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The future of physician advocacy: a survey of U.S. medical students

Abstract

Background

Advocacy is a core component of medical professionalism. It is unclear how educators can best prepare trainees for this professional obligation. We sought to assess medical students’ attitudes toward advocacy, including activities and issues of interest, and to determine congruence with professional obligations.

Methods

A cross-sectional, web-based survey probed U.S. medical students’ attitudes around 7 medical issues (e.g. nutrition/obesity, addiction) and 11 determinants of health (e.g. housing, transportation). Descriptive statistics, Kruskal-Wallis tests, and regression analysis investigated associations with demographic characteristics.

Results

Of 240 students completing the survey, 53% were female; most were white (62%) or Asian (28%). Most agreed it is very important that physicians encourage medical organizations to advocate for public health (76%) and provide health-related expertise to the community (57%). More participants rated advocacy for medical issues as very important, compared to issues with indirect connections to health (p < 0.001). Generally, liberals and non-whites were likelier than others to value advocacy.

Conclusions

Medical students reported strong interest in advocacy, particularly around health issues, consistent with professional standards. Many attitudes were associated with political affiliation and race. To optimize future physician advocacy, educators should provide opportunities for learning and engagement in issues of interest.

Peer Review reports

Background

In recent decades, physician advocacy, particularly regarding social determinants of health and just distribution of resources, has been embraced as a core component of professionalism [1,2,3]. Medical organizations and codes of conduct frequently emphasize the importance of physician civic engagement [4, 5]. The American Medical Association (AMA), for example, urges physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” [6] Similarly, the Physician’s Charter asserts that “the medical profession must promote justice in the health care system, including the fair distribution of health care resources.” [7] And physicians themselves almost unanimously agree that community participation, political involvement, and collective advocacy are important professional duties [8].

Yet few physicians actually engage in these tasks [1]. In a 2004 survey, only a quarter of U.S. physicians reported participating politically (apart from voting) on local health issues [8, 9]. Indeed, physicians take part in community and political activities less frequently than the general population and other professionals with similar levels of education and income [10, 11]. While reasons for physicians’ low levels of engagement likely vary, [1] there is clearly more work to do in equipping physicians to participate in and contribute to civic life.

Educating medical students about their professional responsibility to advocate for health-related issues is essential to promoting more robust physician civic engagement in the future. Yet relatively little is known about students’ awareness of or interest in these vital topics. We therefore set out to understand medical students’ attitudes around civic engagement -- including their interests and future plans around health policy, their sense of responsibilities around healthcare access and costs, their attitudes toward different forms of public engagement, as well as specific issues of interest -- and to determine congruence with professional obligations. We also hypothesized that students would express stronger interest in advocacy around issues directly related to health and medical care (e.g. nutrition, addiction, care access) but lesser support for engagement around indirect determinants of health (e.g. transportation, education, economic inequality).

Methods

Survey administration

We conducted a cross-sectional, web-based survey of U.S. medical students. Participants were recruited from Student Doctor Network (SDN), a non-profit, online forum for current and future healthcare students and professionals. The survey link was posted on SDN’s Facebook and Twitter pages and on the SDN website’s homepage, online forums for allopathic and osteopathic medical students, and blog; the blog post was also distributed to self-identified medical students who had previously opted to receive SDN emails. The survey was anonymous, but participants could opt to provide their email address to enter a lottery for 1 of 20 $100 gift cards.

The survey launched on August 13, 2019, and closed on October 15, 2019. Responses were collected and managed using Research Electronic Data Capture (REDCap), a secure, web-based software platform hosted at Memorial Sloan Kettering Cancer Center (MSK) [12, 13]. Our findings are reported according to the Checklist for Reporting Results of Internet E-Surveys [14] (Supplemental Digital Appendix 1). The study was reviewed by the MSK Institutional Review Board (IRB) and deemed exempt.

