Students will be provided a prompt in the discussion section below. Please respond to the prompt and respond to at least one of your student peer’s reflections for each prompt.
Critical Reflections, 2026-2027
Service and AdvocacyA Fourth-Year Medical Student Elective
Please consider a time during medical school:
when you engaged in advocacy and either it went well or did not go as planned
– or –
a situation when you chose not to engage but wished you would have advocated
Please reflect on the following:
What
Describe the situation you encountered.
What was unique to this experience for you?
What was your response?
So what
Why do you think you responded this way?
Why was this important to you and to the community you were engaging?
What was the outcome – good or bad?
Now what
How did and will you take what you learned to your next opportunity for advocacy?
What skills and resources do you still identify needing to do this?
Please post your response and respond to at least one of your peers by August 31st.
I advocated for a critically ill patient while I was on my neurology clerkship. I was on the neurology consult service and we were asked to evaluate a patient on the floor with new unilateral weakness. For context, this was a 68 year old female hospitalized with an intracranial hemorrhage in the setting of metastatic breast cancer. She recently had a craniotomy with hematoma evacuation and was missing a portion of her skull. Her primary team asked us to come evaluate her for this new unilateral weakness; they feared she was having another hemorrhagic/ischemic stroke.
I helped evaluate that patient with the resident and was told to present her to the team later. When I examined her, I found a patient who was, by what I could tell at the time, actively dying. She was minimally responsive to commands, had severely altered mental status, and could not meaningfully participate in discussions with us nor her husband at bedside. The husband shared the primary team’s concern that the patient was having another stroke. I had a hard time balancing the wants of the husband and primary team (needs which included a full head CT +/- a neurosurgery consult to take her back to the OR if there was a new bleed) vs. what was in the best interest of the patient. I think hers was the first case of medical futility I had encountered during my clerkship years. She had a very limited life expectancy regardless of the presence of a new bleed or not. I was concerned that subjecting her to more scans and possible surgery was actually in keeping with the ethical principles of beneficence and nonmaleficence: would we be harming her? When I presented the patient to the rest of the team, I raised this concern and offered an alternative. I suggested that the palliative medicine team come speak to the husband to have more of a goals-of-care conversation and ensure that the husband was aware of the situation’s gravity.
When I offered this, I tired to put myself in the shoes of both the patient and the loved one. On the patient end, if I knew I had a limited life expectancy regardless of intervention, I think I would want to optimize comfort instead of aggressive intervention. At the time, I was not sure if someone had actually checked in with the family about the patient’s wishes in a situation like this. In putting myself in the husband’s shoes, I wondered whether anyone had set realistic expectations with him in regard to treatment- did he know his wife was dying, or was he under the false pretense that she could have a meaningful recovery? Again, I was not sure if these conversations had been had and so I recommended the palliative folks come by to get us all on the same page. Patients and families deserve this.
The team ultimately agreed with having palliative care come by and hold off on any additional screening. This situation served as an important reminder to me to never shy away from difficult, emotionally charged conversations because these conversations are gateways to patient-centered care. While I’ve done a lot of work in palliative care communication, as I am only a med student I have yet to have the opportunity to lead one of these discussions myself. I think more authentic practice with real patients is an opportunity for me to seek out as I move into residency next year.
Michael, I can see how this was a pivotal experience of advocating for an individual patient. The conversation of palliative care is incredibly difficult to approach, much less bring up on rounds with an attending. This will serve to benefit you and your care in the future as medically complex patients arrive to your care and the need for palliative medicine arises.
I have seen the difficulty of approaching this conversation both on rounds and with families. Especially in the hospital, delivering the critical care has seemed to be the default option despite the presence of medical futility and patient wishes. I have seen one attending wanting to approach palliative care for a patient before another attending pursues aggressive management the next day. This only serves to confuse patients and their families without an overarching goals of care. I hope you continue on this path and become the attending who cares deeply for patients and their best wishes!
