Demystifying Medicine One Month at a Time

Doctors & Advocacy

When I made the choice to be a doctor at a medical school I wasn’t sure exactly what ramifications (beside teaching the next generations of doctors) my job would have.

It became clear to me after a year that being an academic afforded me many privileges: of course, mentoring and teaching relationships, but also the security of letting a big institution worry about the business aspects of my practice (marketing, billing, and even malpractice insurance). Most prized of all was the ephemeral “academic” time, amount varying by year and commitments, that affords me the time to be creative (research, course design, teaching) or simply to catch up on amassed work. Something clicked and made me realize that this was a luxury that academics have that private practice doctors don’t necessarily get; and thus I reached a personal conclusion that we have an obligation to go beyond our mere doctoring (not taking that for granted) to work on some of the societal problems that underpin poor health.

I shared this opinion in a newsletter for the Society of General Internal Medicine, an academic society of doctors doing research, teaching and advocacy at our nation’s medical schools.

One doctor felt compelled to write a rebuttal, telling me, in essence, that physicians (academic or otherwise) have no special role in society beyond taking care of patients; that my idealistic notions of physician advocacy were overblown.

Read the essay below and let me know what you think:

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What are the societal obligations of a doctor?

Academic physicians have the privileges of caring for patients, training future doctors, and engaging in research.  But what is our obligation with regard to advocacy?  Are we required to become advocates, or can we declare, on the basis of our other missions, that we “give at the office?”  Since our academic homes are by and large non-profit institutions that provide under-reimbursed and uncompensated care, is it legitimate to claim that we contribute just by showing up?

To a large extent, advocacy is a natural outgrowth of our daily work, whether on behalf of a patient, a resident, a student, or for the benefit of our own research and careers.  Many of us become advocates through what amounts to happenstance—we are presented with a situation that seems obviously wrong—and we become engaged in finding solutions.  Others of us enter medicine with advocacy passions, though given the long training process, it can take us time to find our “faculty” voice.  A few of us, I suspect, having achieved faculty status, don’t want to rock the boat too much and risk jeopardizing what we have achieved.

I suggest that we have reached a watershed moment:  The new administration in Washington marks a generational shift and will provide opportunities to participate and advocate in new and intensive ways.  No group is better situated to engage in the shifting landscape than academic physicians, particularly those of us that practice in primary care fields.  Ensconced (at least partially) in our ivory towers, we are freer than most of our non-academic colleagues to use our status (and the fact that we are salaried) to engage in issues.  And since we train the next generation of doctors, it becomes all the more vital to role model physician advocacy as a core component of not only doctoring but of citizenship.

For eight years, ending in 2007, there existed a single fellowship in physician advocacy.  First offered by the Open Society Institute, and later housed at Columbia’s Institute on Medicine as a Profession (IMAP), fellowship recipients received 50% salary support for two years in order to free up time from clinical duties to work on an advocacy project.  Goals of the fellowship included requiring recipients to partner with an advocacy organization to develop or further an existing project; building skills in messaging and media; and learning the arts of lobbying and developing legislation.

One crucial component of the program was to build a community of physician advocates from around the country who could network and strategize using their different backgrounds and varied interests to help each other overcome obstacles in their work.  Over the eight years of the program, there were 44 fellows, at least six of them (by my count) current SGIM members.

Assuming that the program ended for budgetary reasons given the current fiscal climate of the nation, I asked IMAP President David Rothman to shed light on why the fellowship program was terminated.  In an email, he replied, “It was not funding as such…but time for a new emphasis…” on trainees rather than mid-career physicians.  IMAP now offers renewable program awards to medical schools and/or residency programs willing to develop clinical rotations for underserved patients that include significant devoted time for learning about and engaging in advocacy.[1] The overarching goal is to reach a “tipping point” for our profession, in which advocacy becomes a professionally normative behavior.

