Learning objectives
1. Describe the four levels of health advocacy as a physician – interpersonal, organizational, health system and policy
2. Identify the six keys for effective advocacy
3. Identify effective ways to incorporate the community into your advocacy
4. Identify key points to effectively advocate in writing through letters to the editor
5. Reflect upon your personal goals for advocacy as a future physician
Please read / view the above readings and then respond to one or both prompts below. As a group, use the page to respond to each other’s posts (at least one response to another student).
I would argue that to a certain degree, physician advocacy is an obligation of the profession. When you become a doctor, you make an agreement to have your patient’s best interests in mind, and that includes advocating for them when necessary. This could happen when you have to advocate to the patient’s insurance company to get them coverage for a medication, advocating to another specialty that the patient needs to be seen, or advocating to the patient’s friends and family what the best course of action is, even when it may not seem that way to them. Being a physician advocate also means advocating for yourself and your teammates, such as advocating against the hazing and abuse that commonly still occurs in the medical field.
There are many ways beyond this that physicians can become physician advocates, however at a certain point I would argue that this is a personal choice and not a full obligation to the profession. For example, writing and calling your congress people to advocate about a particular piece of legislation you feel passion about is not something I would generally consider to be an inherent part of being a physician or physician advocate. However that is not to say that this is not an example of being a physician advocate. I would argue instead that this is an example of “going above and beyond” the standard expectations of the job. Similarly, volunteering as a medical professional in a volunteer run clinic or raising funds and awareness for a specific disease are not things I think are generally thought of as “required of physicians” but more as something extra, a way to advocate for a cause you are passionate about.
There are definitely layers. As a physician, you will need to decide, how involved you will become and that may change over the course of your career and patient populations. As you describe a physician advocating for something they are passionate about, each physician may take a different approach, more foreground or background but engaging yourself in some form is the important aspect.
I think physician advocacy is an obligation in this day and age (as one part of being considered good physician). Medicine is performing at a high level in the hospital, but this form of medicine is purely reactive. I think we have reached a point where we need to start looking beyond healthcare centers and see what impacts our patients’ health in their communities and everyday lives. When we take an oath to serve patients, to me this doesn’t just mean in the hospital or office setting. We have to do what we can and advocate in public spaces for health in all areas, especially with the inequalities that are so present in our healthcare system.
One of the articles makes a good point that there are so many different types of ways one can be an advocate, so not all physician advocacy needs to look the same. Not every physician needs to be up in front of large crowds or in the public eye, but there are also opportunities to advocate on a more local or interpersonal level as well. I also think it’s important that we stay within the limitations of our own professional knowledge, and not overstep boundaries into other territories. Advocating in a professional setting on professional matters, while maintaining the right to advocate for important personal matters as well.
I like your statement about the importance of advocacy to address the inequities in our healthcare system. We see so many in front of us on daily basis. Using our voice through advocacy is one tool.
As a bright eyed bushy tailed medical student, I think it is obvious that physician advocacy is a necessary quality of a successful physician. In a lecture from an IM doctor, we discussed how the failures of providing adequate care and addressing the social barriers of healthcare can be a moral failing for aspiring doctors. While I recognize that there is a need for physician’s to use their privilege, education, and standing to help patients, I think it can be hard to be weighed down by obligation within the way the system is structured currently. From the articles it is clear that there are many levels for advocacy, but it often requires physicians to go out of their way and busy schedules to pursue advocacy. Certain systemic and political methods are a little bit more organized like working to make changes to policy as part of professional organizations like the AMSA, but for many issues that are at the intersection of other fields, I think it can be hard to work within the system and see change in a timely manner. The organization I have partnered with, Jimmy Heath House, works on the housing first model to help those facing drug addiction or participating in sex work find a safe place to address health issues. They often encounter the healthcare system at emergency departments and urgent care centers due to lack of health insurance. However, it can be hard for physicians to navigate the housing system, but staying educated about resources that exist and depending on others like a respected pastor can be the best form of advocacy. Overall, I think a good physician is one who is able to use their strengths and find a way to be an advocate whether at the patient or systemic level. It is most important to choose an area where you can sustainable find time and have resources to advocate without becoming burnt out.
