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 think physician advocacy is an obligation of the profession. Much like the Hippocratic oath or other ethical code that we might ascribe ourselves to throughout our career, I think we, as physicians, commit to advocacy inherently by the nature of our profession. It is difficult to imagine a spectacular physician that does not, in some way, participate in advocacy throughout their career. Some physicians may focus more on advocacy during their training, and others may turn to it later in their life, but a truly inspiring physician incorporates advocacy at some level.
I don’t think either are “more important” but rather complement each other quite well. One does not exist without the other, and failing in one realm means struggling in the other realm as well. Although both are important, I don’t think every physician has to set aside an incredible amount of time to dedicate to each one individually. Rather, committing to small acts of advocacy can be a powerful way for physicians to make an impact on their own patients, their community, and the health system as a whole. Many physicians will choose to make advocacy a pillar of their career, whether that be at the local, state, national, or international levels, which is needed and appreciated. However, other physicians who spend all their professional time seeing patients in clinic cannot be discounted, as they too are dedicated to being advocates for their patients day in and day out.
I really appreciate your comments here about small acts of advocacy being powerful and that the different ways we approach advocacy are all important. For me, this is the inspiring way to look at the prospect of being an advocate because of how different it can look! I get overwhelmed sometimes by the thought of “having to” or being “obligated” do one type of advocacy when another avenue may get me more excited in my day-to-day work. Your description feels inclusive and sustainable! Thank you!
I really agree with the idea that both patients and system complement one another and that both need the other. I also think that advocacy is not something that needs to be something massive and impactful. Small changes over time are powerful. I do think it is crucial that some physicians take up advocacy as a central pillar of their career. Just as we need specialists in clinical medicine to focus on and excel certain areas, the same holds true for advocacy. I think some of the messaging we get is this idea that we all have to be huge advocates and make it our lives. I think the little acts of advocacy rhetoric has a lot of potential for big change.
I actually don’t know. I used to think it was an obligation. But I think physicians are pulled in too many directions to be too many things, and this contributes to burnout. If advocacy and relationships and contributing to a better world brings you joy and helps you find meaning, then yes, I think you should do it. For most people, I think the answer to that question is yes. But I don’t think you should feel obligated. Maybe we should let some physicians be cogs in a machine if they want to be, and let physicians who want to use their knowledge and power for positive impact also do so if they want. Maybe we just need more freedom from administration in our healthcare systems for physicians to be agents of the care they provide. I think for most physicians, they would choose to be a part of advocacy, but lose hope that anything will change, that it is an actual option. Nihilism can be dangerous, though. Maybe by making advocacy an obligation, we actively fight nihilism, and burnout. Maybe a healthy society requires that people feel obligated to help their neighbors – and if so, maybe physician advocacy is a natural extension of that.
I believe patient advocacy is more important, and as Dr. Beck mentions in his intro, I think we underestimate our power as physicians to participate in patient advocacy every day through the conversations we have. We have received a lot of education. The more you know, the more you realize you don’t know. And so – scientists, physicians – we realize how much we do not know, and we try to stay in our lane of expertise. But I think it is okay to expand our lanes – to reach out to others to learn what we don’t know, and always, always try our best to answer questions asked of us by others. I believe the trust endowed by patients when they ask questions is sacred – not an annoyance. Advocacy, to me, looks like engaging in hard conversations, maybe even ones in which your own expertise is being questioned. It is hard to advocate for systems change with other experts who are highly educated, but generally doing so will earn you accolades, and often is encouraged / seen as an obligation by professional societies. It is harder to advocate for evidence-based medicine within the walls of the clinic – with patients from all walks of life, many of whom are very different from you. It may even get you in trouble from administration, because it will require more time and less procedures, creating negative margins. I guess there is something inherently more important to me because of that sacrifice.
I agree Keirsten. I appreciate your perspective, because I often find myself and share in this thought with many others that 24 hours in a day is not enough to get everything you want accomplished. Thus, you prioritize and when given complex patients and high volume schedules, you compromise something. Whether that be personal time or time spent advocating or maybe true centeredness and presence with your patients, something gives.