Survey instrument

We adapted some survey items from prior studies [8, 9, 15,16,17,18,19] and developed additional, novel questions focusing on study objectives (Supplemental Digital Appendix 2). A response to each question was required in order to proceed to the next. The survey included demographic items and several measures assessing participants’ interest in following or becoming involved in healthcare policy. Two measures tested their views of physicians’ responsibilities to patients around healthcare access and costs (providing care regardless of patients’ ability to pay, being aware of the overall costs of care they provide) [9, 19]. Additional items gauged participants’ attitudes toward 3 forms of physician civic engagement: [8, 19, 20] Community participation (providing health-related expertise to local populations), individual political engagement (being politically involved around health issues at the local, state, or national level), and collective advocacy (encouraging medical organizations to advocate for public health).

The survey also assessed participants’ support for individual or collective advocacy by physicians around 18 public priorities, adapted from recent national surveys of the U.S. population [17, 18]. Seven issues directly related to health and healthcare: healthcare costs, healthcare coverage for the uninsured, Medicare/Medicaid/Social Security, drug addiction and treatment, abortion laws/reproductive issues, nutrition/obesity/food safety, and disability rights. Eleven additional issues had connections to or implications for health: education, [21, 22] housing/homelessness, [23, 24] transportation, [25, 26] immigration, [27, 28] LGBTQ (lesbian, gay, bisexual, transsexual, and queer/questioning) issues, [29, 30] racial issues, [31, 32] economic issues, [33, 34] environmental issues, [35, 36] human rights, [37, 38] crime/criminal justice, [39, 40] and military/national security issues [41, 42].

Response options included Likert scales for agreement (strongly agree, agree, disagree, strongly disagree) and importance (very important, somewhat important, not important). We piloted a preliminary version of the survey with 15 medical students and internal medicine residents at Weill Cornell Medical Center and made minor changes to the survey based on their feedback and responses.

Analysis

We used descriptive statistics to summarize participants’ demographics and attitudes. We used census zones to determine geographic region of participants’ schools. We used the Kruskal-Wallis test to evaluate associations between demographic characteristics (including gender, race, year in school, political identification, and anticipated future field) and attitudes around healthcare policy and forms of civic engagement. We also created a composite civic-mindedness score for each participant by averaging the strength of their responses (using scores of 1 for “not important,” 2 for “somewhat important,” and 3 for “very important”) to all 18 public-priorities questions (overall score); we similarly generated composite scores for the 7 issues directly related to health and healthcare (medical score), as well as for the 11 issues addressing indirect or social determinants of health (social score). We used univariate tests and multiple linear regression to evaluate associations between demographic characteristics and overall, medical, and social scores. All analysis was performed in Stata 14.2 [43].

Results

There were 815 visitors to the SDN postings linked to the survey. Three hundred sixty-one unique individuals accessed the survey link, and 356 completed the first page to determine eligibility (based on attendance at an accredited U.S. medical school). Of 277 eligible participants, 240 completed the survey (view rate 44%; participation rate 77%; completion rate 87%) [14]. (Supplemental Digital Appendix 1).

Participant characteristics are shown in Table 1. Eighty-seven percent of participants were enrolled in MD programs. Approximately two thirds were 25–34 years old and white, and about half were women. Participant gender and race were similar to characteristics of U.S. medical students overall [44]. All geographic regions and years of medical school were represented, with slight overrepresentation of first-year students.

Table 1 Participant Characteristics (N = 240)

Interest and intentions around healthcare policy

Three in four participants in our study were members of at least one medical organization addressing healthcare policy issues (e.g. American Medical Association, American Medical Student Association, American Medical Women’s Association). Nearly allreported following healthcare policy in the news (Table 2). Eight-7 % somewhat or strongly disagreed that healthcare policy will have little or no effect on their care of patients, with liberals twice as likely as conservatives to hold these views (p < 0.001). Most also planned to become involved or take leadership in healthcare policy issues as physicians; liberals and those intending to enter primary care were 2 and 6 times likelier, respectively, than others to express strong interest in policy involvement (p < 0.05).