Michael, I really appreciate you advocating for this patient how you did. During rotations I’ve seen it play out from both sides. I’ve been on teams where we hesitate to bring up palliative care or end of life until it was too late, and patients and families didn’t get the opportunity to choose to prioritize quality of life or comfort. I also spent a month on the palliative care consult service at UC this summer and got to experience situations like your patient where we were brought in and able to give those options to patients and their loved ones. Those conversations were certainly difficult to have with many of those patients, but as I held more goals of care conversations I realized just how important that it is. It can make such an immense difference for them to not only understand the reality of their condition and to have realistic expectations, but to have an active choice in how they proceed and to prioritize what is most important to them. You’re absolutely right that out patients deserve this and we should all advocate as you did to give that to them.
I think it’s really admirable that you brought up the idea to bring in palliative care. Culturally, death is viewed as a scary thing to try to avoid for as long as possible. But sometimes comfort and dignity is better for the patient than further intervention, painful as that might be for everyone involved. I have only had limited experience with palliative care teams, but I have heard that it is useful to loop them in earlier rather than later. Even if the patient doesn’t end up going the route of hospice care, it is important not to skirt around the reality that dying is a very real outcome to prepare for. It may even end up being less traumatic for the loved ones to see their family member pass peacefully rather than slowly deteriorate after months of pain. There’s not really a “right” decision when it comes to goals of care, but the conversation still needs to happen.
A recent situation that I came across where I wished that I had engaged in advocacy includes a recent experience with a patient and her family on the wards. This patient had recently been diagnosed with cancer and has been experiencing a very rapid decline both in health status as well as in cognitive ability. Each day as I had been caring for her I witnessed her becoming weaker very rapidly. Over the course of 4 to 5 days the family and I witnessed this patient deteriorate mentally and physically. From a health standpoint, this patient was unfortunately very rapidly progressing to end of life given the acute metastatic spread of her cancer as well as declined nutrition status and pervasive bacteremia.
The family had been very overwhelmed and difficult to communicate with regarding end of life care. As a result, the team had decided to proceed with whatever interventions that we are able to do. Thus we were able to strike a balance where each day we assessed the status of the patient as well as the status of the pathologies we were treating. Long-term care and planning were topics of discussion, however were not the center focus of daily conversations.
The specific instance where I wish I would have advocated more was when our attending had switched and a new attending had come on to see this patient. Upon entering the patient room the conversation was very heavily focused on end of life care and planning and while this was important to address, I wish I had advocated more to the attending about the status of the family and where they were in the process of feeling ready to have this conversation. There is a fine line between life and death that becomes difficult to navigate. As a practitioner there is an understanding of the balance, however the line is very blurred for families who are watching loved ones decline at a rapid pace. In that moment I wish that we would have been able to approach the conversation in a more sensitive manner to preserve trust and uplift family centered autonomy when it came to making decisions.
In future opportunities, I wish to be more confident in advocating for patients and their families and sharing not only objective measures of patient health, but also subjective experiences and conversations. The art of medicine spans beyond numbers and cultures. The heart of this profession is collaboration and empathy. I understand these values and hope to continue working towards being a more compassionate and thoughtful student and practitioner.
Thanks for sharing this Nadia! It’s a tough situation when care teams and families have orthogonal ideas about patient care; it’s even tougher when families feel overwhelmed and need more time, but there is no more time left and we have to act. I think that we can try and get ahead of some of this by having conversations around end of life wishes at the time of admission. This is especially important for older patient/ patients with chronic serious illness who may decompensate while in the hospital. I think setting these goals early pay dividends later on. But, it is really hard when families aren’t ready to think about the end. Advocating for these conversations is an often overlooked part of patient care- it’s great that you are thinking about it!
Nadia, this certainly sounds like it was a very difficult situation. I had a similar patient experience on the palliative care service. Our team had been following a young woman with metastatic cancer who realistically had no meaningful treatment options left and had a limited life expectancy. However, she was not ready to discuss hospice or end of life and her children and family were not aware of the extent of her disease. Our team had been working over weeks with her to build trust and establish a relationship where we could slowly work towards having those important conversations. We then came in one day to find out that the primary attending had come in talking to her about code status and encouraging her to be a DNR because he didn’t think she would survive resuscitation. We later spoke with that attending and of course he did not come from a place of malicious intent, in fact he truly meant to emphasize that resuscitation would likely do more harm to her. As clinicians we can understand this, but approaching that conversation that the patient was not ready for caused a major setback in our progress with her. She became closed off and the trust we had been building had been damaged.