Hi Keirsten,
I agree with you in that many physicians are experiencing burn out at an all time high and that a lot of the contribution is likely stemmed from complex patient care without the resources to support said physician/patient population. I definitely think there is an obligation to care for self first in these cases – whether that would be therapy for self, leaves of absence/vacations, and job changes if the system they work is unhealthy. However, I do think there are still daily opportunities of advocacy that the physician is obligated to perform as the front line for a lot of science/medical information out there. Simply by asking questions such as “what are your preferred pronouns”, “are you having trouble providing housing/food/medications/transportation for yourself” or answering questions such as “what resources do you have for domestic violence”, “why should I get this vaccine” is more than enough to be called advocacy. I think advocacy is something we cannot escape even if we are not active initiators of it.
Is physician advocacy an option or obligation of the profession?
Depending on who you ask, you might receive different answers. However, I do not understand how one can enter into this field and not relate to their vocation as an obligation for advocacy. From the early days of medical school and pre-med curriculum nonetheless, tenets such as ethical duties, assuming positions of influence in society, practicing professional virtues and instilling systems-based change seemed to go hand-in-hand with becoming a physician. The role in and of itself demands this of us and history only bolsters this responsibility: from caring for the dying in their home to running for election and advocating for legislation on a larger scale. It seems to me that one cannot be a doctor and not advocate. On the flipside, one cannot advocate without being a fully competent doctor.
Is patient or system advocacy more important as a physician?
Both patient and system advocacy are essential, but patient advocacy is often the most immediate in reach of the physician. We are frontline, serving as the brigaders and navigators of our complex healthcare system. I recently had to present a case during one of my rotations about a patient who on routine back pain imaging, was found to have metastatic cancer. He didn’t realize this until one of the specialists gave him a call and offered to see him in clinic. He subsequently saw 15 other physicians and had 3 known admissions. His demeanor was often distressed and overwhelmed. Focused on journeying through our hospital, how could he fight his illness? Physicians build direct, trusting relationships with patients, they are uniquely positioned to recognize and respond to injustices or barriers in real time, making patient advocacy a vital expression of our ethical duty.
However, system advocacy addresses root causes. Issues like insurance access, medical billing, health policy, coordinated care rest on much larger shoulders. However, they can be impacted by physicians on a daily basis. I wouldn’t see how one would disagree that a doc who left clinical practice to run for election would be discounting patient care or a family practitioner who day in and day out met every patient’s individual needs but never wrote legislation. Maybe there’s a balance? By engaging in system-level advocacy, physicians can help shape policies and institutions to better serve entire populations. But also engaging in patient-direct care in your average outpatient office I would argue also serves this purpose. Ultimately, while patient advocacy is urgent and personal, system advocacy is essential for long-term, structural change—both are necessary and neither should be neglected.
I appreciated your thoughtful reflections, especially your connection of the historical role of physicians to the modern obligation to advocate. Your case example powerfully highlights how easily patients can get lost in the system and how crucial it is for us, as their providers, to serve as consistent navigators and advocates.
I also appreciated your point that patient and system advocacy aren’t mutually exclusive. As you mentioned, meeting individual needs on a day-to-day basis doesn’t prevent us from working toward systemic change; it often informs and strengthens it. In fact, I’d argue the most effective system advocates are those still grounded in patient care, as their insights are rooted in lived experience.
Hi Quinn, a lot of your thoughts resonated with me, especially how advocacy and the job of a physician go hand in hand. I completely agree that you cannot be a competent physician without advocacy, but I hadn’t thought as much about the flipside: you can’t be in a position of advocacy without being a competent physician. This sentiment is very motivating as it calls us to learn not only about the pathology during medical school, but also how to navigate the health system and resources available in the community.
Is physician advocacy an option or obligation of the profession?
At its foundation, medicine is a moral enterprise. We are trained not only to diagnose and treat but to act in the best interest of patients, which includes addressing the upstream social, structural, and institutional factors that shape health. The Spheres of Influence framework (Karches et al., 2021) makes this point clear: physicians possess influence at the interpersonal, organizational, health systems, and policy levels. With this amount of influence comes immense responsibility to spark change.
The American Academy of Family Physicians and AMSA similarly assert that advocacy is central to, rather than separate from, professional identity. It is a competency to be taught, practiced, and refined, and cannot merely be ascribed to as a political preference or extracurricular hobby. Likewise, the CFMS toolkit on advocacy emphasizes that physicians’ unique insights into health systems and patient suffering give us a responsibility to inform the public and policymakers.
