Residency Training:Advocacy training in neurology

Current-day physicians practice in a complex environment. They are busy and face challenges from every direction.¹ How can we lead in this complex environment? How can we become the best advocates for our patients? Advocacy should be emphasized in physician training and education. Many medical organizations have recognized the importance of physician advocacy as a core component of medical professionalism.² The Accreditation Council for Graduate Medical Education (ACGME) requires pediatric residency programs to include advocacy training as a component of residency training. In a survey of 79 pediatric residents and faculty, nearly 90% of residents felt advocacy training was necessary, and 82% reported that they would continue advocacy activities following residency.³

In 2003, the American Academy of Neurology (AAN)⁴ launched the Donald M. Palatucci Advocacy Leadership Forum (PALF) with the mission of training neurologists in the skills needed to be effective advocates and leaders. Selection to the program is a competitive process. PALF advocates are chosen based on a history of advocacy and leadership, an outstanding advocacy issue, and a commitment to future advocacy on behalf of the AAN. The program is open to neurologists in training and practicing US and international neurologists. The skills taught are universally applicable. Forum graduates become confident leaders, expand their media communication and grassroots legislative advocacy skills, and develop an advocacy project. PALF graduates gain insight from the advocacy experiences of past graduates and then empower and motivate their peers to join the advocacy efforts.⁵

The 3-day program provides instruction on the AAN structure, resources, and networks necessary to complete a 1-year advocacy project. After completing the program, graduates continue their PALF involvement through the AAN Web site and the AAN membership newsletter. Advocates maintain an active blog describing successes and roadblocks in their advocacy efforts. International problem-solving can take place in this forum with graduates and staff helping to guide those in need of information or resources.

To date, there have been 239 PALF graduates from the United States, Austria, Australia, Belgium, Canada, China, Jamaica, Japan, Georgia, Guatemala, India, Ireland, Nigeria, Pakistan, the Philippines, and Sri Lanka, to name a few (table). These advocates work on critical neurologic issues across the globe. Some action plans have included establishing US state neurologic societies, a neurologic advocacy headache consortium, establishing a medical train in India, and developing stroke centers in Australia and Sri Lanka. This PALF advocacy training program has now been modeled throughout the globe.

The PALF program is geared toward an action plan. This is the road map to achieve the advocacy goal. Advocates are encouraged to target 1 or 2 key issues that they would like to see changed or improved in their department, hospital, state, or country. They review action plans of prior graduates to identify tangible projects that can be accomplished in a year.

At the forum, 3 advocates are assigned to an advisor. These advisors are successful PALF graduates who managed to complete their action plans in a timely manner. Advisors and PALF faculty bring practical experience to the forum. Faculty members are successful graduates who have already served as advisors. PALF advocates discuss their ideas with advisors and faculty and develop their action plan. The action plan identifies the issue and the steps that need to occur to achieve the goal. The action plan also identifies possible roadblocks and resources that will be needed to accomplish the goal.

The forum also includes media and legislative training. Interactive sessions are provided to enable PALF advocates to craft their message into an easily understandable format. This information is then processed into sound bites. The advocates participate in short media interviews on camera and learn to navigate tough questions, stay on message, and provide reliable and useful audience information. The camera experience is a rewarding one that is repeated several times during the weekend training. Legislative training involves understanding how an idea becomes a bill and goes through the various stages of congressional revisions and negotiations. PALF advocates learn how to discuss issues with legislators and provide education on important neurologic topics. At the end of the training program, advocates upload their action plan to the advocacy section of the AAN Web site. Each action plan has a timeline with potential for ongoing support from the AAN advocacy staff and other PALF graduates.

The PALF message has spread throughout the world and new advocacy programs have developed internationally modeled after the PALF. The first international program on neurology advocacy was conducted (by several PALF graduates from the Asia Pacific region) at the fifth Asia Pacific Conference Against Stroke in Manila in March of 2008. Twelve stroke advocates were trained at this workshop. Additional workshops have been conducted in India, Sri Lanka, Australia (at the sixth Asia Pacific Conference Against Stroke), and Bangkok (World Congress of Neurology) since then. During these international workshops, key principles of advocacy (mirroring PALF) were highlighted. Advocates in these international advocacy programs learned about action planning and identification of resources. Timeliness in achieving goals is also emphasized. Participants were introduced to the media training process. Tools were provided to formulate a press release and to maintain an effective partnership with the media to achieve action plan goals. Advocates were also introduced to the concept of grassroots legislative training and the importance of participation in government initiatives and planning.

