy opportunities for pediatric trainees,⁵ creating learning opportunities for residents to address inequities. As residents, we are told that our new position of power should be leveraged to speak up on behalf of patients. In our residency interview days, many programs highlight their commitment to advocacy. Applicants are inundated by "Advocacy Day” slideshows, where program leadership shows pictures of herds of residents in white coats on the steps of statehouse buildings one day a year. It’s important to question if this approach to health equity work through traditional advocacy measures is unanimously positive.  Is this the only way for residents to contribute? How can we as trainees continue to learn while simultaneously centering our patients in the social justice work we aim to do?

Advocacy versus Activism

Health equity work needs to be grounded in a larger context; how do we get our feet wet participating in social movements? Even outside of pediatrics, other physicians are recognizing the role activism plays in the evolving political climate.⁶ How can we as learners most effectively use our time and skills in residency to make a difference?

Social movements can oftentimes seem daunting and impractical. Depending on the geographic location, political and legal environment, local history, and the cause itself, social movements vary in their public perception and acceptability.⁷ Given the spectrum of efforts and their relative efficacy, social justice work is easily dismissed as impractical. This pessimistic view of advocacy and activism can kill movements before they even start, so it is important to define what can make social change practical. While movements with vague goals can be ineffective, social movements with specific, action-driven targets have the potential to make measurable change in communities.⁸

Detailed by Bill Moyer, an effective social movement can be mapped into eight stages: 1) normal times, 2) prove the failure of institutions, 3) ripening conditions, 4) social movement take-off, 5) identity crisis of powerlessness, 6) majority public support, 7) success, and 8) continuing the struggle.⁹ In this model, Moyer describes how different tools, like advocacy and activism, can be used to combat injustice by intentionally organizing communities and winning public appeal. To be successful, Moyer argues a social movement should build momentum through grassroot organizing to push the needle of public opinion on a given topic to create effective change.⁹

Zooming in from the collective movement, individual roles within social justice efforts can vary. Social justice theorists have identified general roles like change agents, reformers, rebels, and citizens as necessary but distinct roles in movements to work in coordination to create meaningful change.¹⁰ These four roles each have unique directives that can often fit into the mental model most people are familiar with: people who work within the system and people who work outside of the system.

There is certainly overlap within the different roles and approaches to social justice work, and our positions of power as physicians can be crucial when working within or outside of the healthcare system. Many fields, like public health, are recognizing the importance of centering communities in equity efforts, stating “approaches must include and prioritize leadership by those most affected by injustice and inequity in order to effect structural and systemic changes that can support and sustain inclusive and healthy communities.¹¹” Activism and advocacy, when employed intentionally, can allow pediatricians to leverage their social capital to push forward social movements that are spearheaded by grassroots organizers in their surrounding communities. This leads us to our point: what truly is advocacy? Is it different from activism?

We believe that advocacy and activism are related but ultimately two separate tools to promote health equity. Some might think that this distinction is primarily semantic, but delineating the two is important for us all to reflect on what it really means to participate in social movements as pediatricians. Advocacy is based in conversation, whereas activism is based directly in action.⁷

What is Advocacy?

Advocacy simply means to show public support for a group or idea.¹² It can inherently create leaders for causes, some of which may have no personal stake in the game. As residents, this can take the form of legislative work, writing opinion pieces, or involvement with professional organizations. This is not to say there isn’t value in these experiences, but is this really the extent of the action we can provide to support those around us? It is important for pediatricians and pediatric residents to look in the mirror and question the true intentions behind this work. Is some element of advocacy work self-serving? If so, to what extent and how can it be mitigated?

When participating in traditional models of advocacy in pediatric training, we run the risk of centering ourselves in the conversation. Many of us relocate to unfamiliar areas for our training and gaining adequate comprehension of community history can be daunting during such a short training period. Doesn't that seem odd to become the voice for patients who, arguably, we just met? Should we really be at the forefront of advocacy efforts in a community just to leave 3 years later?