Moreover, inaction is not neutral. Silence in the face of injustice (be it racism in care delivery, inaccessible insurance, or discriminatory algorithms) contributes to the very disparities we are tasked to eliminate. Deciding not to act on injustices we witness as physicians is a conscious decision to allow them to persist.
For all these reasons, I believe physician advocacy is an obligation. We do not serve our patients fully if we only address the biology without challenging the structures that cause and perpetuate their illness. Advocacy is not separate from healing; it is a form of it.
Is patient or system advocacy more important as a physician?
Both patient and system advocacy are essential responsibilities of a physician, but I would argue that system-level advocacy has the greatest long-term potential to advance health equity and transform care, especially when grounded in the lived realities of our patients.
Patient advocacy is the heart of what we do. It builds trust, upholds autonomy, and meets immediate needs. But if we stop there, we’re only patching holes in a broken system. We are fighting for our patients without fighting the structures that make patient care so difficult in the first place.
System advocacy, by contrast, works upstream. It seeks to change the policies and structures that make individual patients vulnerable in the first place. The article “Spheres of Influence for Equity in Medicine” reminds us that physicians are uniquely positioned to drive change within institutions, healthcare systems, and public policy. For example, if you help one patient get an interpreter, that’s meaningful. But if you advocate to ensure interpreter services are fully integrated and funded across your hospital, you’ve impacted thousands.
So while patient advocacy is urgent and personal, system advocacy is scalable, sustainable, and ultimately more transformative.
I agree with you that system advocacy is essential to driving change — and impacts far more people than a face to face encounter with one person. And I agree that by having lived experience as a physician, you have more stake in the public health of your community, and invaluable insight into how systems could better address patient health and safety. After reading your comments, and reflecting on my own conversations with a physician I’ve been working with, I think my own initial response came across as harsh towards systems change. Without changing the systems that overwhelm physicians to the point they are not able to adequately connect with their patients, we cannot participate in the level of patient advocacy that we would like to have. I also agree that participating in advocacy helps prevent burnout.
I think that advocacy is an obligation of the profession, but that each physician should find a unique level of advocacy and become proficient in that area. I remember hearing it said that “medicine is an art, not a science” coming into medical school and just thinking its just another cliché, brushing it off in anticipation of learning anatomy and physiology. However, during the clinical year it becomes readily apparent how vital advocacy is in medicine. I felt confident in knowing the pathology and first line treatments, but it was important for me to take a step back from the labs and numbers and look at the whole patient. I may have been able to come up with a plan for someone with a COPD exacerbation, but where I saw I could make the most difference is finding out WHY its happening and meet the patient at their level to try and prevent it. That is advocacy at its core. At the community and population level, I think it becomes more difficult for one main reason: time. However, I think its important for the physician to realize that the patients they care for aren’t separate from the community. For that reason, I think its important for the physician to be involved in advocacy, but it should be targeted towards one area so that genuine change can be made. I think picking one area and really advocating in that area is far superior to the physician with advocacy interests a mile wide and an inch deep.
I think that patient advocacy is far more important, because it’s a power that we get to use far more as physicians. The conversations we have with patients every single day employ patient advocacy in some form, whether it be for a medication or a vaccine. System advocacy is still markedly important for the reasons noted above. It’s important for physicians to do both, but refining skills in patient advocacy will have the greatest benefit in the long run.
Hi Adam!
I really like the point you bring up in your first response about each one of us having the ability to find our own space within advocacy, at whatever level makes the most sense. I think this is something that can get overlooked when certain issues garner a lot of traction and attention. There is definitely benefit to gaining momentum behind one issue, and at the beginning it can be especially helpful for the sake of managing resources. With that said, there is also so much value in preserving the diversity of issues in advocacy. Like you said, ultimately true and sustainable change can be made when we target our efforts in one area and it’s completely okay and even helpful for that to look different for everyone
You guys are really making me think with your posts! I am enjoying reading everyone’s perspective and excited to discuss tomorrow. I sort of merged the two prompts into one stream of consciousness 😊
I feel like I agree with many above who stated that we take an oath to serve & do no harm to our patients, which ensures that, at least at the patient level, advocacy is intertwined with our jobs. There really is no option there for me, especially as we build our knowledge base of the far reaching effects of social determinants of health and how so many different things affect the health of the patient that will sit in front of us one day in our clinics.
