Illustration of resident with children

Short Take: More Than Medicine

Residents' Dedication Reaches Beyond Clinic Doors

By Krista Conger
Illustration by Christopher Corr

Anisha Patel, MD, MPH, walked into Lisa Chamberlain's office straight from her first night of call as a new pediatric resident at Lucile Packard Children's Hospital. Pushing her hair back from her face she snatched at papers that were threatening to fall to the floor as she pulled out her notes from their last meeting. "I'd really like to help kids without health insurance," she announced. Over the next hour Patel and Chamberlain, MD, MPH, a general pediatrics fellow, began to outline a strategy to improve children's access to health care by sending letters to state assembly members, meeting with San Mateo and Santa Clara county administrators, and handing out information to the parents of Patel's uninsured patients.

Is Patel extraordinarily dedicated? Well, yes. Unique? Not any more. Patel is just the latest participant in a required course in pediatric advocacy. Chamberlain, who designed and implemented the course, first envisaged coaching Packard's pediatric residents on how to champion the causes of their patients — both in and out of the clinic — two years ago after learning about advocacy while earning a master's in public health at UC-Berkeley. The program she has created at Packard fulfills and exceeds what is now a national requirement in advocacy training for all pediatric residents.

"The requirement says you have to have some sort of advocacy training, but there's no predetermined structure. You can meet it with one noon lecture. The amount of time we were given was really extraordinary," says Chamberlain, who carved out the time with the approval of Theodore Sectish, MD, director of pediatric residency training at Packard, and Fernando Mendoza, MD, MPH, professor of pediatrics. "When you're dealing with residents, time is always the limiting factor."

Packard residents spend two and a half days a week for a month during their first year and one day a week for a month during their second year campaigning for a cause of their choosing. UC-San Francisco and the University of Miami adopted the curriculum in 2001.

Chamberlain meets one-on-one with the residents several times during the month to brainstorm about potential topics and to determine whether to address the issue through a change in governmental policy, an educational campaign among fellow residents, a shift in the hospital system or interaction with community groups. She guides them through the options, peppering her comments with useful background and contact information while delivering impromptu lessons on the role of pediatricians as advocates for children.

"The power of your voice lies in your firsthand experience with these kids," Chamberlain emphasizes to Patel as they discuss Patel's plan to write letters urging assembly members to back a bill to maintain current levels of Medi-Cal physician reimbursement. "Explain who you are and why reducing Medi-Cal reimbursement will cut kids' access to health care. Tell them a true story about a patient to drive home the point. Yours is a perspective they can't get from other sources."

Patel shares a unique niche with other pediatricians at the intersection of access, knowledge and concern about children's well-being, says Chamberlain. Parents also trust and confide in their children's pediatricians, making them ideal advocates for their young patients. And although advances in medicine have eradicated some of the most glaring threats to children's health — such as deadly infectious diseases — children still face insidious foes, including obesity, child abuse, motor vehicle accidents and drowning. To effectively address these problems, physicians must step outside their usual hospital or clinic environment. Often the best way to make a difference in these cases is to partner with existing community groups that target the specific problem.

"We're now talking about how to work in the community to prevent teen pregnancy, for example," says Chamberlain. "It's not a feasible model to say that a pediatrician is going to go out and address this problem alone."

Chamberlain sets the residents on the right track by suggesting research articles and case studies on their topic. She also teaches them to use public health data to investigate problems, a skill few learn in medical school.

For example,without consulting this data, one might assume that today's overall decrease in teen pregnancies means the problem is no longer pressing. The data reveals, though, that teen pregnancy rates are actually rising among certain population subsets, such as Latinas and Filipinas.

Chamberlain encourages residents who choose to work within the community to ask community groups how they might help. "Sometimes what you think they need is not what they really need." Chamberlain also helps residents choose projects they can carry out within their limited available time. Often this means gathering data and making a presentation and recommendations to community leaders or fellow residents.

