Thank you so much for joining us today. So we're going to tell you a little bit about how to create an advocacy curriculum at your program. So a little context and back story. I'm the program director at the Dartmouth Residency Program. I am not a content expert in advocacy, though I have become much, much more knowledgeable just through being involved in this process. But the whole point is to say that you don't have to be content experts to be able to create this. So we felt it was a priority in our program to teach our residents how to do advocacy. And to do that, we had to obviously bring in some folks that do know how to do advocacy. So Dr. Ho and Dr. Weeks are our experts here. So as a little introduction, Dr. Weeks is a third-year psychiatry resident. She, the reason we're also telling you about our roles in the New Hampshire Psych Society is later we're going to tell you how you can leverage your local chapter to help you with advocacy. So we wanted to at least mention that we are all to some extent involved in our local New Hampshire Psych Society. So Jess has been one of the resident representatives. I am the vice president right now. And Dr. Ho was the former president, and he's actually the present elect of the New Hampshire Medical Society. And this is where actually a lot of the advocacy work happens, and they've also assisted in our training. Dr. Ho is also the associate program director at Dartmouth, so also very involved in creating curriculum. So now I'm going to let Dr. Weeks tell you a little bit about what advocacy is. Thanks, Dr. Soudan. So this is nice that we have an intimate group because we'll have some time to do some different workshops together. And so please feel free to ask questions as well. But just to give a little overview of an introduction to advocacy in general. So an overview of our workshop. So for the first 20 minutes we'll talk about what advocacy is, the different types of advocacy that there are. We'll talk about our advocacy curriculum at Dartmouth and why we chose the specific type of advocacy to focus on that we did. Then we will dive into a little bit more detail about a portion of our advocacy curriculum called the Eightfold Path. We'll have time to do those group activities, and then of course time at the end for some questions and answers. So just to start off, what is the definition of advocacy? So advocacy is an act. It is an act of supporting. So we're supporting a specific cause. We're supporting a proposal. We're trying to bring awareness to issues. And what's the purpose of advocacy? It's really to cause change. So whether that be through raising public awareness, influencing policy and law, or fundraising. And I do just want to exit out of this and show this YouTube video. Only a small portion of it. Because I think he speaks really beautifully about what being an advocate really means. Are we obliged to advocate? Whether you feel you can or you can't, you could or you should, I have five easy steps to guide you through your advocacy journey. One, lock down those motivations. Advocacy at the core is a deeply embedded sense of purpose. For it's defined by an act that aims to influence the decisions within social, economic, and political systems and institutions. No small act. And if done right, it's a life's work. So I just really loved, you know, the passion and also his definition. Which again, shows that it's this act that we are purposely doing to try to bring change. So to also give an overview of social determinants of health and medicine. So I felt like it was important to just re-talk about these as well when we talk about advocacy. You know, we typically are interacting with other social services as physicians. And usually our patients are needing really significant social needs as well. And advocacy is usually the core thing that's really needed when it comes to these critical components of care. So social determinants of health are things like housing, race, ethnicity, gender, transportation. And they can have a major impact on health. But often cannot be fully remedied just by medical interventions alone. So diving into what does advocacy and medicine then really mean? I feel like advocacy is now this term that has kind of been popping up everywhere. Residents are really supposed to view themselves as advocates. But there are so many different definitions of what being an advocate really means. So if you look at the research, a couple of common themes tend to pop up. So improving access to care. You know, looking at the distribution of resources. Addressing health inequalities. And then also focusing on creating systematic change. In general though, I view advocacy and medicine as using our knowledge as doctors to enact change. Either by influencing resource utilization, policy, law. Really with the overall goal of improving the health outcomes for our patients. So at the end of the day, it's using our knowledge, our specific knowledge, and really unique and powerful knowledge that we have as physicians to improve the health outcomes for patients. The AMA, and again, as I was mentioning before, I feel like advocacy is now this term that a lot of large organizations are wanting physicians to view them as. You know, view yourself as an advocate. And again though, there are so many different roles that physicians can, you know, be acting as an advocate in. But in the AMA's Declaration of Professional Responsibility, it actually now calls doctors to view themselves as advocates. So again, one of our professional responsibilities is advocating for social, economic, educational, political changes that would basically help, you know, ease suffering and contribute to the well-being of our patients. And then the AMA actually came out with another statement. And just to highlight the bolded line. No employer should restrict physician's freedom to advocate for the best interests of their patients. So again, this large institution organization is really calling for physicians to view themselves as advocates. To focus a little bit more, what is the APA's say on advocacy? So if you go to the APA's page where they're talking about advocacy, really their focus is on health equity. So APA supports advocacy focused on health equity, working on supporting policies that reduce disparities, supports policy addressing underlying social determinants of health, and focuses on supporting populations that have experienced economic and social marginalization. So with that all said, you know, the APA, the AMA is now wanting psychiatrists to really view themselves as advocates. But what different roles are there available to us in acting as an advocate? And then why did we choose the type of advocacy to focus on in our curriculum in particular? So just to go through the different types of advocacy in medicine. So the first one is self-advocacy. Self-advocacy isn't actually what necessarily we as the psychiatrist are doing. Self-advocacy is actually the act of the patient directly advocating for themselves when interacting with