I had many of the same thoughts as you Pooja when reflecting for this module. In an ideal world we as physicians would be able to easily advocate in all the ways possible, like helping patients find sustainable housing. Though I suppose in an ideal world that also wouldn’t be necessary. But with the problems that currently exist in our society, we as medical students and physicians won’t always have the time, opportunity, finances, or privileges to be an advocate. That doesn’t mean that we shouldn’t always try to be the best physician and person possible for our patients however. We should always do what we can, but it is important to recognize our own limitations.
You touched on a lot of the things I was thinking as I read through these articles, Pooja. Maybe because we’ve been on the same rotation the last few weeks! We’ve been part of the day to day advocacy for our patients within a large and complex system. From my experience on the renal team, I’ve found a lot of value in identifying small ways to bend (or better navigate?) the existing system on our patients’ behalf. Giving IV antibiotics to patients at their outpatient dialysis centers instead of keeping them in the hospital for additional days? Genius. If we can all find ways to leverage the existing system, and then make that just part of the standard process, we can make that kind of advocacy more sustainable.
Pooja, I would have to agree with Grace and Taylor that you make a lot of really great points and address some of the thoughts I had. So many great points that it’s hard to touch on one. I agree with both you and Dr. Beck that many, including myself, feel bogged down by all of the other “stuff” we have to do that feels like it gets in the way of advocacy. I think an ideal system would be one where all aspects of advocacy are intertwined with our mandatory job requirements. Unfortunately, the current mandatory job requirements do not address those that fall through the cracks which leads to the need for all of the organizations that we are partnered with. Although I don’t have a solution to the healthcare system, I’m glad there are so many physicians and medical students who are leaders in reducing health disparities and trying to address the cracks that exist.
You are correct. There is the dream vision of advocacy and the reality vision of advocacy. There is only so much energy left at the end of the day. What can be done? Is it a phone call to a legislature? Is it attending a rally? Is it calling back a patient? Is it showing up at a community partner meeting? Is it getting a good nights sleep so you can be a good doc for tomorrow? All of these are important in the realm of advocacy – building bricks of support one a time.
When it comes to the importance of patient v system advocacy, the utilitarian part of me wants to argue that system advocacy is going to have the greatest impact. Changing the system, even in small ways, can ripple across communities and make major changes in health and health care. But I am someone who needs a lot of spare brain space to consider and push for system changes, and there isn’t a lot of spare brain space at this point in our training. Personally, patient-level advocacy comes easier to me and is therefore a lot more accessible and sustainable. When you have a specific person in mind as you make those calls or argue with that entity or whatever, it can fuel you. Plus, you never know what kind of ripple effect will come from putting your energy into that one patient. So, while system advocacy may make bigger and more lasting change, I’m a firm believer in doing whatever you can for whomever you can.
I agree with your points, Taylor! While I think systemic change is the most effective way to improve the health of large populations, it is often a slow process and is cumbersome to actually contribute to as a physician. Advocating for individual patients is much more feasible to integrate into a career – and like you said, having an actual person in mind to drive your actions can make you more compelled to actually follow through on your plan. Both system level and patient level advocacy have an important role in improving patient health, and it’s important to find what is the most sustainable way for us to be advocates in our future careers.
I like this response, because I think a challenge is balancing the infinite ways in which a physician can hypothetically advocate for change and the realistic limitations of time, energy, experience, etc. System advocacy has the potential to create change and impact across a greater number of people, but it also requires a far more intimate understanding of the shortcomings, needs, and (often) complicated dynamics of the system before even starting to fathom how to enact effective interventions or advocate for change. In the healthcare system, for example, it’s unrealistic for us as medical student to have had the level of exposure and experience that a seasoned physician has. Whereas the impact of patient-level advocacy may only directly and immediately be to the benefit of one person, this is a much more accessible option for advocacy in the context of limited time or experience. I agree with Taylor because something is always going to be better than doing nothing, and perhaps the opportunity of advocacy also evolves over the course of a career in the sense that small, repeated patient-level interventions over time ultimately spark larger system-level changes.