Table 2 Participants’ interest and engagement in healthcare policy (N = 240)

Responsibilities around healthcare costs and access

The survey probed participants’ beliefs about physicians’ responsibilities around healthcare access and costs (Table 3). Three quarters agreed it is very important for physicians to know the overall cost of the care they provide. A large majority believed that it was very important for physicians to provide necessary care regardless of the patient’s ability to pay, although liberals were more likely than independents and conservatives to hold this view (p < 0.001).

Table 3 Participants’ assessments of civic responsibilities (N = 240)

Public roles: collective, community, and individual

The survey assessed participants’ attitudes toward 3 forms of civic involvement by physicians: collective advocacy, community participation, and political engagement (Table 3). Three quarters said that it was very important for physicians to encourage medical organizations to advocate for the public’s health. This measure correlated with political identification, with liberals more likely than independents and conservatives to hold this attitude (p < 0.001). More than half reported that it is very important for physicians to provide health-related expertise to local community organizations. First- and second-year students and those intending to enter primary care were more likely than others to express this opinion (p < 0.05). Fewer than half agreed that it is very important for physicians to be politically involved in health-related matters at the local, state or national level. Liberals were more likely than independents and conservatives to hold this view (p < 0.001).

Issues of interest

The survey explored participants’ attitudes toward 18 public priorities (Table 4). Nearly all believed it was very important for physicians to individually or collectively advocate around drug addiction and treatment, healthcare coverage for the uninsured, and nutrition, obesity, and food safety. Large majorities also strongly favored professional engagement around healthcare costs, abortion laws and reproductive issues, human rights, disability rights, Medicare, Medicaid, and Social Security, and education. Similarly, most rated physician advocacy on racial issues, housing and homelessness, and LGBTQ issues as very important. Lesser support was evident for physician engagement around environmental issues, immigration, economic issues, crime and criminal justice, transportation, and military and national security issues .

Table 4 Issue priorities (N = 240)

Overall civic-mindedness scores, averaging the strength of participants’ responses (using scores of 1 for “not important,” 2 for “somewhat important,” and 3 for “very important”) to all 18 issues, had a mean of 2.5 and median of 2.6 (IQR: 2.28–2.83). Medical scores, based on participants’ assessments of the 7 issues directly related to health and healthcare (healthcare costs, healthcare coverage for the uninsured, Medicare/Medicaid/Social Security, drug addiction and treatment, abortion laws/reproductive issues, nutrition/ obesity/food safety, and disability rights), had a mean of 2.7 and a median of 2.9 (IQR: 2.57–3.00). Social scores, based on participants’ responses to the 11 issues with indirect connections to or implications for health (education, housing/ homelessness, transportation, immigration, LGBTQ issues, racial issues, economic issues, environmental issues, human rights, crime/criminal justice, and military/national security issues), had a mean of 2.4 and a median of 2.5 (IQR: 2.00–2.82). (Table 4).

Regression analysis indicated that liberal participants had higher overall, medical, and social scores than conservatives (p < 0.01). Nonwhite participants had higher medical scores than whites (p < 0.05); they also had higher overall and social scores, although this trend was not statistically significant. Kruskal-Wallis tests showed women and those intending to enter primary care to have higher overall and social scores than other participants (p < 0.05). However, our regression analysis did not find gender or intended future field to be a significant predictor, suggesting that political identification was driving these differences and capturing the variance in our model. (Table 5, Supplemental Digital Appendix 3).

Table 5 Univariate associations between student characteristics and civic engagement

Discussion

Our findings can assist medical schools in preparing the next generation of physicians to more actively engage in civic life. Nearly all participants in our study expressed nascent interest in healthcare policy and civic engagement. Anticipating its relevance to their future practice, most stayed abreast of healthcare policy news and anticipated some degree of policy involvement as physicians. These results suggest that many students would welcome greater opportunities in medical school to learn about and participate in health policy issues.

Participant views of specific civic roles were more variable. Large majorities expressed a strong sense of professional obligation around the just provision of clinical care, from being cost-aware to treating patients who are unable to pay. These attitudes are similar to those of U.S. physicians. Notably, despite efforts to develop novel curricula, [45,46,47] these fundamental public health issues remain underemphasized in medical school environments. Our findings should encourage further efforts, as they suggest that many students might appreciate instruction around the challenges of caring for patients in a system where costs are frequently high and nontransparent and many patients are un- or under-insured.

