SPECIAL
ARTICLES
Advocacy
Training
During
Pediatric
Residency
Paula Lozano, MD, MPH*j; Vincent M. Biggs, MD*; Barbara
J.
Sibley, MD*; Tern M. Smith, MD*; Edgar K. Marcuse, MD, MPH*; Abraham B. Bergman, MD*ABSTRACT. Despite broad concerns about the welfare of children, most pediatric residents are not able to en-gage in child advocacy during their busy training years. Yet residency can provide an opportunity for young
pe-diatricians to learn valuable advocacy skills by
undertak-ing an independent project with an experienced mentor. We describe the University of Washington Pediatrics Residency Program’s experience in training interested
residents in child advocacy. Basic requirements are that advocacy projects must not interfere with clinical
train-ing, resident participation must be voluntary, and faculty with advocacy skills must be available to help guide the
residents. Four resident projects are outlined and
guide-lines for instituting such programs are presented.
Pediatrics 199494:532-536; child advocacy, pediatric
resi-dents, residency programs.
ABBREVIATIONS. WCAAP, the Washington Chapter of the
American Academy of Pediatrics; WSMA, the Washington State Medical Association; L&I, the Department of Labor and
Industries.
Most medical school graduates entering pediatrics have concerns about the welfare of children that go beyond providing medical care. Yet, because of rig-orous time demands, the chance to engage in child advocacy during residency is extremely limited. Even more rare is the opportunity to learn effective advocacy techniques. In 1991 the University of
Washington Pediatric Residency Program set out to
determine if it was feasible for residents to success-fully engage in child advocacy, provided the goals were realistic and the program carefully structured. The following guidelines apply:
1. The project must not interfere with the resident’s
primary task, learning clinical medicine. Faculty repeatedly remind residents that although there will always be pressing societal problems to ad-dress, the 3 residency years are a unique time in which to learn to be a capable clinician.
From the Departments of Pediatrics of the *Universiay of Washington
School of Medicine and §Harborview Medical Center, and The Robert
Wood Johnson Clinical Scholars Program, Seattle, WA.
The views expressed herein are those of the authors and are notnecessarily
those of the Robert Wood Johnson Foundation.
Received for publication Apr 25, 1994; accepted Jul 13, 1994.
Reprint requests to (P.L) Center for Health Studies, Group Health
Coop-erative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101. PEDIATRK3 (ISSN 0031 4005). Copyright ©1994 by the American
Acad-emy of Pediatrics.
2. The emphasis is on learning the skills and tech-niques of advocacy, not trying to “change the world.” Participation is voluntary, and selecting a project is the resident’s prerogative. Faculty men-tors assist in designing a training experience corn-patible with the resident’s interests.
3. At the beginning of the project the resident pre-pares a timetable that is monitored by the faculty mentor. A tangible final product is required, usu-ally a written report describing the odyssey and the lessons learned.
LEARNING THE BASIC SKILLS OF ADVOCACY Although each project will provide its own specific lessons, three basic skills are emphasized:
I. Selecting a project with an attainable objective and
a definable endpoint. This is the most challenging task. Residents are encouraged to “think small,” especially because most of the work must be corn-pleted in I month.
2. Understanding that success hinges more on per-sistent, unglamorous labor than on high profile speeches or grandiose ideas.
3. Assuming a professional stance. A sincere young pediatrician is perceived by politicians and the public as an authority on children whose words will be heard.
RELATIONSHIP WITH THE WASHINGTON
STATE CHAPTER OF THE AMERICAN ACADEMY OF PEDIATRICS
Close ties exist in the state of Washington among pediatricians working at the School of Medicine, the Children’s Hospital, state and local health depart-ments, and in community practices. There are also excellent relations between the Washington Chapter of the American Academy of Pediatrics (WCAAP) and the Washington State Medical Association (WSMA). Thus, the pediatrics community in the state usually speaks with one voice. Although, as state employees, University of Washington pediatric fac-ulty cannot lobby they may do so on behaif of
WCAAP or WSMA. This mutually supportive
rela-tionship has been important to the success of the advocacy training program.
Once the WCAAP Executive Committee approves an advocacy project, the residents become official spokespersons for the pediatricians of the state of Washington. This provides them with access to the
considerable lobbying resources. This assistance is in itself a striking learning experience. The residents, who from their student days tend to see themselves as powerless outsiders, are amazed to suddenly have access to the “tools of the establishment.” The
bene-fits to the WCAAP are even greater. A group of
energetic and articulate young pediatricians have been attracted to the fold of an organization that always seeks to recruit new blood.