I think I had a very similar reaction to you when thinking about this prompt. I love your point about how changing the system in small ways can make ripples across communities, and I definitely believe it to be true. We often look at examples of advocacy from other physician’s and other hospital systems to help guide our own practice. At the end of the day we as individuals can only do so much, but it maybe setting an example for others, and can ultimately leave an impact on a much broader scale.
Group- don’t discount your patient-level advocacy. That is so important and life-giving to the patient, their families and you as a physician (yes, also draining at times too). The opportunity for system-level advocacy is there once you have more time – to create change for hospital systems, communities , and patient populations occurs in City Council budget hearings, being part of expert panels, and meeting with legislators as examples.
Physicians fill many obligatory roles in their career – with listener and healer chief among them – and I think advocacy, to an extent, is also a role a physician must fill. But as the Haq et al. article pointed out, there is a spectrum of levels at which physicians can participate in advocacy. Just as important as it is to advocate for public policy changes or sit on a national health system board, there are many barriers preventing physicians from taking on these roles. Dr. Beck even noted that time limitations – like wanting to spend his time outside the hospital with family – make it harder to dedicate time to advocacy. But even providing useful resources for a patient during an office visit, following up with them when they leave the hospital, or calling insurance companies to get approval for treatments are ways to advocate for patients that might already align with a physicians daily tasks. At its core, I believe advocacy encompasses all the ways physicians try to work in their patient’s best interest, even if it is not on a grand scale. I also believe it is unreasonable to expect someone to advocate at multiple levels, and in that same vein, I do not think there is a “more important” kind of advocacy work. Just as much as we need systemic change in our country, we need people looking out for individual patients. As with many things in life, we need to empower physicians to make change in the way they feel most compelling, and should not make someone feel that their work is “less than” someone else’s.
I completely agree with your take Caroline! Advocacy at any level is powerful and physicians who advocate at higher levels are in no way superior. I think we all have unique talents/passions to explore in depth during our careers as physicians, and I higher level of advocacy isn’t meant for everyone (i.e. we need people in med ed, research, business, etc). Also, I love what you said about advocacy encompassing all the ways physicians work in the patient’s best interest! No matter the scale, it is truly identifying a need or barrier and partnering with patients to try to overcome it!
I think you are so right about the need to empower other physicians to advocate for their patients and not try to make them feel less than for not advocating in more public ways. It’s important to focus on the fact that we’re all working toward the same goal, and any step forward is progress in the grand scheme of things. You’re also so right- there’s a lot we do on a daily basis to advocate for patients and it’s important to recognize that work as well!
As you note, there are many types of advocacy, and some physicians are going to feel more comfortable with patient-level and some the system-level. Both are advocacy for the patient.
Prompt: Is physician advocacy an option or obligation of the profession?
Response: I believe that advocacy is an obligation of the profession and if you are failing to advocate, you are failing to meet the expectations for that profession. I think it is well expressed by the article titled “Spheres of Influence and Strategic Advocacy for Equity in Medicine” when it says, “Given the many ways systemic problems such as race and class-based discrimination confound our efforts to care for our patients, physicians should consider such advocacy an essential part of their professional duty.” Similarly, as expressed in the article “No Longer An Elective Pursuit: The Importance Of Physician Advocacy In Everyday Medicine,” they argue that advocacy is essential, not optional, in medical practice to address health disparities in marginalized communities. If you fail to consider the many factors that impact your patient’s health outside the clinic’s walls, you are failing to provide good care. Fortunately, many of the standard practices, whether for colon cancer screening or immunization schedules, are based on evidence that helps you advocate for your patients and communities. However, it may be necessary to incorporate additional efforts such as place-based interventions with community health workers, as alluded to in the TED talk we watched, to meet the specific needs of your community
You highlight the importance of race and class-based discrimination in why we as physicians should be advocating for our patients and for systematic changes to the healthcare system our patients engage with and in which we deliver healthcare through on a daily basis.