When we expand to the organization, health systems & policy levels, it’s harder for me to envision my specific place in this type of advocacy. I really identified with Dr. Ravenell in his comments on “place based interventions”, “trusted people in trusted places”, and “community health workers”. The idea of getting barbers to learn how to take blood pressures and help encourage people to see their PCP was so inspiring to me. So I do see expanding my work beyond the interpersonal level, but potentially not as far as the classic stereotype I had of advocacy being only with policymakers at a government level.
Dr. Ravenell’s remarks make me want to say that finding something as a physician that gets you excited to help make people healthier – whether that be at an individual, community or wider systems level – is the most important thing! I completely agree with those above who referenced the competing priorities of our time/burnout, so finding what makes you feel like you are contributing meaningfully seems key. I don’t want to force / feel forced to get involved in a big system change or policy updates when a project that impacts only members of my clinic is what excites me. So I hope myself & others could feel proud even if their advocacy remained in a patient room or a clinic, even if that technically impacts less people. And, I think I actually feel okay that this opinion can differ, even just within this class, because I am reading this as us working towards a collective good and hitting the system from all angles, which is awesome.
Something I am struggling with moving forward is how I envision my role in advocating at higher levels than individuals in our current climate. It feels important when reflecting on these questions in the current state of having a federal government that is pushing us backwards, and doing so with force, retribution and punishment.
Just yesterday I read a headline that RFK has “retired all 17 members of the CDC Vaccine Advisory Committee” amidst all of his other vaccine skepticism. This, in combination with research cuts and other proposed policies, are absolutely going to have impacts on the care that we provide in our offices someday (which is crazily pretty soon). On one hand, I feel like this is the time to stand up and truly get out there at a system level because there is craziness happening!! On the other hand, I feel scared. Maybe the best way to advocate right now is with conversations that do happen individually with our patients and in our smaller communities where we can use our education, our voices and our time more quietly resisting? Sometimes it seems like that is a safer bet to ensure that I can, at least, continue doing something. Excited to hear how others have been reflecting on our current political climate and what this means for us, as advocates, moving forward.
Hi Caroline! It’s clear you read all of these posts with intention and I am so impressed by your commitment to the discourse. I think you bring up some great points here. When you reflect on the balance between levels of advocacy, I think you reach the same point as many of our classmates. As physicians, our training and our mission is to help the patient. So you absolutely should feel proud when your advocacy is in a patient room or clinic. That’s quite literally the job!
The rest of your reflection tends toward a fear that I have also been experiencing lately, which is how does this fit in to our current climate. I saw that same headline and was also taken aback. That advisory board was specifically set up with rotating terms to ensure continuity and fairness (kind of like how the senior rotates off of the team, then the senior, then the attending, then the medical students or whatever order it is). This is not a novel idea and people have trust in a rotation like this. So then the challenge becomes, if we have built institutions to the highest standards of equity, transparency, and safety, but they are still coming under attack what can we, as physicians do? That’s where I get frustrated because seeing the limits of our care is demoralizing. I’m wondering here, how can we change the marketing so that people regain their faith in our expertise? When that’s regained, can we resume advocacy?
The obligations of a physician are to care for their patients. I think we do a disservice to the occupation if we claim that our obligations are any further than that. However, I think that to care for your patient, you have to advocate within that sphere of influence. You have to push for whatever labs your patient needs, whatever imaging, whatever consults. And you have to be willing to annoy some other people to get it done. Our patients trust that we are on their side and that we are working every angle to get them the care that they deserve.
While caring for the patient is the job, the job empowers us to do more than care for an individual patient. We are uniquely positioned in society as highly trained and highly respected. We have the power to move outside of the sphere of influence that envelops us and our patient. As Karches described, there is room to maneuver within health systems, and the national and local policy levels. Do we have to? No. And I would hope that physicians who don’t feel passionate about advocacy at these levels don’t feel obligated, because that tends towards lower quality of outputs. But should we advocate in the larger spheres of influence? Yes, absolutely yes! Though this might be very hard in the current political climate, it is now more important than ever to uplift the perspectives of our patients.
As an individual physician, we have an obligation to our patients, making patient advocacy the most important part of the role. As a collective profession, I believe that obligation extends to system advocacy. Caroline made a great reference to the CDC’s vaccine advisory committee being dismantled. As a profession, we cannot let such an affront to patient safety stand. Anyone accepting a replacement role there should have a very carefully thought out explanation of why they didn’t refuse and insist that the former committee member take their place. As physician’s we are uniquely positioned to push against this change.