While these conversations are important to have, I agree with you that we have to approach this with empathy and a collaborative mindset, meeting each of our patients where they are at. It certainly becomes more difficult when we are limited by time and conversations become more urgent, but we should do our best to build those relationships and partner with our patients and their loved ones in these difficult situations.
This prompt led me to consider how my group’s Service-Learning Project went during our pre-clinical years. For the most part, I was satisfied by our results and believed that we positively impacted the community by offering xylazine wound care kits. I feel like we gave our services in a space of need. However, the follow-up was less satisfying than the project itself. We had attached surveys, including links and QR codes, to the kits themselves and asked the people receiving them to fill them out if possible. We were hoping to assess the effectiveness of the kits and to improve them for future use. By the time we began our analysis, we found that the survey had received zero responses. While all of the kits had been distributed, we had no way of knowing whether they were helpful or even used to begin with. This was disappointing and frustrating, especially with all that had gone into detailing the kits and deciding what could be most useful.
I believe that I responded with frustration because we had gone into the project with clear goals and quality improvement in mind. By not receiving any feedback, I felt lost, ineffective, and questioned whether the kits had been helpful in the way we intended. To better contextualize my feelings, I had to understand why people may not have given the feedback. The people using the kits may not have had access to phones or the internet, they may not have remembered the survey, and it may have taken time they simply didn’t have or didn’t want to spend. All of these reasons are completely understandable, and I know the kits could very well have been useful to the people who requested them.
With this experience, I have taken away that not all advocacy will achieve its goals as written. People and communities are complicated and will not follow the instructions or guidelines of quality improvement. There should always be the structure for these large projects, but also the understanding that people are independent and fluid. Instead, I need to focus on the benefit the community itself.
I think you make a really great point! We develop these quality improvement projects and collect all the data for the communities we’re serving, but it can be easy to lose sight of that when we get really focused on outcomes. It’s important to remember the point of why we’re doing it in the first place. Easier said than done though! And I certainly agree it can be frustrating to not see the results of your hard work, or to not even know if it paid off. I think medical students are particularly susceptible to becoming too outcome driven; we are used to always having grades and evaluations as metrics of our effort. And you’re definitely right about people being independent – I would guess that a lot of underserved communities are even less likely to respond to surveys than average. As you said, many of them may have reduced access to resources or may be too busy.
A situation in which I wish I had advocated for a patient occurred while I was on my IM AI. The patient came to our service from the ICU, where he had been for over a month. He was initially hospitalized for complications during a surgery, and went on to develop post-op ileus and then pneumonia with ARDS. By the time he came to us the ileus and pneumonia had resolved. He was still very weak, but medically there no reason for him to stay in the hospital; it was determined that he should go to a rehab facility where he could work more with PT. You’d think that after so much time in the hospital, he would have been overjoyed to leave. However, it soon became clear that this was not the case. He seemed very reluctant to pick a facility, and then began to express doubts as to the care he would receive there. However, the attending decided that it was time for him to go, thinking that he was just a bit nervous and needed a little push. Later that day, the team was notified that our patient was back in the ED. During the ride to the facility, he’d had a panic attack and the ambulance returned to the hospital.
Thinking back on this patient, I realized that this might not have happened if someone had sat down to talk with him about what he was going through. He was not my patient, so I never felt like it was my place to say anything; however, the intern was very busy and never ended up having time to do it. This patient had gone through so much in the past month, and his health would never be what it was before. We all noticed on rounds that he seemed depressed. He had been offered psychological services during his hospitalization and had always declined, but no one had ever tried to find out why. We had no idea what was going on inside his head. He certainly could have benefited from mental health support, and if we knew why he was reluctant it’s possible we could have found something he was willing to try. I let my fear of overstepping keep me from speaking up or talking with him in a way that might have saved him from yet another negative experience. I learned that in the future, I shouldn’t let anything stop me from advocating for patients because their health and wellbeing is far more important than my pride.
