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Title: Bridging the Gap: Exploring Barriers and Opportunities for Students to Facilitate Advocacy Integration in Canadian Medical Education
Ayshia
Bailie
1
Benedicta
Asante
1
Dr.
Fiona
Clement
1,2✉
Emailfclement@ucalgary.ca
1
Department of Community Health Sciences
University of Calgary
Calgary
AB
Canada
2
O’Brien Institute of Public Health
University of Calgary
Calgary
AB
Canada
Authors: Ayshia Bailie1, Benedicta Asante1 and Dr. Fiona Clement1,2
Affiliations:
1Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
2O’Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
Corresponding Author
Fiona Clement, fclement@ucalgary.ca
Abstract
Background
Health advocacy remains inconsistently integrated in Canadian medical education despite being a core CanMEDS competency. This review examined barriers to medical student advocacy participation and identified practical opportunities for self-directed engagement.
Methods
We conducted a systematic literature search of MEDLINE and grey literature (from 2010 to 2025) focusing on medical student advocacy participation, educational frameworks, and barriers. Two independent reviewers screened 1,253 citations using predefined criteria. Forty studies were narratively synthesized.
Eligibility criteria: Population: Medical students
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Intervention or exposure: Participation in advocacy efforts (e.g., health policy, health equity, political engagement). Educational frameworks, curricula, or structured programs supporting advocacy in medical education. Comparator: Not required. Primary outcome: Barriers to medical student advocacy (e.g., time constraints, institutional resistance, lack of training). Opportunities for enhancing advocacy skills within medical education (e.g., mentorship, policy involvement). Effectiveness of structured frameworks in integrating advocacy into medical training. Study designs: Any study design that produced primary data. Other criteria: Published in English or French language.
Results: Three primary barriers emerged: inconsistent advocacy training across institutions, lack of recognition of physician influence on health policy, and insufficient health policy skills development. Four evidence-based opportunities for student engagement were identified: seeking mentorship from faculty advocates and external advocates, participating in legislative lobby days, developing communication skills through writing and public speaking and collaborating with medical societies and nonprofit organizations.
Conclusions: Medical students can proactively develop advocacy competencies through structured self-directed activities. Future work should focus on implementing standardized advocacy curricula across Canadian medical schools with ongoing evaluation of effectiveness.
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Introduction
Health advocacy is a recognized core competency of physicians under the CanMEDS framework, yet it remains one of the least consistently integrated skills in medical education (McDonald et al., 2019). Many medical students have an innate desire to be involved in social justice advocacy work, but there aren’t effective outlets and opportunities available for medical students to actively participate in these efforts (Huntoon et al., 2012). There are especially limited opportunities to develop political and legislative advocacy skills, often seen as extracurricular rather than embedded in curricula (Griffiths, 2017). This gap leaves students underprepared to navigate complex health policy environments despite their unique position to contribute meaningfully to systemic change (Krishnamurthy et al., 2023). Given inconsistent institutional support, medical trainees need evidence-based guidance on self-directed advocacy engagement that bridges personal passion with professional competency development. This review examined barriers to medical student advocacy participation and identified practical opportunities for students to proactively develop advocacy skills.
Methods
An experienced medical information specialist developed and tested the search strategies through an iterative process in consultation with the review team. Another senior information specialist peer reviewed the MEDLINE strategy prior to execution using the PRESS checklist (McGowan et al., 2016). Using the multifile option and deduplication tool available on the Ovid platform, we searched Ovid MEDLINE® ALL. We performed all searches (Appendix A) on February 11, 2025. We utilized a combination of controlled vocabulary (e.g., “Medical Education”, “Advocacy”, “Student Participation”) and keywords (e.g., “medical student advocacy”, “curriculum integration”,” barriers and facilitators”). Vocabulary and syntax were adjusted as necessary across the databases. There were no language restrictions, but we limited results to the publication years 2010 to the present and removed animal-only records and conference abstracts where applicable. We downloaded and deduplicated the records using EndNote version 9.3.3 (Clarivate Analytics) and uploaded these to Covidence (Veritas Health Innovation). Targeted grey literature searches were conducted by searching Google Scholar. Bibliographic searches of relevant reviews were conducted to identify studies that were not captured in the original searches.
Three independent reviewers conducted a calibration exercise on 10 retrieved abstracts until > 90% agreement was reached. Two reviewers then screened the remaining abstracts in duplicate. Inclusion criteria included medical student populations, advocacy participation interventions, and outcomes related to barriers, opportunities, and framework effectiveness. All primary study designs published in English or French from 2010 to the present were eligible. Full-text review proceeded similarly after > 85% agreement on 10 sequential studies. Discrepancies were resolved through discussion and consensus. Narrative synthesis was conducted to extrapolate themes and develop recommendations.