the healthcare system. So for example, let's say a patient starts a new med, they talk to their local pharmacist, figure out that it's a side effect of their new medication. And then, you know, our patient comes back to us and advocates for themselves by asking for a different medicine. And so what our role as a psychiatrist in that moment is how do we respond when patients are self-advocating for themselves? How do we meet a patient where they're at? How do we use our knowledge in order to maybe influence and help them to make the best decision for their care? But again, in self-advocacy, that's really what the patient is doing. Individual advocacy in medicine. So this is how we as healthcare professionals advocate effectively, collaboratively for an individual patient who we are working with that's trying to navigate our extremely complicated healthcare system. So an example of this is let's say a patient comes in with schizophrenia, they're on clozapine, they do have a history of somatic delusions, presents to the ED an abdominal pain. Initially, the ED is concerned for worsening psychosis. However, when you're talking with the patient, you learn that they haven't had a bowel movement in four days, you're concerned about side effects, and so then you as a psychiatrist are advocating for a more thorough medical workup to be done. So that's individual advocacy. Then there's another layer of advocacy, which is more structural systems-level advocacy. So this is where, as the physician, you are acting in a role to try to influence change that benefits our patients at an institutional or a legislative level. So this is really working with lawmakers, working with administrators, CEOs of hospital systems, working with other social service organizations such as, you know, the Juvenile Detention Center System, and so trying to enact change on those more institutional levels. So just an example of this would be, let's say you've noticed new moms, they have a history of substance use disorders, and they have a challenging time affording care. So then you go, you advocate to your state policy makers to maybe expand Medicaid for this at-risk population. So just to go back to what, sorry, I keep on knocking this mic, what the research was saying about all the different, you know, themes that come up when we look at advocacy of medicine in the research. You know, a lot of them sure are talking about self, they're talking about individual-level advocacy, but really what most of them, what the APA is calling for, what the AMA is calling for, what the FDA is calling for, what the AMA is calling for is for physicians to view themselves at more of the system-level advocacy role. So fair distribution of resources, addressing health inequalities, writing and changing policy, creating systematic change. And so again, it's calling physicians to view themselves as an advocate and to interact with these more large system-level policy-making organizations. So this is just a brief overview and a kind of introduction into how do we actually advocate on a systems-level way. You know, this is working with elected officials, participating in public hearings, talking, again, interacting with our elected officials, and getting involved even in like submitting opinion pieces, but really starting to participate in more of those higher-level organizations. So I thought that this would be an important thing to add just an example for how influential, like day-to-day, legislators can be on the practice of psychiatry and medicine in general. So in our state, in New Hampshire, actually prior to 2020, let's say a patient came into the ED and they needed to have an involuntary psychiatric hold placed. The due process of, so the actual court hearing, was not scheduled until after the patient physically arrived at the state psychiatric hospital. So due to the lack of psychiatric inpatient beds in the boarding crisis that the state of New Hampshire has also been experiencing, patients could be boarding in the ED for weeks and weeks and weeks and weeks, and they would not be able to get out of the hospital for weeks without their court hearing having occurred, because they were not physically transferred yet to the state psychiatric hospital. The ACLU of New Hampshire went against the state of New Hampshire, saying that this was unconstitutional, and they won. And so now, patients must now have their court hearing, 72 hours after an involuntary psychiatric hold is placed, regardless of their physical location. And again, just to show how influential legislation is in our everyday practice as psychiatrists. So, now the question is, with so many types of advocacy, so many different roles that physicians can, you know, view themselves in the sense of being an advocate, how do we train psychiatrists to be better advocates for their patients and profession? So, we decided to focus on, as I'm sure you probably could have guessed, the structural and systems level advocacy. So, building our curriculum to help residents to feel more comfortable actually interacting with legislators, working with lawmakers, you know, working with CEOs of hospitals to really influence change at these higher institutional legislative levels. Some of the reasons why we, you know, decided not to focus on things like self-advocacy, individual advocacy, you know, in self-advocacy, I think as psychiatrists, we get a lot of training in how do we meet our patients where they're at, how do we empathetically, you know, be available for our patients. And, you know, very often if a patient says to me, oh no, I've heard the name of that medicine, and my best friend had a really bad reaction to it, then okay, maybe we're going to go for a different medicine. And so, I think we get a lot of training on how do we listen to our patients as much as we can and align with them. Individual advocacy, I kind of view this as using your interpersonal effectiveness skills from DBT. So, I do think that we get a lot of training too on individual advocacy for our patients. But again, even, you know, me being a resident, this systems level advocacy and how do I feel comfortable going and speaking to a legislator about a policy that they may be developing is not something that I felt super comfortable with before we developed this curriculum. So, with that said, I will segue back to Dr. Salden. Yeah. So, thank you. I think Dr. Weeks explained pretty well why we made this curriculum. Because I think that the systems level advocacy is so important, but I didn't learn how to do that in residency. And I realized we weren't actually training our residents how to do it. And it's not intuitive. Actually, the more you learn, the more you realize it's very nuanced, it's very challenging, and you really need to know how to do it. So, one of our goals was this wasn't a one and done. This was something that needed to actually span the entire residency. So, as you can see, it actually starts in year one, and then we repeat it in year two, three, and four. Again, part of the goal of the