I definitely agree with your feeling of wanting to step in but not feeling that it’s appropriate as a student and/or if it’s not your patient. I really resonate with your reflection of considering the mental health aspect of patients and feeling like it can be overlooked at times. That is something I have found difficult to navigate in medicine, and something I hope to advocate for with my patients as a resident. We need more of it!
Wow! That is really tough, especially as a medical student and with a patient who is not yours. What I learned from this is that we should also advocate for patients, including ones that may not be our own. This can be difficult as a medical student because the person with seniority is the one managing that patient, and medicine emphasizes a hierarchy. This is what can make advocating for patients at times even more difficult as a medical student or in medicine in general.
On the flip side, our seniors tend to be much busier than us and, of course, carry many more patients, as you mentioned. Stepping aside to talk to the intern/senior to ask how we can advocate is a great middle ground.
I had a patient on my family medicine AI that thinking back, I wish I would have advocated for more. He was a middle-aged male with uncontrolled hypertension, diabetes, and severe renal disease on dialysis. He had very frequent hospitalizations for similar presentations. The first time I met him, I was on night shift doing his admission as a step down from the ICU where he’d been managed for severe volume overload and possible pneumonia. In that conversation, he expressed fears to me about declining health and wanting to be there to raise his son. He also shared that he was very inconsistent in taking his medications at home. We had some discussion about why that might be but didn’t come up with a good solution. He was soon after discharged by the day team but represented less than a day later. I was back on days and did his readmission, again presenting for similar symptoms. I continued to try to come up with ways to decrease his hospitalization rate and to improve his medication adherence at home, even bringing up whether we could get him home nursing to assist with medication preparation. I remember the team agreed that it might be good for him but from our conversations, I got the impression that they didn’t think things would change and he’d continue to be readmitted. At that time, he was already close to discharging to inpatient rehab, and setting up home care was never pursued.
My rotation ended shortly after that, but I have continued to think about him frequently. I was glad to see him go to rehab where he might get stronger and where I hoped he may get connected with resources to help him moving forward, but part of me felt I hadn’t done my best to advocate for him. I continue to wonder about where he is now and if he has continued to struggle with medication adherence and managing his health conditions on his own. I don’t know that we could have gotten him approved for help at home and I can’t know if it would have helped, but I do look back on those conversations and last days during his admission and wish I would have brought it up again and pushed to actively pursue it and try to take more time to figure out a solution for him. I think as a medical student, even as an AI, it’s sometimes hard to voice these types of things even if you think it’s in the best interest of the patient, and it’s easy to follow the lead of your seniors and team. Caring for this patient and reflecting on his case afterward gave me confidence to be more vocal and proactive if I encounter something similar during the rest of my training.
I appreciate your honesty about your multiple interactions with this patient. It sounds like you did your best to advocate for an individual in a difficult situation. Did you have any specific ideas about how you could have been a better advocate for him?
It sounds like you did a pretty good job of making your concerns known to the team. It can be difficult when there are both patient-driven and system-wide factors at play creating a challenging clinical environment. Sometimes no matter how much good you do while in the hospital, when the patient is discharged, it’s up to him and his primary team to ensure he stays well. You could have had a perfect plan and advocated for him perfectly, and it still might not have helped. On the other hand, the patient probably really appreciated how much effort you put into his care while you were on service. Whether or not you perceive you made a difference in his care or his outcomes, you almost certainly made his hospital stay more tolerable, especially as he was dealing with serious health complications.
A bit different from other posts regarding advocacy, but a time when I chose not to engage in advocacy but wished I would have is relating to volunteer work with NAMI (National Alliance on Mental Illness). I was initially introduced to NAMI during my M1 year, and was interested in participating as a volunteer for “Ending the Silence”. This is a project that focuses on ending the stigma of mental illness by discussing difficult topics surrounding mental health with adults and adolescents. This felt like a unique experience because it was an opportunity for me to go directly into the community and encourage others who may have/know someone struggling with their mental health. This volunteer opportunity would also open the door for me to volunteer for NAMIWalks, which is an annual walk to raise awareness and money to support mental health services. At the time, I saw this as a way to advocate for the community and future patients I may see with mental illness, but I was nervous at the time to participate and also wanted to focus on my studies during M1.