About half of participants saw civic engagement by individual physicians, whether through community service or political involvement, as crucial. While similar to the views of practicing physicians in the U.S. [8], these attitudes stand in contrast to broad recognition of the important role of individual physicians in driving health system changes that will better meet the health needs of society [48]. More transparent role modeling of civic engagement by educators and better student access to meaningful advocacy opportunities could lead to greater student awareness of the importance of individual engagement and greater commitment to future action [49].

Most participants strongly supported public health advocacy by medical organizations. This finding mirrors the attitudes of U.S. physicians [8] and indicates that medical students would likely be interested in learning about how medical organizations have advocated around public health issues, as well as the obstacles (internal and external) to success. This would give students crucial insight into organized medicine’s mixed record in challenging or perpetuating the inequalities that pervade the U.S. healthcare system. It could also give students a greater appreciation for the enormous value of and need for civic engagement by individual physicians, who are often at greater liberty than medical organizations to critique inequities and participate in community and political affairs. To this end, schools should also highlight the numerous training and career opportunities available to medical professionals interested in advocacy.

Attitudes varied importantly by issue. Participants showed broad support for individual or collective physician advocacy around most of the public priorities included in our survey. Our findings regarding specific issues were consistent with results from physician surveys, [8, 9] with the exception of healthcare coverage for the uninsured, which was rated as very important by 81% of students in our study compared with 58% of practicing physicians in a 2006 study [8]. The overall similarity in attitudes is notable, given differences in generational attitudes, and may reflect a commonality of concerns among individuals with an interest in healthcare [50]. The greater emphasis on problems related to the uninsured in our study may related to increased public awareness of the issue [51].

As hypothesized, directly medical issues rated higher than those with indirect connections to or implications for health. This finding, while intuitive and broadly consistent with results from physician surveys, [8, 9] suggests that medical students in our study may not entirely understand the ways in which social determinants such as immigration, [27, 28] economic issues, [33, 34] transportation [25, 26] and crime/criminal justice issues [39, 40] can profoundly shape patients’ health. More, seemingly disparate issues are inevitably connected in that government budgets are finite, so choices in one area frequently have implications for others. For example, higher military expenditures are consistently associated with lesser funding for health and welfare programs [41, 42]. Medical schools should ensure that students fully grasp these and other ways in which non-medical issues systematically influence health.

Attitudes were generally stable across all years of medical school, but, as in physician surveys, [8, 9] many correlated to gender, race, future field, and political identification. Political identification was the most frequent and strongest predictor. Notably, conservatives in our study were more likely than liberal participants to doubt that healthcare policy would affect their care of patients, and conservatives had lower overall, medical, and social scores than liberals. These findings highlight the importance of ensuring that medical school curricula related to civic engagement recognize political diversity and remain attentive to appealing to concerns of students across the political spectrum. They also raise the question of whether some opportunities for education about and participation in civic engagement issues should be elective, providing opportunities for students to explore issues that best align with their interests.

Our findings with regard to race are also noteworthy and corroborate findings from physician surveys [8, 9]. Our sample was approximately one-third non-white; non-white participants identified predominantly as Asian (28%), with few (7%) identifying as Black or African American. Non-white participants had higher medical scores than whites, with a trend toward higher social and overall scores, as well -- suggesting consistently higher levels of civic engagement and perhaps broader interests compared to white students. The drivers of these attitudinal differences require further research, but may reflect the influence of diverse backgrounds and experiences.

However, as among medical students overall, Black students were underrepresented among our participants compared to the U.S. population [52]. Stronger representation of the views of underrepresented minority students is important for identifying issues for physician civic engagement that reflect the priorities of the broader population. More representative student populations might also engender greater student interest in a broader range of civic engagement issues, and ultimately a more engaged physician workforce. To optimize physician engagement, medical schools should redouble their efforts to recruit medical students who represent the diversity of the overall population.