curriculum is not just to teach, but is actually to get our residents excited about being advocates and really instill this idea that this is actually part of our job. So, in the first year, it's really just an introduction, defining it like Dr. Weeks just did, talking about the history and importance, and an introduction to what you're going to learn about, the eightfold path. We're going to do a little experiment on that. There are probably many ways to create a curriculum. We decided to go down the eightfold path route. You don't have to do it that way, but we're going to tell you a little bit about that in case, you know, that's something you think would be helpful. The first year is more now, how do you become an effective advocate? So, learning a little bit more about the legislative process, the benefits of collaboration. If you do go into advocacy, you realize this is not a one-man show. Now, doing a little bit more on the eightfold path and then actually trying to get people to do projects So again, we're really trying to get people excited and to give them ideas So things they can do and it might be small things. It might be as little as like write a letter to your senator But really trying to get people to boots on the ground do it not just sort of learn about it Third year we have a great Q&A panel so we bring in people from all over we have our lobbyists we have Like dr. Ho is on the panel because he has done a lot of advocacy. He was a resident now He's faculty. He was the the president of the New Hampshire Psych Society. He's testified We've our chair of our department does a lot of advocacy. He's on the panel. We have some legislatures. So we have people Really telling you about, you know, all the different aspects and how they work together And then the fourth year we have an advocacy day. This is probably the best part. So we actually involve a Agency whose job it is to work on advocacy and they give free trainings and so they do a whole day down at the state Legislature so not only do you learn but you actually have the opportunity to testify yourself or observe other people testifying So a little bit on the advocacy day So in the morning you learn a little bit about policy and advocacy how our state Legislature works because obviously every state is very different. And so you actually really do need to know how your own state works Things like how a bill becomes a law, so I went to one of these trainings and I was Blown away. I had no idea how a bill becomes a law and actually after leaving the training I'm not sure how any bill becomes a law because there are so many ways they can be thwarted And then ways to message so that you saw an earlier slide that talked about different things You can do like calling your legislature having coffee with your senator, you know Learning those things so they go through all those different things like that. There's op-eds. There's Also time set aside to prepare your own Individual messages and then the afternoon is very hands-on. So you might attend hearings Watch actual votes in action have the opportunity to testify and even have one-on-one meetings with the legislatures, so again, we're not just Teaching you how we're showing you how we're trying to get you to actually do it as well These are some pictures from my advocacy day. I actually try to Sort of almost mandate that our fourth years go. I give them the day off and They're pretty much voluntold that they're going unless they have a good reason and you know what there's a lot who wouldn't go and Then after they go, they're so grateful. They did so I've learned you kind of have to tell them you're doing this You know if you just leave it So we used to have this available to every resident and I think before we mandated it Very few people went is my understanding and now we get you can see that turnout. There's you know, eight or nine residents there And so these are just some of the quotes advocacy day was really informative and demonstrated Just how important it is to have our voices heard so we can change policies to better support our patients Before this training, I felt like you needed to be an expert to do advocacy work. Apparently the expertise bar is not that high So again, these are people that didn't really consider themselves advocates and I think when they went and they saw it and they Learned oh, this is something I can do. You know, it was eye-opening for them This was a survey we did to say, you know, how interested are you being involved in advocacy? And it goes from basically some people are not so interested about 25% But the the rest are either somewhat or very interested How important is it to learn these are our residents answering this you can see that Everyone said it's either somewhat or very important Then we asked how helpful the advocacy curriculum has been in expanding their knowledge of how to advocate and Okay, 10% thought it wasn't helpful But 90% thought it was either somewhat or very helpful And then we also want to know about your interests So not just learning how to but like that, you know, you want to do more and again It's probably the same 10% that found it not so helpful that they're no longer interested either, but the majority Are now more interested as well So we've been mentioning it a lot but now we thought it would be helpful to walk through and a little bit more in detail What exactly? This eightfold path to more effective problem solving is And then we'll break up into a small group activity So we're going to start with a little bit more detail and then we're going to talk a little bit more about Problem-solving is And then we'll break up into a small group activity So just to give a broad overview we do have printed out handouts up here That go into the eightfold path in more detail. And then we also have a qr code if people want to do it that way But the eightfold path to more effective problem solving. Basically, this is by eugene bardock He is a policy Analyst and so he's not only working, you know in the medical field, but he's working in economics He's working in all different types of fields where they think about how do we systematically actually think about problems? And think about coming, um to solutions for them. We also have some up here I will be honest. I was not having a good time with the printer when I printed these out There's also a qr code later. Yes Feel free to have it digitally or physically Beautiful Um So to go over again, why did we think that this was an important thing to talk about? So the eightfold path is literally a way to think through the problem that you're seeing in your hospital system You're seeing patients face time and time again And then how do you actually come up with a statement with an actual coherent? argument to maybe go to legislators And and say to them and so the eightfold path to more effective problem solving again It walks us through okay How do we actually really define a problem that we're seeing the health care system is so complex And so it can be