I responded this way because sharing details of mental health with strangers is incredibly vulnerable, and I wasn’t sure if I was ready to do so, even though I felt a pull to. I was also worried about the transition to M1 and didn’t want to take on too many things at once. Volunteering for NAMI felt important for me because I wanted to be a source of encouragement for adolescents and adults who may be struggling. In the community, minimizing the stigma of mental health is incredibly important so others can feel empowered to seek help. Ultimately, it fell to the back of my mind until I encountered NAMI again during my M3 psych rotation. I wouldn’t say the outcome was “bad” at the time, but I didn’t impact as many people as I could have if I started during M1.
Once I was reintroduced to NAMI during M3, I made the decision to volunteer and advocate for those struggling with their mental health. It made me realize that I could have impacted a lot more people if I had taken the opportunity earlier, however I was still proud of myself for pursuing it during M3. Wherever I end up for residency, I hope to continue volunteering for NAMI in that region.
A time that I remember, I wish that I had advocated earlier, actually involves a story with a loved one who was ill. My grandmother would come from Sierra Leone every summer for her annual health checkup. When the Ebola epidemic happened, she could no longer make it. By the time she was able to come to the U.S., her health was in much worse shape. She had nonspecific symptoms and weeks to months of workup to eventually diagnose her. She had a rare form of GI cancer and passed shortly after. Even though I was a teenager, I wish there were moments within her care that I did advocate for her. She unfortunately suffered from a stroke after surgery, and I never really truly understood what went wrong. Now, being a medical student, I understand that there may have been steps along the way that were missed and I can better understand the nuance of the situtation. Was she properly anticoagulated, etc? I really only started to understand this due more recently to my new medical knoweledge and experience gained in the hospital, but of course I did not know nearly as much as a teenager.
Many patients or their families may not have the medical knowledge or health literacy in order to best advocate for themself or their loved ones. Because of this experience that I had growing up, I really value when patient’s and their families ask a ton of questions in an effort to best understand their care. This experience has helped me to really empathize with families, even when they may appear frustrated or upset, I can understand where they are coming from and try my best to assist them in advocating for their loved one.
Thank you so much for sharing this Mariama, this is such a sensitive and emotional experience and so admirable that you wish to encourage others to ask questions as you wish you had in the past. It is so difficult to lose a loved one and in hindsight think of questions or ways to advocate. You did an incredible job then and continue to do so now! In regards to advocating for your patients, I think that just remembering and reflecting on this sentiment in of itself is powerful. You recall what you wish would have been done, and take that into your daily practice, to ensure others have information and opportunities to share their concerns. I think sometimes even just sitting with families, in moments of confusion or anger, and allowing them to vent their concerns sometimes brings up necessary questions. I love that role as a medical student specifically, because we have the time to ask questions and garner a stronger history for these patients that better paints the picture of why they are in the hospital and what they better need. Overall, my takeaway from your story is to think through a case with empathy, not just for the patient’s medical needs, but also connecting all the pieces of their life and story and how that contributes to the entire treatment plan.
I was working a night shift in the rural emergency department at Adams County Hospital when paramedics brought in an 18-month-old girl after a 25-minute generalized tonic-clonic seizure while she was in her grandparents’ care. EMS had given her Versed en route, which appeared to break the seizure. She’d had a fever earlier that day, so the team’s working assumption was a febrile seizure, though we had our doubts that a febrile seizure would last 25 minutes.
On arrival, she was minimally responsive. Both my attending and I attributed this to a post-ictal state compounded by a heavy dose of benzos. In retrospect, she probably should have been intubated at that point, given how minimally responsive she was and that she required a non-rebreather mask. Her initial neuro exam was reassuring in the sense that she was no longer actively seizing, or at least it appeared that way.
After thirty to forty-five minutes with no resolution of her post-ictal state, continued non-responsiveness, and non purposeful eye movements, I started to worry about non-convulsive status. I wanted to follow the status protocol I’d just learned on my neurology rotation: another benzo and likely an anti-epileptic like Keppra. My attending wasn’t as convinced, though he was already considering transferring her to Children’s, and he wanted to get as much of a workup done as possible while she was still with us.