This study has several limitations. Our modest sample size and online recruitment strategy raise the possibility that our findings may not be representative of all U.S. medical students. However, our study did capture attitudes from medical students from diverse geographical locations and with demographic characteristics similar to U.S. medical students overall [44]. In addition, we intentionally framed questions about specific issues in a neutral, apolitical way. However, some participants may still have perceived political bias in some items, such as “environmental issues” and “abortion laws and reproductive issues”; this perception may have influenced responses, particularly among conservative students. Finally, our survey was conducted prior to the COVID-19 pandemic, which has highlighted health disparities in minority populations, [53, 54] and the widespread Black Lives Matter protests following the murder of George Floyd [55]. These events may have influenced medical student attitudes toward civic engagement, particularly around issues with indirect links to health. Our findings do not reflect these potential shifts; future studies should evaluate the influence of these events on the attitudes of students and physicians.

Conclusion

Medical students in our study reported keen interest in civic engagement and advocacy, particularly around issues directly involving health or healthcare services, which is generally consistent with professional standards. Many attitudes and interests are associated with political affiliation, race, gender, and intended future field. To optimize future physician advocacy, educators should provide opportunities for student learning and engagement in these vital matters.

Practice points

Medical students want to learn about just provision of care and advocacy by organizations.

Advocacy by individual physicians is under-appreciated by students.

Students may incompletely understand how social determinants shape health.

Advocacy curricula should appeal to students across the political spectrum.

To ensure robust future advocacy, schools should recruit a diverse and representative student population.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. We are developing another manuscript and prefer not to openly post the data until this work is complete.

Abbreviations

AMA:

American Medical Association

IRB:

Institutional Review Board

LGBTQ:

Lesbian, gay, bisexual, transsexual, and queer/questioning

MSK:

Memorial Sloan Kettering Cancer Center

REDCap:

Research Electronic Data Capture

SDN:

Student Doctor Network

References

  1. 1.

    Earnest MA, Wong SL, Federico SG. Perspective: physician advocacy: what is it and how do we do it? Acad Med. 2010;85(1):63–7. https://doi.org/10.1097/ACM.0b013e3181c40d40.

    Article  Google Scholar 

  2. 2.

    Kanter SL. On physician advocacy. Acad Med. 2011;86(9):1059–60. https://doi.org/10.1097/ACM.0b013e318227744d.

    Article  Google Scholar 

  3. 3.

    Sethi MK, Obremskey A, Sathiyakumar V, Gill JT, Mather RC. The Evolution of Advocacy and Orthopaedic Surgery. Clin Orthop Relat Res. 2013;471(6):1873–8.

    Article  Google Scholar 

  4. 4.

    Huddle TS. Clarifying the dispute over academic-industry relationships. Am J Bioeth. 2011;11(1):47–9. https://doi.org/10.1080/15265161.2010.534540.

    Article  Google Scholar 

  5. 5.

    Huddle TS. Perspective: medical professionalism and medical education should not involve commitments to political advocacy. Acad Med. 2011;86(3):378–83. https://doi.org/10.1097/ACM.0b013e3182086efe.

    Article  Google Scholar 

  6. 6.

    Riddick FA Jr. The code of medical ethics of the American Medical Association. Ochsner J. 2003;5(2):6–10.

    Google Scholar 

  7. 7.

    ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millenium: a physician charter. J Am Coll Surg. 2003;196(1):115–8.

    Article  Google Scholar 

  8. 8.

    Gruen RL, Campbell EG, Blumenthal D. Public roles of US PhysiciansCommunity participation, political involvement, and collective advocacy. JAMA. 2006;296(20):2467–75. https://doi.org/10.1001/jama.296.20.2467.

    Article  Google Scholar 

  9. 9.

    Campbell EG, Regan S, Gruen RL, Ferris TG, Rao SR, Cleary PD, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795–802. https://doi.org/10.7326/0003-4819-147-11-200712040-00012.