Wasay and Hauth⁶ demonstrated the success of PALF in a survey. Approximately 80 PALF graduates completed the questionnaire. Primary outcomes of this survey were the number of hours spent each month on advocacy-related matters and achievement of advocacy-related goals. Seventy-eight percent of the PALF graduates confirmed that they spent twice as much time on advocacy after the forum. Ninety percent of graduates reported partial or near-complete achievement of their advocacy goals.

The action plan of the first author was aimed at decreasing the incidence of stroke and stroke-related deaths in Sri Lanka. The first International Stroke Conference in Sri Lanka was organized with the Association of Sri Lankan Neurologists. Another goal was to improve public awareness of stroke with the help of the media. Using the skills acquired in PALF training, a collaboration was formed with a leading media company in Sri Lanka to produce and distribute 50,000 free booklets on stroke prevention. This educational initiative was started in late 2008. Subsequently the first Asia Pacific Stroke Conference occurred in Colombo in September 2011.⁷ The next step will be to establish neurorehabilitation programs in Sri Lanka. This program will begin with 3 Sri Lankan trainees who will go through a 12-month period of training in neurology, stroke, and neurorehabilitation.⁷

The first author was also instrumental in establishing the International Association for the Study of Pain (IASP) chapter in Sri Lanka as Sri Lanka Association for the Study of Pain (SLASP) in 2008.

With a grant from IASP, SLASP conducted a series of pain education workshops throughout Sri Lanka and published 2 books and a CD-ROM covering the key clinical topics of pain. Two international conferences on pain were then coordinated in Sri Lanka. The enthusiasm that started at these conferences regarding neurologic advocacy contributes to an increased awareness of neurologic issues in Sri Lanka.

In India, Dr. Man Mohan Mehndiratta convinced the Indian Academy of Neurology (IAN) to establish a section on advocacy. He was instrumental in spreading the teachings of PALF throughout the world through his leadership and active participation in multiple international advocacy workshops. He spearheaded the second international program on advocacy in New Delhi at the 12th Asian Oceania Congress of Neurology. Advocacy support was provided by the AAN advocacy staff and PALF graduates from India, Pakistan, the Philippines, and the United States. Also in India, Dr. Mamta Bushan Singh applied her advocacy skills to increase epilepsy awareness and care through innovative programs. She uses a hospital train to provide medical treatment to rural populations. She has done an outstanding job working to expand epilepsy services and awareness.

Dr. Mohammad Wasay, a fellow PALF graduate, led the government in Pakistan to work toward the eradication of rabies and tetanus. He was also instrumental in setting up an advocacy training program for the neurologists in Pakistan similar to the PALF program.⁸ He remains active in organizing international teaching programs on advocacy and is interested in expanding the awareness of patient safety issues in his country.

In Austria, Dr. Wolfgang Grissold was instrumental in promoting advocacy in Europe. He contributed to advocacy education through his initiatives with the education committee of the World Federation of Neurology. He participated in several PALF programs and has served as a mentor to new PALF advocates.

In the United States, Vermont neurologist Dr. Robert E. Shapiro initiated the first Headache on the Hill program calling for increased support for headache research from the NIH. He coordinated a visit to Washington, DC, in 2007 for 45 physicians, researchers, and migraine sufferers. They visited 135 congressional offices representing 29 states. Also in the United States, Alabama neurologist Dr. Daniel C. Potts focused his advocacy efforts on improving the quality of life of patients with dementia through art therapy. His father served as the inspiration for his exemplary work. Dr. Potts promotes dignity and self-worth for patients with dementia. He has also written a book discussing the issues faced by caregivers of patients with Alzheimer disease.⁹

The PALF has inspired neurologists throughout the world to take action to improve the care and education that we provide to our patients. This program is available to neurologists and neurology residents throughout the world. Hundreds of neurologists have already benefitted from this program with outstanding results. Expansion of this PALF advocacy initiative outside of the AAN has resulted in advocacy improvements to other neurologic associations around the world. We must now move forward to establish a formal residency curriculum in advocacy to ensure that our future neurologists continue this noble tradition.

• © 2012 American Academy of Neurology