really easy to jump to a conclusion of what the problem actually is But if you don't think about it in a systematic way Then you may be putting all your resource and your efforts into something that's not going to wind up You know solving an issue. He also talks about how in defining the problem It's really important to think about you know We see so many devastating things in medicine and not you know, not necessarily is everything going to be solved by a policy Adjustment and so really thinking about okay in a systematic way Is this something that a law that going and talking with administration could really help to to influence and change um Step two talking about assembling some evidence. So how do we actually you know? um when I went to advocacy day something that was really telling that the um, New futures. They're the organization that puts it on that the um advocates were talking about was that a lot of the time Legislators don't actually do their own research when it comes to bills And so how can you um use your research? um to You know boost The solution that you're proposing um, it's thinking about um different alternative solutions, so Let's say and we'll walk through one problem in particular that I kind of created Um, but there can be so many alternative solutions to all the problems that we're seeing And so how do we think logically through those alternatives? How do we not limit ourselves? Sometimes, you know the The goal isn't going to be to just figure it out in one step and that's okay, too um Selecting the criteria. So a lot of the times this is going to depend on what um population you're actually You know giving the statement to and maybe we're going to use efficiency if we're working with insurance companies um, but then maybe we um, we'll use something like justice Or the gold standard of care if we're talking, you know to a ceo or a doctor of a hospital so what is the criteria that we're actually looking at to um, Show that the proposed solution that we came up with for the problem is actually going to Be helpful Um, and then the last couple of steps are really just more about talking about how do we actually give a motivating statement? um, how do we you know speak, um Again just in a motivating way, um when we're talking to legislators or administrators So um, just to read so basically now this step and please um, Feel free to You know kind of group off if you want together if you want to work together in a group We'll also be walking around and helping Um, but with this step we thought it would be helpful to actually walk through what the eightfold path is Um to a problem that we developed Um to show you, you know what we are teaching our residents to kind of think through Um, so again, I do have the printed out copies Um, I was fighting with the printer when I printed those out So the ones that are uh double-sided and have two pages per side the boxes aren't as beautiful Um, but we also have a qr code up here if people want to do stuff more electronically Um, so the problem that we basically developed um for this issue or for um Our practice is so you're a cl psychiatrist Um, you're working at a local hospital You've noticed um difficulty finding nursing home placement for people on methadone for evidence-based treatment of opioid use disorder Many associated nursing homes do not have the ability to prescribe methadone for opioid use disorder Though they are able to prescribe the medication for pain control Patients on methadone may board for weeks on the medical units due to this barrier to discharge Often the barrier to discharge to a nursing home is so great that patients must be cross-tapered to suboxone Despite being stable for years on methadone So using the worksheet again using this eightfold path We were going to walk through one solution to the problem that you know using the eightfold path So just to go back to the qr code if people want to scan that Yeah Any questions jumping out at people right now Yes Yeah, why don't we take about 10 minutes or so to kind of talk through this We may not get through all eight steps and that's okay this point of this case is really just to kind of Introduce you to the framework. We we try to apply to these types of clinical problems through a structural advocacy lens Um, so we'll walk around too and in case people have questions So, maybe we can all come back as a large group just so we have A little time to discuss it We know we are not going to get through all eight steps In you know in full transparency, I think that takes three years of our curriculum maybe four years of our curriculum So we just wanted to give you a a taste of it um and you can certainly read the book if you want to know more, but Um so I thought it would be kind of fun to just walk through so if you Uh turn to the last page of the document um So example of you that using the eightfold path to more effective problem solving and I am talking to a legislative audience So then I basically typed up this little You know statement of what I might say if i'm going and speaking to a legislator and then with each sentence I um Put okay, which step am I using for each sentence here? So You know, my name is dr. Smith. I'm a current psychiatrist at a local hospital Thank you for your time and consideration to this proposed legislation I am proposing that pharmacies be allowed to dispense methadone to patients who have been on a stable dose For their opioid use disorder and are currently residing in or will be transferring to a nursing home So that's step eight and step eight. He talks about how it's really important to Kind of come up come out quick with what you think the solution is what you're talking about um Then the next line There are too many patients on methadone for opioid use disorder boarding in the hospital and with the rise of opioid use disorder Odds are this problem will continue to worsen leading to ongoing missed opportunities for efficient hospital bed utilization So that's step one. So that's my problem. That's how I phrased it um Then in the past year there have been 127 patients That have been admitted to our hospital and need transfer to a nursing home Following their stay and have simultaneously been on methadone for opioid use disorder So again, that's assembling some of that evidence it take it has taken on average 57 days To transfer these patients even when they are medically ready for discharge Meaning they no longer require hospitalization step two again assembling some of that evidence using actual data points And again, this is all kind of made up data right now. Um, but just for the the point of the activity um Often the barrier to discharge to a nursing home is so great that patients are switched from methadone to different medication Despite being stable and for years on methadone This causes an increased risk of relapse one patient I cared for Was stably on methadone for 12 years and suffered severe withdrawal and unnecessary pain due to needing to be switched from methadone So that he could be transferred