When she came back from a non-contrast head CT, I re-evaluated her. By then it had been over two hours since arrival, and she still hadn’t regained purposeful movement. Her pupils were unequal and nonreactive. What her parents and grandparents had been interpreting as intermittent purposeful movement of her arms and legs for the past hour was likely posturing (flexing elbows and pointing toes) from continued seizure activity. I called in the attending immediately. He agreed she needed to be transported to Children’s right away and that she needed more aggressive treatment.
While doing a head-to-toe exam to find the source of her fever, we found what we believe was the actual nidus of infection. Her parents had removed her earrings two weeks earlier and lost the plastic backing to the left one. They’d noticed an indurated, raised lesion on the back of her earlobe and had her primary care provider look at it, who told them it was a keloid scar. When we pressed on it, the plastic piece came out.
The family (both sets of grandparents and parents were present) was terrified. To be honest, I was terrified. I saw my nine month old in that patient, and my heart broke for the family. I wanted to do so much more, but I couldn’t.
Ultimately, the outcome was mixed. She did get transferred to Children’s and treated more aggressively, and my re-evaluation was what triggered that shift. But two hours passed between when I first raised a concern and when the picture became undeniable, two hours during which a child was likely in non-convulsive status. I don’t know what the counterfactual outcome would have been with earlier treatment, and I probably never will. That uncertainty is part of what makes this case stick with me.
Going forward, I want to bring two things into my next opportunity to advocate. The first is learning to state my clinical concern with more specificity and more insistence the first time, rather than offering it and then deferring when I meet resistance — something like naming the specific finding I’m worried about and the specific harm of waiting, rather than a general “I think we should treat.” The second is recognizing that as a student, my job isn’t just to have the right instinct; it’s to make sure that instinct doesn’t get lost in the hierarchy of the room, especially in a rural setting where the next specialist might be an hour away.
This prompt is such a challenging and interesting one to me. Advocacy can mean so many different things its really hard to pinpoint specific experiences. I spent a lot of time trying to think of individuals in the hospital I advocated for, but in the ED, every patient I talk to my attending about I’m advocating for in a way. Even before clinicals, one experience comes to mind. On a walk to class, I was confronted by a woman who appeared to be unhoused who would regularly come up to classmates and me asking for help. A few of those times, I brushed her off with an “I don’t have any money” or “I can’t help” (a partial truth). One day I thought “we are at a big institution, surely there is something we can do to help her, regardless of her circumstances, regardless of what end she’s seeking” so as an M1 I very innocently emailed Dr. Kiessler, my trusted advocacy faculty, about her. He emailed back some resources that might help her and ultimately said we can’t do much beyond give her this information. She had some kind of smart phone which I could contact her on, and ended up making her a little care basket of food, gave her some resources, and wished her well. I saw her walking around UCCOM for about a year later and would say hi, but our conversations remained similar to the first one we had. I haven’t seen her in a while, but I hope she’s doing well. Ultimately, my biggest reflections here are about the limits of individual advocacy. If the system is failing people, the system needs to change. I don’t know what circumstances left her hungry and asking for help, but I couldn’t help but feel she slipped through a crack somewhere (Step 2 Swiss Cheese Model and all that). I also think of the phrase “you can lead a horse to water, but you can’t make them drink”. Even if there were perfect systems for this woman, if she didn’t want to take that step to ask for help, she wouldn’t get any. There is still a large degree of human choice that influences the lives of people we interact with, patients and otherwise. I think my job isn’t to “fix” anyone so much as it is to try my best to use my resources and help create environments where they can heal and grow. I don’t know what my ultimate responsibility as a 22yo M1 was to this woman, but it felt like the responsibility I have to my patients now, and to anyone I meet who is suffering. I can’t place exactly what that responsibility is, but my conscious wouldn’t let me sit in inaction and maybe that is what the heart of advocacy is: recognizing that you might be able to do something in a situation of need, and trying your best to mobilize your talents and abilities toward resolution.
Hi Laura, this was an incredibly kind thing you did! I hope she is doing well. I also have been struggling recently with individual vs systematic advocacy. I feel like much of the advocacy I have been doing as a medical student is on the individual/patient level. It is easy to see the pattern of systematic disparities affecting these patients. I know that advocating for individual patients does make a difference… but the disparities and struggles will continue to affect others until we identify and implement systemic changes that can help proactively. The question now is how I plan to use “talents and abilities” at a systemic level.