Is physician advocacy an option or obligation of the profession?
One of the most common questions that a patient will ask a physician is “what should I do?”, and when the answer to such question is outside of the limitations of the patient’s lived environment, a physician’s role should be to adapt to these constraints or to expunge them. A treatment plan is only ever useful if the patient has the necessary resources and knowledge to succeed, thus the short answer to this question is that a physician’s role MUST include advocacy to serve the patient’s best interests. The main example illustrating this idea is my experience at Hopple. Many of the children there were low-income with unstable housing, and the clinic expectingly had twice the rate of asthma exacerbations as the national average. If we were to perform our physician duty minimally by the book, the treatment plan would be as simple as increasing dosage/frequency, adding inhaled steroids, or whatever GINA required in step up. However, at Hopple, such a plan was ineffective as it did not account for the family’s socioeconomic limits – they were uninsured and could not pay for a daily inhaler and thus children often stretched their inhaler use way beyond recommendations; the nearest pharmacy was outside of their bus route and thus the child ended up with a preventable exacerbation; the child’s asthma continually worsened under their living conditions of black mold and mildew due to a neglectful landlord; and so on and so on. As a result, the treatment plan had to include some level of advocacy. The resident physicians there had to call in social work to direct repercussions to neglectful landlords, to relocate families, or allocate resources for transportation or payment of inhalers/steroids. In the end, a physician’s best answer to the patient’s question of “what should I do?” is “what can we do for you?” beyond the bedside.
Is physician advocacy an option or obligation of the profession?
I believe physician advocacy is an obligation of the profession. Physicians have patients under their care, not guidance or watch or supervision. Think of when hospital administrators or insurance companies refer to patients as “customers,” for most of us pursuing medicine it instills uneasy feelings. That is because we know that physicians don’t just treat illnesses, but care for the people under their care. In order to truly care for patients physicians have to obviously treat their patients, but also maintain their health which requires advocating on their behalf at least in some capacity. Advocacy, even if be in small ways as discussed in the Curbside Consultation article above, is an integral aspect of the profession.To treat a patient of something that is caused by their material conditions without addressing the underlying cause becomes an exercise in futility. Moreover, in a for profit healthcare system like the one in this nation, profiting off of treating patients without in some capacity advocating to improve the material conditions that caused them to seek medical care in the first place, begins to verge on unethical as they will inevitably come back for treatment again.
Is patient or system advocacy more important as a physician?
Building off of the last question, I do believe that the focus of advocacy should be on patients. However, this question is a bit of a trick question. Its like asking a chef what is more important, the restaurant or the people that come eat there? The healthcare system exists because it is a way for more patients to be cared for and better cared for. The first modern hospitals were established in Baghdad during the Abbasid Caliphate because the physicians at the time sought to help and care for more people. The healthcare system was born out of a need to better help more patients. The system gives patients the care that they need, and the patients needing care makes the system indispensable. Advocacy for patients is what is most important, but in order to do that physicians must advocate for the system as well. As such, physicians must advocate for a system that works well, is efficient and of high quality, and treats the people that are part of it properly.
Physician advocacy is an obligation, and as I see it, both action and inaction are their own forms of advocacy with their own set of consequences. If you spoke to the average physician in the US, it would be a coin toss whether or not they consider themselves a patient advocate; but in truth we all are. The role of the physician and the nature of the doctor-patient relationship are such that we have unique insight into the needs and experiences of individuals and communities we serve. There are few other roles that hold the same level of privilege, and as a result there is no area of neutrality. To see a need and speak up or create change is to advocate for a solution, while dismissing it or ignoring is to advocate for the issue to remain. As stated in the Health Affairs article, physician advocacy is necessary for the delivery of quality care and breaking down structural inequalities. If we do not take action, there aren’t many others who can and even fewer who will. Medicine and therapy don’t just come in the form of a pill or injection; but also in the form of food security, housing stability, and safe environments that educate and empower. By entering the profession we acknowledge and accept this great responsibility to care for and fight alongside patients seeking better health for themselves and their communities. And whether a physician feels that they are an advocate or not, it’s undeniable that we have a hand in our patient outcomes.