PROGRAM STRUCTURE
Residents typically begin advocacy projects in the third year, during a 1-month elective at the county hospital, Harborview Medical Center. (All residents spend 2 clinical months at Harborview during their second year.) The elective involves taking regular
night call in the Harborview emergency room in
addition to a daytime independent project. The coy-erage schedule does require that one-third of all R-3s participate in this rotation, however most of these residents choose their projects from among Harbor-view’s clinical or research activities. Those who de-cide to undertake a child advocacy project during this elective do so of their own initiative.
Usually, after the large initial time investment over the elective month, the project continues for several months at a slower pace during lighter rotations. Some residents have begun projects of their own initiative during the second year and then used the third year elective to further develop a particular facet.
Experienced faculty are an essential component. Early in the project, the resident identifies a faculty mentor well-versed in advocacy whose responsibil-ity is to ensure that the project is feasible and that there is a satisfactory endpoint. The supervisor is available to provide guidance and logistic support as needed.
ILLUSTRATIVE EXAMPLES
From July 1, 1991 to February 28, 1994, 11 residents have participated in the advocacy training program. Their projects include: regulating child labor in the state of Washington, educating parents on the effect of secondhand smoke, improving medical care of poor children with asthma in King County, reducing the use of infant walkers in the United States, iden-tifying barriers to immunization for Hispanic chil-dren, organizing residents to teach health education in middle schools, preserving the state of Washing-ton’s bulk purchase vaccine program, improving ac-cess to health care for the Oromo (East African) community in Seattle, educating families about safe storage of handguns in the home and expanding Washington’s child restraint law. The flavor of the program can best be demonstrated by the illustrative examples written by the four residents carrying out the project.
EDUCATING PARENTS ON THE EFFECTS OF
SECONDHAND SMOKE (T.M.S.)
The adverse health impact of secondhand smoke has become an increasingly publicized issue with public concern most focused on limiting smoking in
public areas. As a resident, I was acutely aware of the harmful effects of tobacco smoke on the children in my continuity practice. Despite major legislative ad-vances to protect the public from passive smoke, I felt at a loss as a physician in trying to educate parents about decreasing this risk in their homes. A major obstacle was the lack of appropriate educa-tional materials. I often found myseif writing out instructions for families by hand, as part of the well-child visit. Frustrated by this situation, I chose to make it the focus of my advocacy project.
During my 1-month elective, I met with local anti-smoking activists, attended meetings of American Stop Smoking Intervention Study, Doctors Oughta Care, the State Health Department, American Cancer Society, and the American Health and Lung Associ-ations. I found a paucity of appropriate educational
material on secondhand smoking and decided to
develop a pamphlet to help teach parents about sec-ondhand smoke.
I was able to enlist the pro bono participation of one of the leading advertising agencies in the North-west, “The Worker BEEs,” to design artwork and text. We targeted low income, low educational level parents and pregnant teens because this is a popula-tion with many new smokers, and frequent contact with children. The finished product is an easy-to-read, four-page foldout with eye-catching illustra-tions (Figure).
I then turned my attention to getting the pamphlet published and distributed. That involved raising fi-nancial support from public agencies and private companies. The goal was to supply pamphlets to all primary care physicians in the state of Washington for free distribution to their patients. Although I was able to get the local Blue Shield organization to agree to do the printing, at the end of the month I was unable to come up with the $5000 needed to produce the pamphlet. (A colleague continued these efforts during her advocacy elective a year later, but we have thus far been unable to come up with the needed money.)
The process taught me a great deal about politics as well as patient education. I continue to appreciate the need for persistence, as I work to make this pamphlet available to families.
EXPANSION OF WASHINGTON’S CHILD
RESTRAINT LAW (B.J.S.)
During a health supervision visit early in my R-2 year, I told a mother that children were legally re-quired to be secured in a safety seat up to age 4 or 40 pounds-reiterating the norm of the other states where I had lived. Much to my surprise the mother argued that Washington law required car-seats only until I year of age. I checked with the state patrol and, as usual, the parent was right. The state of Washington’s law was inadequate: a 13-month-old could be legally restrained in an adult lap belt, a device not designed for the anatomy of a toddler.
‘-I
Second-hand smoke can be
as bad for kids as smoking.
So light up ifyou mui4. Jus;t dont do it around them.
American Academy ofPedlcatrics
Washington chapter
Figure. Cover from a pamphlet designed to teach parents about the effect of passive smoke on their children.
intestinal perforation when strapped in with an adult lap belt.