Results
Database and grey literature searches yielded 1,253 unique citations. After abstract review, 70 studies proceeded to full-text review, with 40 meeting the inclusion criteria (Fig. 1).
Fig. 1
PRISMA flow chart of study selection
Identified Barriers
Broadly, the literature underscored 3 barriers. These themes were seen recurrently throughout the literature and were noted at all stages of the medical education journey, including medical school, residency, and while in the workforce.
Advocacy training is inconsistent
The literature widely agrees that advocacy training for medical trainees is inconsistent across institutions and is often elective rather than mandatory (Burnett et al., 2025). This leaves students feeling unprepared to influence change and address the systemic barriers to health we learned so much about. Medical education heavily emphasizes the social determinants of health and how structural issues negatively impact population health, but doesn’t teach the knowledge base and skills required to make positive change past individual patient advocacy efforts (Hayman et al., 2020).
Lack of recognition of the potential influence of physicians
There has been a shift in all health professional trainee education to emphasize the social determinants of health and how structural factors influence health. There is a current lack of connecting these ideas to how health policy and legislation construct and perpetuate these issues, as well as how to effectively engage with politics to make effective change (Berman et al., 2019). At a time when there are international and local threats to evidence-based medical practice, it is more important than ever to properly educate health providers on how to advocate for the best patient care and understand how government decisions impact their work (Aksel et al., 2017). Not only this, but physicians are in a privileged position to see the direct impact social, economic, and political factors have on the health of vulnerable populations and can use these experiences to provide powerful patient anecdotes when advocating (Andrews et al., 2019). The position of physicians engaging with communities directly affected also avoids top-down advocacy approaches, which can disempower and alienate communities we seek to help (Berman et al., 2019). This valuable vantage point, combined with our scientific, clinical, and public health knowledge, can make us very effective change agents, but this requires specific skills that are not currently at the level students want.
Lack of health policy skills
A Canadian study in 2013 found that 75% of medical residents had never had any health policy training (Douglas et al., 2018), and the lack of skills required for advocacy work was a recurring theme throughout our literature analysis. To effectively advocate as a physician, you require a knowledge base of health costs, the legislative process, and the influence politics has on policy, along with soft skills such as communication, leadership, and creative problem-solving (Arends & Herman, 2020). Multiple studies highlighted that students found many barriers to engaging in advocacy work, including a lack of time, proper education, experienced faculty, resources, and experiential learning (Aliani et al., 2021; Arends & Herman, 2020).
Effective solutions
With strong student interest in advocacy efforts, we used the evidence found to develop four ways students can self-engage in political advocacy, attempting to address some of the current barriers and support students by providing tangible first steps into the advocacy field.
Seek Mentorship
One of the key barriers to learning effective health advocacy was the lack of knowledgeable role models within medical faculties. The literature reviewed demonstrated a strong theme around mentorship as an effective way to engage in political advocacy. Many described how working with faculty champions, other medical students who have experience in the field, physicians, and mentors outside of healthcare providers can be a catalyst for health advocacy learning and opportunity, as well as prepare them for potential pushback they may face specific to their area (Clarke, 2023). This can be accomplished in a few different ways, whether it be shadowing a mentor while they engage in advocacy work, informal coffee for advice and resources that could guide them, or meeting with someone who is not a physician but engages with health policy in other ways like lawyers, lobbyists, and political staffers to gain broader perspective on all the moving pieces (Griffiths et al., 2021).
Participate in Legislative Lobby Days
Experiential learning in advocacy was identified by students as a seriously lacking area of their medical education. Often student-led, legislative lobby days are incredibly beneficial learning opportunities for medical students. Multiple studies, both on student-led initiatives and pilot medical education programs, highlighted the effectiveness of these opportunities and received very positive reviews from participants (Brown et al., 2024; Douglas et al., 2018; Hayman et al., 2020). Every program approached the idea slightly differently, with some programs having small groups developing their own health policies and presenting them to stakeholders (Peterson-Perry et al., 2017), some attending lobbyist training sessions (Arends & Herman, 2020), and some with field trips to the legislature for engagement with policymakers (Douglas et al., 2018). This was also noted to be an effective engagement activity as we can continue to engage with policymakers in this way when we become physicians and start off with a good understanding of the process, the communication skills required, and who to connect with when trying to instigate change (Aksel et al., 2017).