It is crucial that we learn to build trust WITH communities before speaking FOR communities (Figure 1)

Figure 1. Advocacy versus activism. Figure 1A shows how advocacy impacts desired change by speaking on behalf of groups. Activism in Figure 1B, however, shows that activists work to support community members to amplify their existing efforts to create change.

What is Activism?

Activism, however, refers to direct action where people work together to achieve a common goal.¹³ This could involve routine volunteer efforts with community organizations, attending rallies put together by grass-root efforts, supporting local affinity groups, placing ourselves as "workers among workers.” Collective leadership in activism efforts, in a balanced partnership with the people we aim to support, includes a diverse set of voices that allows for everyone to have a platform. We still use our privilege as physicians, but we focus on amplifying the voices of other activists who are not afforded the same opportunities. Activism nourishes service leadership, centering those who are impacted by the inequities we hope to eradicate.

Activism, however, is flawed as well. While it is grounded more firmly in action with communities, it runs a similar risk as advocacy in being performative and ineffective if not done intentionally. Many residency programs already offer one-and-done volunteer projects, where residents go to community organizations for a few hours and never go back. The traditional model for medical residency prescribes a time-intensive schedule that makes it near impossible to brush our hair, let alone “fight the good fight.” Community organizations cannot count on us for dependable work. For pediatric residents to be effective activists, we must use the privilege that accompanies our physician titles to amplify efforts in the community around us in longitudinal partnerships.

Moving from Advocacy to Activism

It is important to understand the distinction but also recognize that both advocacy and activism exist on a spectrum together. At the heart of advocacy and activism, both are grounded in core values and a desire to create change. To incorporate more activism to balance out existing advocacy efforts, pediatricians must move from speaking in support of social change to acting in support of it.

Traditional healthcare models place doctors as the head of medical decision making, so it is easy to slip into a mindset that we should lead the charge in problem solving. This mindset, if subconsciously applied to advocacy work, can set pediatricians up to be blinded to the already existing efforts supporting a given cause. To begin participating in activism rather than just advocacy, pediatricians must first seek out existing community efforts prior to publicly speaking up about a cause. Before we throw on our white coats and head to the state house for handshakes and painful small talk, physicians who truly seek to make a meaningful contribution to social justice should ask community organizers what it is that is actually needed.

This additional step to seek out existing efforts will allow pediatricians the opportunity to lend our efforts and our privilege over to those already dedicated to a cause. This can include frequent volunteering, listening sessions and storytelling events for people most directly impacted by the issue, or inviting key community leaders to educate our peers about local issues and current efforts to combat them.

Including Activism and Advocacy in Pediatric Residency

We argue that both advocacy and activism efforts should be meaningfully incorporated into pediatric training. There can be and should be room for both experiences, as they are both crucial in creating social change (Figure 2).

Figure 2. Social change toolbox. These are examples of both advocacy and activism efforts pediatric residents can get involved with to help create positive change in their surrounding communities. This figure was created using Canva Pro, which includes free license use of photos, icons and illustrations, videos, audio, fonts, and templates.

Where could broader activism efforts start to contribute? Consider the following as examples of activism efforts:

1. Protesting alongside longstanding community organizers in existing demonstrations can be a way that we can show up visibly as community-engaged physicians.

2. Union participation would allow residents to help connect families with others in the local community experiencing similar issues. Even unofficial collective bargaining efforts, like Kansas City Tenants, have mobilized through actions like “rent strikes” in efforts to demand acceptable living conditions.¹⁴

3. Campaign organizing for local government candidates or policy can have an influential impact on our patients and their families. Recent mayoral primary elections in New York City and Seattle have demonstrated the power of collective action as a competitive foe to corporate interests.^15,16 Prop 1A, a policy requiring wealthy corporations to contribute to social housing, was passed in Seattle through grassroots efforts by groups like House Our Neighbors.^17,18

Residency programs moving to X + Y schedules offer an opportunity for both advocacy and activism to be incorporated more concretely into training, with the outpatient Y blocks allowing for meaningful relationships with communities. Building trust and sustainable partnerships with stakeholders, however, cannot be an afterthought in this work. Dedicated personnel from residency programs should be required to serve as program liaisons that actively work with community organizers to develop partnerships. Many residency programs have dedicated tracks, faculty experts, chief or executive residents, and associate program directors dedicated to building longitudinal relationships with the communities around them. These individuals would be easily identifiable and could very easily expand their roles to include activism.