I decided to try to change the existing Washington law to protect more children from the morbidity and mortality of being inappropriately restrained in a motor vehicle crash. Little did I suspect that such a seemingly noncontroversial issue would raise such hackles and require endless political maneuvering to achieve passage. Nor had I been taught that passage of legislation is based more on well-timed phone calls, faxes, and behind the scenes bargaining than on the merits of the bifi.
After a planning session with my mentor, I put
together a fact sheet on child care restraints and sent it to the press and state legislators. The lobbyist of the WSMA arranged for my mentor and me to have lunch with the chairman of the Senate Law and Justice Committee at which time he agreed to spon-sor the bill. His staff, with the help of the Traffic Safety Commission, investigated the legal aspects, studied other states’ laws, and drafted the bifi.
Testifying in the state capitol before the Senate subcommittee gave me the opportunity to state our case both in medical and emotional terms. As the
representative of WCAAP, my statements were
taken seriously. Although no outright opposition
arose, the bifi almost died that first day due to
in-fighting among committee members over an
unre-lated issue. (I learned this was a common
occur-rence). The bifi did pass out of the subcommittee at
the last possible minute.
From that point on, our strategy was to garner the support of key legislators needed to keep the bill
moving through the various house and senate
sub-committees, committees, and general assemblies, all
of which occurred at a frantic, gripping pace. We
enlisted the help of pediatricians statewide to urge legislators’ support. We targeted outspoken pediatri-cians in pivotal legislative distriCts. The WSMA
lob-byist advised us where, when, and on whom we
should focus our attention. On the last day of the
1993 session, the bifi was passed and was signed into law later that summer.
The law doubled the age of mandatory car seat use
from I to 2 years old (we would have preferred age 4), elevated it to a primary offense, and made any driver (not just the parent) responsible for compli-ance. (In 1994, the Washington legislature increased the age limit to 3). Our media campaign also
in-creased public awareness of the importance of car
The pediatric community’s strong participation in our campaign taught me that our state has many practitioners committed to advocacy and willing to take part in a coordinated lobbying effort on behalf of child safety. I also learned about finding my way through state government and was amazed that with tenacity and the right strategies it is possible to bring about change.
REGULATING CHILD LABOR IN
WASHINGTON STATE (P.L)
From 1990 to 1992, the state of Washington became embroiled in an emotional debate about the state’s role in protecting the health and welfare of children in the non-agricultural workplace. The restaurant,
grocery, and convenience store industries rely
heavily on the teen work force, a situation that the public has long viewed as innocuous. The debate began when the Department of Labor and Industries (L&I) called together an Advisory Committee on
Non-Agricultural Child Labor to reexamine the
state’s long unrevised child labor regulations. The Committee’s work brought child labor issues to the fore and raised questions about the effects of work-ing on the health and welfare of children. The risk of child labor was framed not only in terms of occupa-tional hazards, but perhaps more importantly, in terms of educational losses. The rising tide of criti-cism of the state of Washington’s educational system and the much-publicized lack of job skifis among high school graduates gave weight to the arguments of child advocates, including the WCAAP, that the state needed to help protect teenagers from long work weeks and late nights on the job.
L&I asked the WCAAP to provide a representative to this new committee. The Chapter’s leadership of-fered me this opportunity during my second year of residency. I served for I year, attending bimonthly meetings throughout the state. My initial role was to interpret the scientific literature on child labor for the business and labor representatives, educators, attor-neys, and legislators on the committee. As the debate
became more heated, I coordinated a media
cam-paign to publicize WCAAP’s position that I helped formulate; namely, that although many teenagers benefit from part-time work, the economic concerns of businesses must not be allowed to place children’s health and education at risk.
The committee’s final report to L&I, presented in February 1992, recommended allowing 16- and 17-year-olds to work 20 (instead of 40) hours per week and limiting the amount of late night work for teens. The report also listed a number ofjobs and duties felt to be potentially hazardous for adolescents. In the ensuing months, the business groups opposed to this report waged a political battle aimed at derailing the reforms at the legislative level. In this phase of the project, I actively lobbied the legislature and gover-nor, working with lobbyists from the various inter-ested parties, including business, labor unions, and the parent-teacher association, and by speaking to the press.
The opposing legislative initiative failed and in October 1992, L&I announced the adoption of what
the New York Times called one of the most
progres-sive set of child labor regulations of any state in the nation (New York Times. August 17, 1992:A12).
The experience demonstrated to me that because pediatricians may be one of the few parties in the
debate who speak solely for the child, our opinion
can carry surprising dout. However, I also learned that daiming the moral high ground is no substitute for hard work and shrewd coalition-building.