for a nursing home In the last couple of steps again, he talks about how do you? eloquently and also motivatingly use Your time when you're speaking with legislators and a lot of the times that is using personal Experience so using patient stories in a non-identified way if you can When speaking so this is the portion I really like that. He talks about this When speaking with local nursing homes about the difficulty with transferring these patients to their facilities They note that it is because they are not opioid treatment programs And thus do not have the rights to dispense methadone for opioid use disorder So again, he talks about how it's really very important to get the opinions of the outside people so going and actually talking with the nursing home or talking with people that may Disagree with your point just to get their perspectives It is also often timely and taxing on staff to bring patients to The dispensing facilities which are far away. Meanwhile pharmacies are much easier and physically closer to bring patients In canada methadone is still the primary treatment for opioid use disorder due to its accessibility through pharmacy dispensing instead on Instead of relying on opioid treatment programs So again that is using Research from from other Countries other states how they handle the situation Opioid use disorder is the deadliest psychiatric disorder in the country And patients deserve access to medications that have been shown to be life saving. So step four that's talking about criteria So am I using efficiency here? Am I using rights? Am I using justice? You know, it may depend upon what Population you're speaking with if I was talking with the insurance companies in particular, you know, maybe I wouldn't be trying to drive home. You maybe my points would be a little bit differently different. Um, But in terms of talking with legislators using right rights-based criteria Patients also have the right to timely and accessible care which people boarding on the medical floor limits So again, this is thinking about the people who are waiting in the emergency department Because maybe a hospital bed on the floors isn't immediately available um If we continue to not address the issue the hospital will continue to lose fifteen thousand dollars per month due to this boarding crisis So that's projecting the out, you know the outcomes so actually thinking about okay if changes don't occur What is this going to continue looking like? Um, and then the last part of it is just basically wrapping up So switching someone off of methadone is not only clinically painful. It also increases risk for relapse and length of stay for hospitalization Please consider this legislation which be in support of pharmacies being able to dispense methadone To patients who have been on a stable dose for their opioid use disorder and are currently residing in or will be transferring to a nursing home um, so yeah, so that's the statement that I basically Crafted um By using this eightfold path, which again, I know we did not have A lot of time at all to walk through it, but please feel free to to take this home Um, we did bring a copy of the book. There are newer editions. Um, but we did bring a copy of the book Um, and also if you download it from the QR code, that's fine, too. Any questions right now about the Eightfold Path? Yes. So that is actually reminding me there's, let me just look through it real quick. There's part of one of the steps that kind of talks about negotiating. So it's in actually step three. So points on a continuum, when we're thinking of different alternatives. So splitting the difference, lower and upper. Basically, this can help people to negotiate to come to a common agreement. So a lot of the times when we think about bill creation, it has to go to the House. I mean, depending upon where the bill originates. But it has to go to the House. The House agrees on it. Then it has to go to the Senate. Maybe the House doesn't fully agree on it. So then it goes into this time of, can we negotiate some things? And so that would kind of be where, OK, let's say the legislators are like, I'm really feeling kind of nervous about pharmacies dispensing methadone. Well, could we negotiate there for a moment? Could we say, OK, what about patients that have been on a stable dose of methadone for over 10 years? Could they be the first population that we kind of roll out this program with? And so that's kind of where I would say some of that negotiating and almost like next phase could kind of start happening. You do. You have to. Bills, you can track bills as they're going through the cycle. And so there are a lot of times where things are coming back and getting edited. Great question. And I would hope, sorry, go ahead. I was going to say, if you work with companies, so like New Futures is a sort of free nonprofit that does just advocating, does our trainings. They track things. So I mean, it's incredibly hard for you individually to track things. And so you can work with them. So they'll tell you. Or for example, the New Hampshire Psych Society part of, we work with lobbyists. And so we'll get emails saying, this bill's being discussed this day. Who can go and testify? This bill's changing. And so part of it really is you have to have some other people whose job it is. Because we can't be full time people watching what bills are going through when and how they're changing. Right. And I would add too that this is actually something we are going to discuss in the next section. But it's hardest to get your foot in the door also. So once this process rolls, then it's a very long process that will require continued stakeholder engagement. And as I was mentioning too, then the energy of activation to really start the process is so high. But then once you've done that, then you do have these open lines of communication with all of your stakeholders. And this process does require continued engagement with those stakeholders throughout its life and the effort for any advocacy interventions. Yeah. Absolutely. And so you mean in a sense of how do we make the patient story as meaningful and meaningful to the community? Mm-hmm, yeah, absolutely. Yeah, that's another really important point, too, is that generally what we find is that legislators don't really care about our numbers or our expertise a lot of the time. That doesn't really resonate with them too much, and part of this is that oftentimes legislators like to feel like the smartest person in the room, and so if you're coming at them with your medical jargon, then that's really not going to get you anywhere, but what legislators do respond to much of the time is the patient story, and so the patient story is the centerpiece of these advocacy efforts, depending on your audience, of course, so it's especially true if you're talking to a legislator, and then the other thing that I would add, too, is that if the patient that, maybe a composite patient that you're telling them about is a constituent, too, then I think that adds