During M4, I’ve had the opportunity to rotate through many unique settings where childhood health disparities are at the forefront, including the Juvenile detention clinic, CHECK (foster care) clinic, and the Mayerson Center (Child Abuse). The way the physicians in these settings advocate for each of their patients every day is so inspiring.
In these last few months, I have encountered – more than I ever have- children and families who were hurt by the systems we have in place in state/country. Experiences and continued disparities that affect the trajectory of their lives. I have been reflecting; I know I can do my part and provide resources to those I encounter, but this doesn’t change their already lived experiences. There will also be countless others that I won’t have the opportunity to help – and who might not interface with healthcare in general. To increase the impact of my advocacy, I feel that the next step is to start advocating for children and families at a systematic level – especially in regards to poverty. I am unsure where/how I will start, whether I can identify any local organizations to join and devoting time to better understand the legislation in place. I have a sense of guilt and regret about not having done this sooner. “What have I done that actually made a difference?” But I have to remind myself that advocating for individual patients, and being a good listener, can make a huge difference in a life.
I experienced an amazing example of individual-turned-system advocacy at Juvenile detention clinic with Dr. Johnson. There was a patient who was left in restraint chair for 6+ hours and subsequently developed rhabdomyolysis. Dr. Johnson learned about this after the fact and identified many moments of system protocol failures that led to this unjust and dangerous event to occur. She set up meetings with higher-ups to implement changes to the restraint protocol to try to prevent this from occurring again. She told me “Theres always one person who initiates changes for everyone”.
It will be my goal going forward to develop the skills to “initiate changes for everyone”.
A time during medical school when I engaged in advocacy was during my psychiatry rotation. I was on an inpatient floor that commonly housed patients that were acutely psychotic and court dates were a regular occurrence for forced hospitalization and forced treatment. One patient was admitted because she came into the ER acutely manic with psychotic symptoms. The problem was, on top of her psychiatric symptoms, she also reported a rape which was the reason she went to the ER in the first place. A police report was filed, and a SANE exam was done, but the team had no knowledge of any information beyond that. My attending and resident were not even sure if the assault truly happened or if it was a symptom of her psychosis. When we went to interview her on rounds, she wanted updates on the investigation and was insistent that she should be able to go home; in her eyes, she sought help after being victimized and now was being locked up against her will. It was painful to listen to her plead with the attending to believe her. I didn’t know the truth of the situation, but I could tell the attending was pretty certain it was all a part of her psychosis and more importantly, she could sense it too. Then she turned to me, the only other woman in the room, begging to be understood. I felt stuck. If this was a delusion, I didn’t want to make things worse, but I also couldn’t let her just believe I thought she was lying or making things up. That already happens to people even when they aren’t psychotic. So, I threaded a careful line. I made sure to emphasize that I believed she was telling her truth, that her experiences are real to her, and that we only want to help her get healthy again. I couldn’t help but think about the fact that statistically, the chances she was raped were pretty high and I didn’t feel comfortable dismissing that just because of her psychiatric history. I didn’t lie or go against my attending, I didn’t make any promises I couldn’t keep, but I did make her feel heard. The team later applauded the way I handled the situation. And better yet, the next time she saw me her whole demeaner changed and she had the biggest smile on her face. I think there a lot of different issues at play in a situation like this that go beyond our medical system, and my ability to actually fix anything was limited. But at the very least, I helped her feel supported and helped her trust we were on her side.
I really appreciated your reflection on this situation, especially how you described the difficulty of balancing the possibility of psychosis with the possibility that the assault truly occurred. I think you did a great job recognizing that advocating for a patient does not always mean changing the outcome, but sometimes simply making sure they feel heard and supported. Your point about how easily psychiatric diagnoses can cause someone’s concerns to be dismissed was especially powerful. It also stood out to me that you were able to advocate for her without undermining your attending or making promises you could not keep. This is a great example of how small actions and communication can make a meaningful difference in a patient’s trust and experience with the healthcare system.