REDUCING THE USE OF INFANT WALKERS IN
THE UNITED STATES (V.M.B.)
During my 2-month ambulatory pediatrics rota-tion as a second-year resident at Harborview Medi-cal Center, I took care of several infants with walker-related injuries. One had sustained a severe closed head injury when he fell down a ifight of stairs. Others had suffered scald burns that often required skin grafting and prolonged hospital stays in the burn unit. Concerned that walkers represented a sig-nificant hazard to preambulatory infants, I reviewed the medical literature and found numerous artides consistent with my clinical experience. Convinced that walkers were a hazard, I decided to look for ways to reduce their use. This evolved into three sequential projects over the course of 2 years.
With the help of my mentors and the Consumer Federation of America, a national consumer advo-cacy organization, I drafted a formal petition to the
Consumer Product Safety Commission requesting a
ban on the manufacture and sale of infant walkers in the United States. Submitting this controversial peti-tion generated considerable media attention and en-couraged me to take further action. Predictably, the petition was denied I year later; however, the pub-licity surrounding the Commission’s decision pro-vided yet another opportunity to publicize the dan-gers of infant walkers.
The next step was to get the American Academy of
Pediatrics to help. As a representative of the
WCAAP, I authored an infant walker resolution and succeeded in getting it passed at the Annual Chapter Forum in September 1992. As a result, the American Academy of Pediatrics is planning to issue a policy statement in Pediatrics discouraging the use of infant walkers and will incorporate infant walker education in the next revision of The Injury Prevention Pro-gram.
The third strategy was an infant walker turn-in campaign in the spring of 1993 aimed at educating the public via mass media. I contacted pediatricians and children’s hospitals in Boston, Chicago, Cincin-nati, and Los Angeles to launch aggressive education campaigns. Two cities (Boston and Seattle) staged
“turn-ins,” where parents turned in their walkers to
During the campaign I learned that effective child advocacy involves skillful work with the news me-dia. I was also exposed to the field of injury preven-tion and the politics of consumer protection.
CONCLUSION
Pediatric training programs should consider broadening their offerings to foster residents’ interest in child advocacy. Participation should be voluntary, and the presence of faculty experienced in advocacy to serve as mentors is imperative. An achievable concrete goal must be defined at the outset and the project must not be allowed to interfere with the
resident’s clinical responsibilities. Our experience demonstrates that in a carefully structured program, pediatric residents can learn useful skills and gain personal satisfaction from advocating for children.
ACKNOWLEDGMENTS
The authors would like to recognize the efforts of the other
residents and faculty mentors who participated in the advocacy
training program as of February 1994: Rick Levine, Cliff O’Callahan,Jim Olson, Susan Omura, Traci O’Neill, Ellen Passloff,
and Michael “Dooley” Womack (residents); and Effie Graham,
David Grossman, Kathi Kemper, Case Koiff, and Fred Rivara
(faculty).
FLORIDA APPROVES MEASURE ON RIGHT TO BREAST-FEED
IN PUBLIC
TALLAHASSEE, Ha., March 3-In an action that is being hailed by women’s and health groups as an important symbolic victory, the Florida Legislature has enacted what is apparently the first state measure guaranteeing women the right to breast-feed their children in public.
By a unanimous vote, the Florida Senate on Tuesday passed a bifi that amends the state’s statutes on indecent exposure, lewd and lascivious behavior and
ob-scenity to exempt and protect nursing mothers from arrest or harassment by
law-enforcement or private security officials.
The bifi also endorses breast-feeding as the preferred method of nurturing an
infant and condemns “the vicious cycle of embarrassment and ignorance” and
“archaic and outdated moral taboos” surrounding the practice.
The measure has been praised by organizations like La Leche League, a breast-feeding advocacy group, which describes it as the first instance in the nation of a state’s codifying support for breast-feeding.
Rohter L. Florida approves measure on right to breast-feed in public. The New York Times. March 4, 1993.
1994;94;532
Pediatrics
Abraham B. Bergman
Paula Lozano, Vincent M. Biggs, Barbara J. Sibley, Terri M. Smith, Edgar K. Marcuse and
Advocacy Training During Pediatric Residency
Services
Updated Information &
http://pediatrics.aappublications.org/content/94/4/532
including high resolution figures, can be found at:
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtml
entirety can be found online at:
Information about reproducing this article in parts (figures, tables) or in its
Reprints
http://www.aappublications.org/site/misc/reprints.xhtml
Information about ordering reprints can be found online:
at Viet Nam:AAP Sponsored on September 1, 2020
www.aappublications.org/news