Workshop Policy Communication Skills
Civic engagement can take many forms and can vary from meeting with elected officials to voting. One key skill many students felt was not sufficiently taught is the communication skills required for advocacy work. Some pilot education programs have begun implementing projects where medical trainees get to research health issues and write blog posts, letters to the editor, letters to legislators, call constituency offices, and practice their public speaking with a focus on ‘elevator pitches’ (Agrawal et al., 2023; Arends & Herman, 2020). These efforts don’t require formal initiatives and can be practiced throughout your medical education, providing a strong foundation of communication skills that will benefit your advocacy efforts indefinitely. There is less pressure participating in these initiatives and may make students feel less imposter syndrome when engaging, a barrier identified in some of the literature (Aliani et al., 2021). This is also an opportunity to engage in both local and national advocacy issues. Many op-ed articles noted that although it may be the most glamorous and exciting opportunity to engage in high-profile national advocacy efforts, local, grassroots efforts have the most significant impact and often involve less bureaucracy and road blocks to influencing major change (Griffiths, 2017). Engaging in as much political advocacy as possible fosters effective communication skills, understanding of the system, confidence, and is the most accessible, making it a tangible way to engage as a medical student.
Collaborate with Organizations and Leverage All Resources Available
It may be difficult to know where to turn to for advocacy information, opportunities, and to make connections with potential mentors, but a lot of the studies reviewed emphasized collaboration with organizations and utilizing resources you may not initially think of. For example, non-profit organizations often advocate for important social issues with elected officials during budget allocation discussions, providing an opportunity to get involved and helping you gain insight on how to advocate for initiatives you believe in and make a difference for patients (Brown et al., 2024). There are also many medical societies for specific specialties, geographic areas, and social issues which engage with policymakers and provide opportunities like writing policy briefs, presenting patient stories, or attending health committee meetings (Hartmark-Hill & Maurer, 2021).
Discussion
Many medical students choose medicine to create positive community change. Foundational political advocacy knowledge reinforces these values while providing opportunities to influence systemic change. Participation in advocacy during training increases the likelihood of career-long involvement, benefiting future advocacy efforts. Meaningful engagement reinforces physician identity, assists with stress management, mitigates burnout, and supports professional development. Yet minimal literature guides medical trainees in self-directed advocacy involvement. This review's limitations include potential publication bias, English/French language restriction, and limited assessment of intervention effectiveness given heterogeneous study designs. Future research should evaluate long-term outcomes of self-directed advocacy engagement and compare effectiveness across different strategies. Despite these limitations, our findings provide tangible steps medical students can take to develop required advocacy skills. These strategies can also inform the development of standardized advocacy curricula addressing current gaps in medical education.
Conclusions
Medical students can proactively develop advocacy competencies through mentorship, legislative engagement, communication skill development, and organizational collaboration. These evidence-based strategies address current barriers while providing accessible entry points into health advocacy. Future work should focus on developing and implementing standardized, evidence-based advocacy curricula across Canadian medical schools, with ongoing evaluation of effectiveness in equipping students with skills and confidence for meaningful engagement in health policy and systemic reform.
Declarations
Ethics approval and consent to participate:
Ethics approval was not required for this study as it involved a review and analysis of published literature only. No human participants or identifiable personal data were involved.
Consent for publication:
Not applicable.
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Data Availability
All data generated or analyzed during this study are included in this published article and its supplementary information files. The search strategies used are available from the corresponding author on reasonable request.
Competing interests:
The authors declare that they have no competing interests.
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Funding:
The authors received no specific funding for this work.
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Author Contribution
AB: analysis and interpretation of data, draft of manuscript; BA: analysis and interpretation of data, draft of manuscript; FC: conception and design of work, draft and review of manuscript. All authors were involved in the final review of the manuscript.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
References
Agrawal N, Lucier J, Ogawa R, Arons A. Advocacy Curricula in Graduate Medical Education: An Updated Systematic Review from 2017 to 2022. J Gen Intern Med. 2023;38(12):2792–807. https://doi.org/10.1007/s11606-023-08244-x.
Aksel S, Evans ML, Gellhaus TM. Training Physicians in Advocacy: Why It Matters. Obstet Gynecol. 2017;130(6):1334–7. https://doi.org/10.1097/AOG.0000000000002335.
Aliani R, Dreiling A, Sanchez J, Price J, Dierks MK, Stoltzfus K. Health Advocacy and Training Perceptions: A Comparison of Medical Student Opinions. Med Sci Educ. 2021;31(6):1951–6. https://doi.org/10.1007/s40670-021-01394-9.
A
Anderson HL, Lewis N, Rezet B. A Qualitative Study of Resident Advocacy Work. Pediatrics. 2024;153(3). https://doi.org/10.1542/peds.2023-061590.Andrews J, Jones C, Tetrault J, Coontz K. Advocacy Training for Residents: Insights From Tulane’s Internal Medicine Residency Program. Acad Medicine: J Association Am Med Colleges. 2019;94(2):204–7. https://doi.org/10.1097/ACM.0000000000002500.