an extra little piece of really ownership to that specific legislator. I was gonna say, I mean, again, I guess it depends on what your relationship is with the patient and if it feels like it's appropriate, but when you go and you testify for bills, you don't have to be alone when you're standing up there. People from other perspectives can be standing with you, and so would the patient even be able to participate, too? You know, it's just an idea, but I do, I think patient stories can be very, very motivating, and also, you're right, there is still quite a lot of stigma when it comes to the diseases we're caring for. Yeah, the numbers, I made that up in my head, but do you mean in the sense of what would you, and what would you do in the sense of, like, with that anger, or? Yeah, to ask them to do that. Meditate on it as well, you know, as a patient. Yeah, yeah, yeah, yeah. And so I think, in some ways, that comes to, like a point that just popped in my head, was sometimes legislators do get faced with, or so many different problems come to them, and it can feel, like, extremely overwhelming, especially if someone hasn't been able to, like, formulate kind of an argument and a proposed solution to them. So in our advocacy day, we had some of the representatives from the House come and talk to us, and they talked about how, very often, if they are meeting with someone for coffee, maybe the person that they're meeting for coffee will say, this is a really big problem that I've been, you know, seeing or experiencing, but then they may not be coming with a proposed solution, and so then that feels extremely overwhelming for that legislator to kind of do anything about, and so at least presenting them with some type of solution can be really helpful, basically to kind of make it easier for them, you know, in a way. So we'll maybe talk about this a little in the next section, and we're gonna talk about ways that residents really can get involved, and for our program, it's really been through the New Hampshire Psych Society, because we've learned it's very hard to get things done through our own institution. In fact, we will get a slap on the hand if we go and say to a legislator, hey, I'm a resident at, you know, Dartmouth, this is what I think. We can't do that. That has to go through government relations, and so we have learned that our ally in this process is the New Hampshire Psych Society, and so that is a way that people, and we have had residents testify, we are actually in the process of trying to make a bill for the next round, and there are residents involved in that and I am learning how difficult it is because of the politics, obviously, something I thought was a no-brainer. Then we talked to our lobbyists, and she's like, oh, no, actually, this is gonna be really difficult because this is what's going on right now. There's a lot of suspicion about doctors. You can't do it that way. We'll have to try to do it this way. So I think if we go on to the next section, we'll try to show you that I do think you need to find what's your inroad so for us, it's the New Hampshire Psych Society where your own inroad might be something else, and so I think we're gonna tell you a little bit about, part of it is not only creating the curriculum, but also figuring out who are your experts, who are, and like I said, we've got residents now involved in trying to make a new bill because they saw a problem, and I said, okay, well, let's talk to the people who can maybe help us make a change. Absolutely good question. Okay. Well, maybe that would transition us nicely to our next step, which is talking about barriers to creating a curriculum, and I'll give it over to Dr. Hope. Well, thank you, Dr. Weeks. So in our last sections, then, we've really been kind of talking about the nuts and bolts of what we do, what our curriculum looks like, and to answer your question very quickly before we move on to the next section, then I would say, too, that it's also very difficult at Advocacy Day to create a new idea that then gets turned into a bill just because the process takes so long, but like Dr. Sowden mentioned, we're kind of starting that now, but for our Advocacy Day, too, then the other thing that we can't control is what's gonna be on the actual docket that day, what's gonna be on the legislative schedule, which bills have a hearing or a floor vote that day, so what we end up doing is kind of knowing what the schedule is a few days in advance, and then at that point, then we can kind of plan for which sessions we might take the residents to and which sessions we might end up testifying for or against on any certain issue. So now with this next section, then we wanted to talk a little bit more at a very high level of just kind of what a curriculum might look like for your residents or at your institution, and to do so first, then just wanted to do a little bit of thinking about barriers, too, because every institution certainly is going to have different barriers and feel differently about getting involved in systems-level advocacy, and so for our institution, like Dr. Sowden was mentioning, being a large healthcare system in an academic medical center with an entire government relations department with a national arm, as well as a state governmental relations arm, then this is something that, a barrier, another barrier that, for instance, we might have that smaller institutions may or may not have, but then otherwise, thinking about who at our institutions has the expertise and the time, certainly, to teach advocacy, and then thinking about what are some of the other resources and stakeholders that you could leverage, too, because it does become difficult sometimes when you're working on your own, but is there any sort of relationship with your state psychiatric society or your district branch of the APA, and what is that relationship like? Is it very helpful? Have they helped you do things with your residents in the past and given talks and engaged with you? And then, frankly, just logistically, where do you find time on the didactic schedule? So as we were building this curriculum, too, then this is something that we would run up against as well just because our didactic schedule is very full, so moving things around and figuring out what you can consolidate or how we can consolidate this curriculum is sometimes a logistical barrier that is not expected. Mentioning a little bit more about the APA resources as well, then, I mentioned that our institution has a government relations team, and oftentimes, issues that we care about will also be issues that our government relation team does care about, too, but that may not always be the case. There may be some reason related to political capital that your government relation teams may take a position either at odds with what we as psychiatrists and clinicians want or maybe just not take a position on an issue that we really care about. So otherwise, then, it's important to think about leveraging your state's district branch or state branch