For example, yesterday, I took care a a 67 year-old African-American male with history of COPD CVA and who was sleeping outside on a park picnic table because he lost his apartment. We start at patient level advocacy and work on the system-level…
Physician advocacy is described as a “core component of medical professionalism”, as such, I believe all physicians should be responsible for upholding some level of advocacy in their professional careers. At baseline, all physicians can work to be advocates at the interpersonal level. The reading materials discuss practicing advocacy within our spheres of influence and provide many practical examples for physicians to advocate at this level. Advocacy efforts at the organizational, health system and policy level often end up being left to those with a level of passion/dedication to advocacy to the extent that they desire it to be a key component of their professional careers. The reality is that, in a healthcare system driven by revenue and efficiency, advocacy work can be deprioritized and devalued compared to other “scholarly work.” For example, intentional advocacy in the research space usually demands more time than traditional clinical research and can be viewed as less academically rigorous. In a time where physicians already have less time to spend with patients compared to a decade ago, interpersonal advocacy alone may seem like a tall order to many. Despite being described as a core component of our field, our healthcare is not well structured to support advocacy work, something I hope can change for the better over time!
Ebun, I completely agree with you that advocacy, including a minimum level of interpersonal advocacy, is at the core of the duty of a physician. I particularly enjoyed your discussion on how higher levels of advocacy often get deprioritized especially because it is not very good at creating revenue for hospitals (at least in the short term). Personally, I firmly believe think some of these advocacy projects and research could likely improve just as many, if not more health outcomes than some of these clinical research projects. Ultimately, this would generate more community social capital and community economic growth (and potential alleviate an economic burden on hospitals), though this would be more of long-term investment.
You are right. Like many things, the healthcare system is not structured to support advocacy of any type. Advocacy for patients to get their meds or needed procedures. Advocacy for hospital systems to change policies to extend uninsured coverage. All of this is why you need to have the strength of your colleagues and staff as you work together to commiserate, collaborate, and celebrate.
Ebun, I completely agree with these sentiments. I think it is really important that you voiced the reality that advocacy work is often devalued in our healthcare systems and is effectively de-incentivized. Often times, those who have great passion for patient advocacy and dedicate time to doing so in the clinical setting are penalized given the structure for pay in most systems. Medical practices are also discouraged from accepting patients with public insurance, who often need the assistance navigating the medical system. Restructuring this system would inevitably lead to better outcomes, but it will take buy in from both physicians and hospital systems.
I think that a level of advocacy is intrinsic to the position of a physician, but the extent to which a physician participates in advocacy varies widely. Throughout our training, we discuss autonomy, justice, non-maleficence, and beneficence as pillars of medical ethics, many of which naturally overlap with advocacy. Andrew Beck talks about how this may look different over the course of a career, with varying levels and types of expertise that enable advocacy. Through providing patient care, physicians aim to “do good” for their patients. Some of this arguably falls in the realm of the job description during work hours, for example by advocating to insurance companies for a needed medication, supporting and directing patients to local community programs and resources, or assisting patient education and participation in relevant clinical trials. I would argue that those drawn to a career in medicine tend to enjoy the “doing good” aspect, which tends to lead towards advocacy activities naturally expanding beyond work hours. Through their career, physicians gain expertise in the healthcare needs of patients and communities and are uniquely positioned to understand how they can “do good”. So while it might not be an obligation to participate in larger advocacy efforts, for example systems-level advocacy, I think that the type of person that strives to be an exemplary physician views advocacy as a natural extension of the profession rather than an obligation.