Arends R, Herman J. Improving health policy competency through collaboration and enhanced curriculum delivery. J Prof Nursing: Official J Am Association Colleges Nurs. 2020;36(6):681–4. https://doi.org/10.1016/j.profnurs.2020.09.010.
A
Basu G, Dryden EM, Pels RJ, Stark RL, Jain P, Bor DH, Sullivan AM, McCormick D. Lessons from a social medicine and advocacy curriculum. Med Educ. 2020;54(5):466. https://doi.org/10.1111/medu.14114.A
Basu G, Pels RJ, Stark RL, Jain P, Bor DH, McCormick D. Training Internal Medicine Residents in Social Medicine and Research-Based Health Advocacy: A Novel, In-Depth Curriculum. Acad Medicine: J Association Am Med Colleges. 2017;92(4):515–20. https://doi.org/10.1097/ACM.0000000000001580.Berman ML, Tobin-Tyler E, Parmet WE. The Role of Advocacy in Public Health Law. J Law Med Ethics: J Am Soc Law Med Ethics. 2019;47(2suppl):15–8. https://doi.org/10.1177/1073110519857308.
Brown A, Wall TN, Pratt G, Talen MR, O’Grady C, Reitz R. Even one voice: Teaching legislative advocacy as a core competency in family medicine. Int J Psychiatry Med. 2024;59(4):424–31. https://doi.org/10.1177/00912174231190136.
Burnett JR, De Lima B, Wang ES, McGarry K, Kim DI, Kisielewski M, Manley K, Desai SS, Eckstrom E, Henry TL. How Are We Teaching Advocacy? A National Survey of Internal Medicine Residency Program Directors. J Gen Intern Med. 2025;40(1):89–95. https://doi.org/10.1007/s11606-024-08753-3.
Clarke L. The need to include intellectual/developmental disability in medical school curriculum: The perspective of a student advocate. J Intell Dev Disabil. 2023;48(1):100–4. https://doi.org/10.3109/13668250.2022.2111770.
A
Covidence systematic review software. [Computer software]. Veritas Health Innovation. www.covidence.org; 2024.Douglas A, Mak D, Bulsara C, Macey D, Samarawickrema I. The teaching and learning of health advocacy in an Australian medical school. Int J Med Educ. 2018;9:26–34. https://doi.org/10.5116/ijme.5a4b.6a15.
Griffiths EP. Effective Legislative Advocacy—Lessons from Successful Medical Trainee Campaigns. N Engl J Med. 2017;376(25):2409–11. https://doi.org/10.1056/NEJMp1704120.
Griffiths EP, Tong MS, Teherani A, Garg M. First year medical student perceptions of physician advocacy and advocacy as a core competency: A qualitative analysis. Med Teach. 2021;43(11):1286–93. https://doi.org/10.1080/0142159X.2021.1935829.
Hartmark-Hill J, Maurer J. Medical advocacy training for virtual or flipped-classroom learning. Med Educ. 2021;55(11):1318–9. https://doi.org/10.1111/medu.14644.
Hayman K, Wen M, Khan F, Mann T, Pinto AD, Ng SL. What knowledge is needed? Teaching undergraduate medical students to go upstream and advocate on social determinants of health. Can Med Educ J. 2020;11(1):e57–61. https://doi.org/10.36834/cmej.58424.
Huntoon KM, McCluney CJ, Wiley EA, Scannell CA, Bruno R, Stull MJ. Self-reported evaluation of competencies and attitudes by physicians-in-training before and after a single day legislative advocacy experience. BMC Med Educ. 2012;12:47. https://doi.org/10.1186/1472-6920-12-47.
Krishnamurthy S, Soltany KA, Montez K. Incorporating Health Policy and Advocacy Curricula Into Undergraduate Medical Education in the United States. J Med Educ Curric Dev. 2023;10:23821205231191601. https://doi.org/10.1177/23821205231191601.
McDonald M, Lavelle C, Wen M, Sherbino J, Hulme J. The state of health advocacy training in postgraduate medical education: A scoping review. Med Educ. 2019;53(12):1209–20. https://doi.org/10.1111/medu.13929.
McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol Jul. 2016;75:40–6. 10.1016/j.jclinepi.2016.01.021.
Peterson-Perry S, Buckmaster AM, Funkhouser S. Engaging medical students in health policy through legislation. Med Educ. 2017;51(5):544–5. https://doi.org/10.1111/medu.1331.