Response to the program from the residents has been resoundingly positive. Their chief complaint on the course's anonymous evaluation forms: too little time for advocating. "I really enjoyed learning how I could make a difference in children's lives," wrote one respondent. "This curriculum gave me the motivation and the tools to do so."

Lisa Chamberlain, MD, MPH

Lisa Chamberlain, MD, MPH, at home with her daughter. Chamberlain trains pediatric residents to become children's health advocates.

How They Helped

Advocacy projects run the gamut from child-passenger safety to media violence

  • Obesity, pregnancy, gun violence and poor oral health are just a few of the problems facing today's children. They also have to grapple with HIV, tobacco, homelessness and child abuse. A new advocacy training program for pediatric residents at Lucile Packard Children's Hospital has spurred campaigns to alleviate these problems and many others.

  • More than 60 percent of the 38 recent participants

  • Focused on the main categories of health promotion, injury prevention and children's health-care access. Health care in at-risk populations, child development, children with special health-care needs, community and academic center partnerships and the media rounded out the mix.

  • Some topics — including suicide prevention, media violence, tobacco use and children in foster care — attracted attention from only one resident. In contrast, bicycle safety, childhood obesity, teen pregnancy and health-care access were popular with two or more participants.

Advocacy 101

Would you like to learn to be an effective advocate?

Here are some tips:

  • Pick a topic that means something to you.

  • Teamwork is the key. Do some research to find community groups or government programs that are addressing the same problem. You can accomplish more by pooling your efforts.

  • Inquiring minds are the most helpful. Ask the groups what they need. They've probably assessed the needs and can easily tell you where you can be most useful.

  • The i's have it. Use firsthand experience to get your point across when explaining your concerns to government officials, potential supporters or donors.

  • Be persistent and convincing. Don't let detractors sidetrack you from your goal by explaining to you why something can't be done. A powerful person on your side can move mountains.

  • Be specific. Suggest concrete action that can be taken to improve the situation.

Anisha Patel, MD, MPH

Pediatric resident Anisha Patel, MD, MPH, launched a letter-writing campaign urging legislators to protect children's access to health care

Advocacy Anatomy

A first-year resident tackles health-care access

Anisha Patel worries about kids she never sees.

"You can do a lot for the patients that you see in your clinics, but what about the kids who never get to you?" asks the pediatric resident at Lucile Packard Children's Hospital. "Those are the kids that are most at risk." Families of children without health insurance often delay or forgo preventive medical care until they are forced to seek emergency help.

Patel took matters into her own hands during her recent training in pediatric advocacy. Coached by general pediatrics fellow Lisa Chamberlain, MD, MPH, she worked to improve health-care access for local uninsured children by writing letters to state assembly members and spreading the word about successful outreach tactics used by the Santa Clara County Children's Health Initiative — a consortium of programs aimed at offering health insurance to every child in the county.

Patel targeted her letter-writing campaign to support a bill before the state legislature that would protect children's access to health care. Her letters recounted her experiences on the Lucile Packard Children's Hospital Health Van, which provides care to uninsured local children.

"These uninsured patients have no resort but to accept the health van as their primary health provider," she wrote. "If proposed cuts of Medi-Cal are passed, even more children will be left without adequate health care." After speaking with Patel about the issue, five of her 19 fellow interns also chose to send letters to the legislature in support of the bill.

Then Patel turned her attention to local matters, investigating what worked and what didn't for Santa Clara County's outreach program. She found that the use of lay health counselors, or promotoras, was an effective way to spread the word in Spanish-speaking communities that health insurance is available for all children in the county, regardless of immigration status.

"Health insurance is a really touchy issue for families, especially for undocumented individuals," says Patel. "The promotoras really build trust." Other tactics, such as targeting children who qualify for the federal lunch program, have also been successful.

Patel wrapped up her advocacy experiences by turning over the results of her fact-gathering mission to San Mateo County administrators. The information will aid the launch of a similar initiative in San Mateo next year.

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