    Article  Google Scholar 

  10. 10.

    Grande D, Asch DA, Armstrong K. Do doctors vote? J Gen Intern Med. 2007;22(5):585–9. https://doi.org/10.1007/s11606-007-0105-8.

    Article  Google Scholar 

  11. 11.

    Grande D, Armstrong K. Community volunteerism of US physicians. J Gen Intern Med. 2008;23(12):1987–91. https://doi.org/10.1007/s11606-008-0811-x.

    Article  Google Scholar 

  12. 12.

    Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O'Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. https://doi.org/10.1016/j.jbi.2019.103208.

    Article  Google Scholar 

  13. 13.

    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010.

    Article  Google Scholar 

  14. 14.

    Eysenbach G. Improving the quality of web surveys: the checklist for reporting results of internet E-surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34. https://doi.org/10.2196/jmir.6.3.e34.

    Article  Google Scholar 

  15. 15.

    Antiel RM, James KM, Egginton JS, Sheeler RD, Liebow M, Goold SD, et al. Specialty, political affiliation, and perceived social responsibility are associated with U.S. physician reactions to health care reform legislation. J Gen Intern Med. 2014;29(2):399–403. https://doi.org/10.1007/s11606-013-2523-0.

    Article  Google Scholar 

  16. 16.

    Grischkan J, George BP, Chaiyachati K, Friedman AB, Dorsey ER, Asch DA. Distribution of medical education debt by specialty, 2010-2016. JAMA Intern Med. 2017;177(10):1532–5. https://doi.org/10.1001/jamainternmed.2017.4023.

    Article  Google Scholar 

  17. 17.

    The Pew Research Center: Public’s 2019 priorities: economy, Health Care, Education and Security All Near Top of List. In.; 2019.

  18. 18.

    The Pew Research Center: Economic issues decline among Public’s policy priorities. 2018.

  19. 19.

    Kirchhoff AC, Hart G, Campbell EG. Rural and urban primary care physician professional beliefs and quality improvement behaviors. J Rural Health. 2014;30(3):235–43. https://doi.org/10.1111/jrh.12067.

    Article  Google Scholar 

  20. 20.

    Gruen RL, Pearson SD, Brennan TA. Physician-citizens—public roles and professional obligations. Jama. 2004;291(1):94–8. https://doi.org/10.1001/jama.291.1.94.

    Article  Google Scholar 

  21. 21.

    Cutler DM, Lleras-Muney A: Education and health: evaluating theories and evidence. In.: National bureau of economic research; 2006.

  22. 22.

    Conti G, Heckman J, Urzua S. The education-health gradient. Am Econ Rev. 2010;100(2):234–8. https://doi.org/10.1257/aer.100.2.234.

    Article  Google Scholar 

  23. 23.

    Shaw M. Housing and public health. Annu Rev Public Health. 2004;25(1):397–418. https://doi.org/10.1146/annurev.publhealth.25.101802.123036.

    Article  Google Scholar 

  24. 24.

    Gibson M, Petticrew M, Bambra C, Sowden AJ, Wright KE, Whitehead M. Housing and health inequalities: a synthesis of systematic reviews of interventions aimed at different pathways linking housing and health. Health & place. 2011;17(1):175–84. https://doi.org/10.1016/j.healthplace.2010.09.011.

    Article  Google Scholar 

  25. 25.

    Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976–93. https://doi.org/10.1007/s10900-013-9681-1.

    Article  Google Scholar 

  26. 26.

    Shier G, Ginsburg M, Howell J, Volland P, Golden R. Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Aff. 2013;32(3):544–51. https://doi.org/10.1377/hlthaff.2012.0170.

    Article  Google Scholar 

  27. 27.

    Androff DK, Ayon C, Becerra D, Gurrola M. US immigration policy and immigrant children's well-being: the impact of policy shifts. J Soc Soc Welfare. 2011;38:77.

    Google Scholar 

  28. 28.