Current Y blocks at different institutions vary in structure, but one way to dedicate time to activism work specifically would be to include community partners in already scheduled didactics. This would allow residents to hear first-hand from local organizers related to specific health issues (i.e. environmental health during asthma didactics from tenant unions).  Activism activities could then tie into the related themes of didactics or clinical exposure for a given Y week with trainees could allow for them to count towards ACGME requirements.

It is important for residents to still be given autonomy and avoid being forced to participate in activities that are discordant with their personal values. Even with hopes that principles like community health would be universal, there will undoubtedly be discordance in what people see as solutions. Residency liaisons hoping to establish longitudinal partnerships with community organizers should connect with multiple groups to provide residents with diverse options. Having a wide selection of community organizations to work with will reduce the risk that residents would feel obligated to participate in something that aligns with their values and interests.

Similarly, residency program liaisons should have opportunities for residents who want to seek out their own interests. Having a prepared guide to navigate community partnership work will empower residents to follow their own interests and reduce the risk that advocacy or activism choices create tension with program leadership. While this would lose the longitudinal benefits with the program liaison, this would provide residents the opportunities to avoid conflict with residency programs on controversial issues.

Implementation Challenges

As with any proposed social justice work, systems-level considerations and potential barriers to activism work in residency should be considered. Institutional and employment policies may limit the type or extent of activism, depending on the political involvement of the identified community partner. For example, it is unlikely that residents would be permitted to work for political campaigns in a direct and official capacity where they are representatives of their program or institution. There are a few ways in which residents may be able to circumvent this potential roadblock.

One measure could be to partner with their residency union that often allow residents to engage in political advocacy and activism as representatives of the union and not their home institution. Additionally, residency programs could still create meaningful, but still unofficial partnerships with community organizers and grassroots efforts that may be identified as politically polarizing. Programs could make efforts to not host events that require institutional identification or funding if the cause is for a direct political candidate or party. Residents should still be allowed to engage in these grassroots efforts, but they should receive training to protect themselves from consequences. They can refrain from identifying as a representative of their home organization and ensure that they are not wearing any institutional identification. Residents can and still use their physician title to leverage their power and privilege, but using self-identifying phrasing like “concerned local doctor” or “community pediatrician in training” to avoid individual liability.

Issue-based organizing that is not directly affiliated with political campaigns (i.e. gun violence prevention, social housing, immigrant rights, anti-war protests, universal healthcare, or LGBTQ+ rights) can and should be encouraged. While similar precautions should still be taken to shield from employment repercussions, issue-based activism will likely be less polarizing. Even with these potential limitations, it is critical that residency programs and their trainees alike still push for more activism in pediatrics given the dire need for change.

Conclusion

Pushing for social change needs to remain a cornerstone of pediatric training with advocacy and activism opportunities working symbiotically. Using our privilege as resident physicians to amplify the existing work of surrounding community organizers through action-based and relationship building efforts, like activism, is a difficult but indisputable next step in promoting health equity for the children we all aim to protect.

References

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Contributors Statement

 Dr. Thomas Agostini conceptualized the content for this article, wrote, and edited the paper in full.

 Dr. Kanwarabijit Thind helped write and edit the paper in full.

Artificial intelligence was used to proofread the manuscript, but it was not used to develop content. Authors performed final review after AI grammatical check to ensure no content was changed and only minor grammatical errors were resolved. Both authors agree to be accountable for all aspects of the work.

Acknowledgments

 Thank you to Anna B. Hall for her review and guidance on figure creation.