or your state medical or psychiatric association. In our state, they work very closely together. They're very hand-in-hand, and this may be different for different states as well. Certainly, local nonprofit organizations are typically very willing to help, especially if we align on certain issues, which is often the case. And then there are regional APA resources. I have here a map of the APA region, so region one is a smaller region but split kind of bicoastally, and so we, being from New Hampshire, are in region one and have access to a lot of resources that the West Coast and Pacific Northwest might also have, too. But each of these regions in the APA does have some staff members that can help you with kind of region-specific resources, too. Otherwise, the APA also has their state affairs website, which if you haven't had a chance to take a look at this part of the APA website yet, this is something that we do frequently utilize as well in both the psychiatric society as well as the medical society in our state, too. So one piece of legislation that we had worked on in the past was collaborative care model service legislation as well, and so you can see on the, oh, sorry, on the side here, then you have in the state affairs section of the APA website, you have several pieces of model legislation that you can utilize as you're proposing perhaps a solution to any of your legislators. And so one of the very difficult parts of advocating is knowing what a solution might look like, and so some of these pieces of model legislation do all the work for you, and so you don't have to actually do that. Otherwise, too, if there's not a particular issue that you're actively working on but just kind of wanna see what the APA's working on, then there's also advocacy alerts that you can sign up for on this section of the APA website. So now, as I mentioned, then we really just wanna think at a very high level about kind of what a curriculum might look like at your institution, and so we just have a few questions here about what that would kind of look like, what some of the barriers would be, and so taking a look at the time, I think we can maybe just kind of spend some time, let's do another 10 minutes looking at it before we kind of come back together. I'll also leave the QR code up here if you'd rather use the virtual version as well. All right, we're gonna come back together a little bit earlier just because I think we have a lot of really good questions, a lot of really good discussion that I thought maybe we could do as a large group, too, and also Dr. Stoudt and Dr. Weeks reminded me, too, that we had forgot to mention at the beginning that we do not have any financial disclosures related to the content of this work as well, so just wanted to make sure we had said that. So anyway, as- We're gonna carry out the endorsement. Coming, that'll be for next year's session, yeah, exactly, but as of yet, so what did we think about? What came up as we discussed the available resources at your institutions? So I've kind of mentioned the big APA resources as well as your district branch or medical society resources or your institution's governmental relations department. Did anything else come up as you discussed this? We had a few over here in our group over here. So some questions in psychiatry, so maybe bring me on board. It's again, like, other disciplines involved, like nursing, social work, um, and then, um, from my standpoint, like, veterans' groups, veterans' athlete groups, PDA, and, um, in DeKalb, we have to that being on stage and having to give quick answers and what not. Absolutely. Yeah, great ideas. And what's the... I think our next retreat will be an improv session. Exactly, what do they say in improv? One in doubt, be a dinosaur, right? So yeah, probably also good for advocacy. Oh, really? We'll look into that, it's a good idea. Absolutely, just like karaoke, it's great. Did anything else come up as far as other available resources? Yeah, and I think leveraging other subspecialty or specialties in medicine is a really good idea too because we often find ourselves, of course, working with, for instance, the Pediatric Society or the Emergency Medicine and General Medicine Society as well. What about barriers? What did people discuss as barriers? Yeah. Sure. Absolutely, yeah, and something that depends so much on where you are as well because we can tell you that New Hampshire is a really unique, very unique state with a very kind of unique political position is always difficult to navigate, absolutely, but then also kind of thinking about the political capital you have and where you want to spend that political capital because if it were up to us, oftentimes then we would kind of go full bore at each issue that we care about, but then when we kind of utilize the New Hampshire Psychiatric Society and they remind us that there are certain issues that we should maybe take no position on because it's already a done deal and we don't want to burn any political capital, then these are things that we wouldn't have thought about or things that we wouldn't otherwise know about that are certainly important and matter as well, but then also becomes a big barrier like your group was discussing. We actually saw this year it backfired when somebody, actually they spoke on behalf of the society even though they shouldn't have, and they in very good intentions spoke on certain bills and then certain politicians decided to take that as political ammunition against us and it was just like you can't win sometimes. So sometimes if you actually go too far, it can backfire and that's where the lobbyists are very helpful and that's, I think one of the things we're trying to teach in the curriculum too is that it's not just about having a good idea and going up and testifying, it's about being smart and how you do it and so we're trying to teach the residents how to be smart because sometimes it's better to say less depending on the political climate you're in. Please. Yes, I'm curious. Obviously legislature. Absolutely. So first and foremost, I think what you mentioned too, especially with the other pieces, parts of the whole political apparatus in each of our states and in the country is so important and I would say that our curriculum for our psychiatry residents is meant to be at a very high level overview and so kind of starting with even just the process of how a bill becomes made and then an introduction to the chambers and parts of our legislature is kind of where we start. In our third year on our panel, then we have opportunities for people from DHHS in our state to come and kind of talk about their roles with the residents, but otherwise we don't really get into the kind of complex interplays of some of the state governmental agencies with our politics and our policies. I also run a similar course for our preventive medicine residency and that is meant to be at a more high level and that is an area where we do talk a little bit more about some of those things, especially the involvement