    Castañeda H, Holmes SM, Madrigal DS, Young M-ED, Beyeler N, Quesada J. Immigration as a social determinant of health. Annu Rev Public Health. 2015;36(1):375–92. https://doi.org/10.1146/annurev-publhealth-032013-182419.

  29. 29.

    Blosnich JR, Farmer GW, Lee JG, Silenzio VM, Bowen DJ. Health inequalities among sexual minority adults: evidence from ten US states, 2010. Am J Prev Med. 2014;46(4):337–49. https://doi.org/10.1016/j.amepre.2013.11.010.

    Article  Google Scholar 

  30. 30.

    Hatzenbuehler ML, Pachankis JE. Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: research evidence and clinical implications. Pediatr Clin. 2016;63(6):985–97. https://doi.org/10.1016/j.pcl.2016.07.003.

    Article  Google Scholar 

  31. 31.

    Brondolo E, Gallo LC, Myers HF. Race, racism and health: disparities, mechanisms, and interventions. J Behav Med. 2009;32(1):1–8. https://doi.org/10.1007/s10865-008-9190-3.

    Article  Google Scholar 

  32. 32.

    Williams DR, Sternthal M. Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav. 2010;51(1_suppl):S15–27.

    Article  Google Scholar 

  33. 33.

    Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. Bmj. 2000;320(7243):1200–4. https://doi.org/10.1136/bmj.320.7243.1200.

    Article  Google Scholar 

  34. 34.

    Marmot M. Economic and social determinants of disease. Bull World Health Organ. 2001;79(10):988–9.

    Google Scholar 

  35. 35.

    Brulle RJ, Pellow DN. Environmental justice: human health and environmental inequalities. Annu Rev Public Health. 2006;27(1):103–24. https://doi.org/10.1146/annurev.publhealth.27.021405.102124.

    Article  Google Scholar 

  36. 36.

    Prochaska JD, Nolen AB, Kelley H, Sexton K, Linder SH, Sullivan J. Social determinants of health in environmental justice communities: examining cumulative risk in terms of environmental exposures and social determinants of health. Human and Ecological Risk Assessment: An International Journal. 2014;20(4):980–94. https://doi.org/10.1080/10807039.2013.805957.

    Article  Google Scholar 

  37. 37.

    Mann JM, Gostin L, Gruskin S, Brennan T, Lazzarini Z, Fineberg HV. Health and human rights. Health and human rights. 1994;1(1):6–23. https://doi.org/10.2307/4065260.

    Article  Google Scholar 

  38. 38.

    Chapman AR. The social determinants of health, health equity, and human rights. Health and human rights. 2010;12(2):17–30.

    Google Scholar 

  39. 39.

    Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. J Urban Health. 2001;78(2):214–35. https://doi.org/10.1093/jurban/78.2.214.

    Article  Google Scholar 

  40. 40.

    Xanthos C, Treadwell HM, Holden KB. Social determinants of health among African–American men. J Men's Health. 2010;7(1):11–9. https://doi.org/10.1016/j.jomh.2009.12.002.

    Article  Google Scholar 

  41. 41.

    Fan H, Liu W, Coyte PC. Do military expenditures crowd-out health expenditures? Evidence from around the world, 2000–2013. Defence and Peace Economics. 2018;29(7):766–79. https://doi.org/10.1080/10242694.2017.1303303.

    Article  Google Scholar 

  42. 42.

    Hyatt RR Jr. Military spending: Global Health threat or global public good? Glob Health. 2007:311–30.

  43. 43.

    StataCorp L: Stata statistical software: release 14.[computer program]. StataCorp LP 2015.

  44. 44.

    2019 FACTS: Applicants and Matriculants Data [https://www.aamc.org/data-reports/students-residents/interactive-data/2019-facts-applicants-and-matriculants-data].

  45. 45.

    Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P. The necessity of social medicine in medical education. Academic medicine : journal of the Association of American Medical Colleges. 2015;90(5):565–8. https://doi.org/10.1097/ACM.0000000000000571.

  46. 46.

    Finkel ML. Integrating the public health component into the medical school curriculum. Public Health Rep (Washington, DC : 1974). 2012;127(2):145–6.