Advocacy does comes a natural extension as you suggest. How this is implemented can vary by physician, but the goal is the same – improving the health outcome for patients and communities.
I don’t think I have a definitive answer to the question whether patient or system advocacy is more important. As the journal articles pointed out, there are many ways in which physicians can get involved in advocacy, with levels ranging from interpersonal all the way to advocating for policies that will impact patients at the system level. I think first and foremost it is important for physicians to advocate for their own patients. Those are the patients that you are directly taking care of, that you have gotten to know both as a patient and as a person, and where you can make a direct impact for your patients within the confines of your “job”. As my classmates have pointed out in their posts, advocacy for physician’s sometimes means additional work outside of what is considered your “job”. I think advocacy is becoming an essential part of a physician’s career. If you focus on advocating for your own patients, sure, the impact may not be as broad as advocating on the level of policies or healthcare systems, but imagine if every single physician was able to actively advocate for the patients that they are taking care of. The impact that would leave on our patients, system wide, would be substantial, and it is also more feasible as an individual person.
There’s a saying in school, that if you have a question, odds are there are several of your classmates who have the same question. We use this statement to teach students that they should not be afraid to speak up and ask questions. I think we can apply the same thought to advocacy as physicians. Odds are that if we see the system negatively impacting or failing one of our patients, there are many other patients out there who are being impacted in the same way, and we should not be afraid to speak up. No singular physician can change the system as a whole. But if different physicians take interest in specific areas of advocacy, just as they do medical specialties, we can cover a whole lot more ground than leaving it up to one person alone.
You are right- it cannot be left to one person. It needs to be all of us playing some part. I like your analogy of the students- too often we as physicians or learners feel we are the only one that has the problem or the solution. It will take all of us contributing.
To answer the question of whether patient or systems advocacy is more important, you have define what is meant by “Important”. Because on one hand, patient advocacy is at the core of the duty of a physician. Listening to a patient, understanding their health needs, and addressing them, are, broadly speaking, at the essence of what it means to be a physician. It is also patient advocacy that allows individuals to build trust with physicians in the community. And it is that trust which the physician can then utilize the trust and influence to perform more systems and community advocacy.
However, with systems and community advocacy, physicians can broadly and tangibly impact the lives of their patients and communities in numbers far beyond what they likely could in the clinic through patient advocacy. They are able to see problems in their community that are impacting the health of their patients and actively work to alleviate needs on a much greater scale. Ultimately, though, patient and systems advocacy are important for different reasons, and it is hard to say which is more important because both are essential to addressing the health needs of individual patients and communities.
You are right to question the word important. Yes, both are needed as you state. Now we just need to find better ways to support physicians to engage in both.
In my opinion, advocacy is an important role of physicians across all specialties. Physicians have the privilege of acting within a broad sphere of influence and can advocate within clinical environments, hospital administration, research, healthcare systems, and by participating in policy making. Also, as society leaders, physicians can act on an interpersonal level by using their expertise to address the individual or collective needs of members in their communities. Whether on a large or small scale, advocacy can have a positive and meaningful impact on patients when physicians. For instance, as described by Karches et. al, reducing stigmatizing language in clinical documentation can be empowering for patients struggling to navigate the healthcare system and comply with prescribed treatments. By avoiding labeling patients as noncompliant, physicians can prevent harmful perceptions of patients from being perpetuated throughout their medical records. Additionally, physicians can also act on a system-wide level. There is a great need to identify injustices in practice guidelines and work to correct them. In the US, there exist many disparities in outcomes between different patient groups. For example, patients are often diagnosed with later staged cancers and have poorer survival rates. Studying the cause of these disparities is an essential form of advocacy, so that healthcare can evolve to be more equitable.
Whether acting at the point-of-care or at a higher level, physicians are responsible for using their training to improve the quality of the healthcare they provide their patients. Most importantly, it is important to look beyond the illness of a patient and to work to address the issues that present difficulties in delivering care.