of DHHS because one of our faculty members in preventive medicine also happens to be the medical director of DHHS, who actually also works for our department, oddly enough, is employed by the department of psychiatry and contracted out to the state and so I think you bring up a good point. This is another opportunity to involve a very important stakeholder and introduce our residents to this piece of advocacy at an earlier stage. It's not something that we've done yet because we've, at this point, found that there just, especially with some of our survey data too, that there isn't a lot of kind of pre-existing knowledge about the system just yet and so we had been hoping, now it's been two years, in the first initial run of this curriculum to really just introduce the residents to these concepts and so we're kind of thinking about how to expand that, especially as next year we start this program for our child and adolescent fellows as well, who might be ready for a little bit more of that. And as part of our advocacy day, which occurs in the fourth year of the residency program then, one of the lectures that I give is kind of about testifying, so as part of that then we do kind of discuss the Aristotelian triad too, of ethos, pathos, and logos. And what we find too is that although our residency programs, I think, do prepare residents to develop this voice that is big enough through more of perhaps the logos and the pathos, then residents are just not very comfortable with their ethos and the implicit authority that they do have at this point in their training and so this is where some of that work is and kind of building this comfort for the residents to utilize their voices, develop and then utilize their voices. And so that's a very good point, that it's so difficult, especially at certain stages of your training, to really begin to leverage, but something that we do try to introduce within the curriculum. I think we talk about the importance of collaboration with other partners, where obviously we have a limited amount of time, we can teach the residents, but for example, I think I told you we were meeting with a lobbyist with other residents to try to make a law and I thought it was going to be a straightforward thing and immediately the lobbyist was like, no, we have to talk to these people and these people and these people, we need to get these stakeholders involved, we need to leverage this, and so we are teaching the residents that that is part of it and then I think until they're doing it, though, they're not actually going to be working with those, but for example, we are actually bringing residents in to try to make some change and those residents are actually seeing it and it is sort of eye-opening how many people need to be leveraged for what I think is a very small, no-brainer sort of law. Yeah, and although in this talk we are intending to talk a little bit more about our curriculum than, yeah, that is something that comes up quite a bit, too, just because residents will often express surprise, why do we have to talk to the insurance carriers and what could we possibly add without kind of understanding how big a piece of stakeholder engagement that is and oftentimes we'll be kind of at odds with the insurance carriers, but engaging stakeholders that may take a different position than you early on is something that we really try to kind of, we really try to bring home for the residents. And just to add on that, too, I think that sometimes maybe we feel that we don't necessarily have the authority to talk on certain issues when in reality I think our voices are really strong just at, you know, any level of training that when it comes to, you know, being a physician and we have such a unique role in our society and so, you know, I was hearing bills being debated in the Senate and a recent bill that came onto the floor was about a minimum mandatory sentencing period for people who were arrested for selling, you know, different substances and I heard how the Senate floor used the testifying of one individual, his one perspective on the situation, influenced how they voted on that bill pretty dramatically. And so I think it was a really eye-opening, you know, when my co-resident, I was telling one of the other groups, my co-resident Zoe, her quote that was up there earlier in the presentation, it was in response to that moment because she saw how influential that one person actually going and talking to the legislators was when it came to this bill. And so I do think it's important to realize, too, that yes, of course, we need to make sure that we're talking with, you know, people that can give us different perspectives and also that, you know, to believe that we do have a good voice and an important role to play in this, too. Yeah, I see a question here. This may happen in the state of New Hampshire, that you do have a good voice. I would argue that in some states, our trusted doctors took advantage after COVID and I highly doubt that the moving signs that we present would move the needle. So collaborating with other people, especially with institutions like the U.S. Department of Health and Human Services, I think it's important to have a good voice. And I think that is the same in New Hampshire, and we are teaching that. The bill I was telling you about that I thought was a no-brainer when we met with the lobbyist, she said, you, a physician cannot do that because they won't trust you. And they'll think that you're trying to take the rights away from patients. Even though I'm like, I just want to, like, help my patients. So she talked about who could do that. Or she actually came up with, is it another way we could get the same outcome, which gets the alternatives, that doesn't go down the route? And so those nuances we are including in the curriculum, I mean, we obviously can't cover it all today, but you're spot on, I think, in terms of that's what we need, that's what we're trying to convey to the residents. Advocacy is so hard, so nuanced. This is what I didn't know as a resident and what I've learned just through sort of creating this curriculum, and that's what we're trying to teach them. We've seen it get weaponized when people go too far testifying, and we've seen, you know, we've heard from our lobbyists that politicians don't trust doctors anymore, at least not in our state. And so I should mention, we are at time, but I don't think we're getting kicked out of the room. So we're glad to stick around for additional questions or comments, too, if there are more out there, too. Trust me, I'm a doctor. Doesn't work the same way you do, unfortunately, as we're finding the hard way. Well, thank you, everyone, for participating and the wonderful questions, too. Yeah, thank you. I've learned a lot from you guys today, so thank you.

advocacy curriculum

residency program

healthcare policy

Eightfold Path framework

legislative hearings

health inequalities

stakeholder collaboration

political landscapes

professional societies

systematic advocacy