    Article  Google Scholar 

  47. 47.

    Godfrey S, Nickerson K, Amiel J, Lebwohl B. Development of an online public health curriculum for medical students: the public health commute. BMC Med Educ. 2019;19(1):298. https://doi.org/10.1186/s12909-019-1734-4.

    Article  Google Scholar 

  48. 48.

    Berwick DM, Finkelstein JA. Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new "public interest". Academic medicine : journal of the Association of American Medical Colleges. 2010;85(9 Suppl):S56–65. https://doi.org/10.1097/ACM.0b013e3181ead779.

    Article  Google Scholar 

  49. 49.

    Louw A, Turner A, Wolvaardt L. A case study of the use of a special interest group to enhance interest in public health among undergraduate health science students. Public Health Rev. 2018;39(1):11. https://doi.org/10.1186/s40985-018-0089-4.

    Article  Google Scholar 

  50. 50.

    Hoonpongsimanont W, Sahota PK, Chen Y, Patel M, Tarapan T, Bengiamin D, et al. Physician professionalism: definition from a generation perspective. Int J Med Educ. 2018;9:246–52. https://doi.org/10.5116/ijme.5ba0.a584.

    Article  Google Scholar 

  51. 51.

    Huguet N, Valenzuela S, Marino M, Angier H, Hatch B, Hoopes M, et al. Following uninsured patients through Medicaid expansion: ambulatory care use and diagnosed conditions. Ann Fam Med. 2019;17(4):336–44. https://doi.org/10.1370/afm.2385.

    Article  Google Scholar 

  52. 52.

    Smith MM, Rose SH, Schroeder DR, Long TR. Diversity of United States medical students by region compared to US census data. Advances in medical education and practice. 2015;6:367–72. https://doi.org/10.2147/AMEP.S82645.

    Article  Google Scholar 

  53. 53.

    Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891–2. https://doi.org/10.1001/jama.2020.6548.

    Article  Google Scholar 

  54. 54.

    Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. Jama. 2020;323(24):2466–7. https://doi.org/10.1001/jama.2020.8598.

    Article  Google Scholar 

  55. 55.

    Ayanian JZ, Buntin MB: In Pursuit of a Deeper Understanding of Racial Justice and Health Equity. In: JAMA Health Forum: 2020: American Medical Association; 2020: e200765-e200765.

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Acknowledgements

The authors wish to thank Laura Turner, Executive Director at Student Doctor Network, for her invaluable assistance in fielding the survey.

Funding

This work was made possible by a grant from the Laura and John Arnold Foundation. This work was also supported in part from a grant to Memorial Sloan Kettering Cancer Center from the National Cancer Institute (P30 CA008748). The funders had no role in the design of the study, collection, analysis, and interpretation of data, or in writing the manuscript.

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Contributions

All authors (SC, MM, AK, DK) have made substantial contributions to the conception and design of the work and the acquisition, analysis, and interpretation of data. SC drafted the work; DK, MM, and AK substantively revised it. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Susan Chimonas.

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Ethics approval and consent to participate

This study was reviewed by the MSK IRB and deemed exempt. Participation was voluntary. The MSK IRB approved a waiver of informed consent; clicking on the survey was deemed adequate evidence of consent to participate. Additional information is provided in Additional file 1: Appendix 1.

Consent for publication

Not applicable (manuscript does not contain data from any individual person).

Competing interests

Dr. Korenstein’s spouse serves on the Scientific Advisory Board of Vedanta Biosciences and provides consulting for Takeda. No other authors have conflicts of interest to report.

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Supplementary Information

Additional file 1: Supplemental Digital Appendix 1.

Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

Additional file 2: Supplemental Digital Appendix 2.

Survey instrument.

Additional file 3.

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Chimonas, S., Mamoor, M., Kaltenboeck, A. et al. The future of physician advocacy: a survey of U.S. medical students. BMC Med Educ 21, 399 (2021). https://doi.org/10.1186/s12909-021-02830-5

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Keywords

  • Medical education
  • Professional development
  • Physician advocacy