What does the data show with regard to our attitudes on advocacy?  The most cited study shows that a broad consensus of physicians, whether generalists or specialists, believe in the idea that we have an obligation to help our patients directly and, furthermore, to carry some sort of “public role.”[2] Beyond that, physicians seem less likely to be directly engaged in political activity by self report but to believe that behaviors that underpin poor health (i.e. tobacco, nutrition, etc.) are fair game for advocacy.

My own conclusion is that there has never been a more urgent time for us to make our voices heard as advocates—individually and collectively—whether for health care reform, federal research funding, human rights, or even the very survival of general medicine as both a discrete field and as a business enterprise.

As academics, we have long had the privilege of fora in which to generate and develop our ideas.  We benefit from a community of colleagues and a society that permits opportunities to test our ideas and collaborate on projects across institutions and around the country.   Our faculty status makes it incumbent upon us to take the lead in making advocacy a normative part of our professional lives.

Just this morning, SGIM advocacy emailed me to urge me to reach out to my Senators and to remind them of the importance of Title VII funding.  With a few clicks of a computer mouse, I will have used my status to advocate on behalf of something crucial to my both my institution and the future of our profession.  It makes an easy starting point.


References

1.     http://www.imapny.org/education/

2.     Gruen, RL et al, Public Roles of US Physicians: Community Participation, Political Involvement, and Collective Advocacy, JAMA 2006;296(20):2467-2475.

7 Comments

  1. David Rubin

    John,

    Thank you for sharing this piece. I happen to agree with you that we have an obligation to advocate for the health of the community, but I don’t think that academic physicians are any more or less obligated than our community based colleagues.

    However, as you know, just as the choice of specialty and type of career varies greatly, so too does an invidual’s sense of belonging to the greater whole we define as “community.” I know of multiple private practice physicians who are more generous with their time and money than many of my academic colleagues.

    At the University of Chicago, we have our own foundation that raises money for gastrointestinal research. Grateful patients have been extremely generous in their support of our mission. I have always contended that all of the faculty should likewise support the foundation and demonstrate that we are all in this together – both to show that we “put our money where our mouth is” and that we demosntrate our solidarity with the patients and set an example for our trainees. As a young(er) faculty member, I suggested this to our faculty and was sharply rebutted. “Academic faculty don’t make private physician salaries, after all.” As I am sure you agree, it has nothing to do with the amounts but the action itself. This sentiment voiced by one of our senior faculty didn’t change my opinion at all, but it did remind me about how differently some colleagues think about this issue.

    When it comes to public advocacy in the form of government policy, I honestly believe that if more of our colleagues understood that they can really make a difference, they would do so. However, part of what I have personally witnessed, both as a temporary representative to the AMA for one of our GI societies, as well as in my visits to Washington to meet with legislators (or more often, their very young staff members), is that the system is so bloated and complicated and so affected by politics and individual missions, it literally feels like you are “spitting in the ocean.”

    These realities don’t change the need for advocacy, but perhaps for many of our colleagues it occurs in smaller ways with individual patients every day of the week. Fighting insurance policy to get your patient the medication they need, writing a letter to secure disability or FMLA benefits, and being available to their family members when they need additional explanations and support are all ways that most physicians perform their jobs every day. We all can do more, but for each physician the “more” is different, but probably just as meaningful to them and to their patients.

    David

    • glasshospital

      I do agree that it’s the action itself, not the amount. The Obama campaign demonstrated the astounding power of collective action, even with very small donations.

      I also agree that for many colleagues it’s the individual advocacy that matters and makes them feel like what they’re doing is a social good. But I’m challenging the academic docs to go beyond that “give at the office” only mentality and reach into the advocacy spheres that you enumerate.

      My very brief forays into local and Washington political arenas have shown me that though the game is complex, doctors get an audience and our words do matter.

      Thanks so much for reading and for your comments.

  2. joe marlin

    I concur with John and thought David’s comments are quite to the point about advocating for individual patients. I recall reading a recent article (where?) reporting on a research effort which indicated many doctors do not ascertain why or to what degree patients may not follow medical recommendations re future care, presecription use. etc. This is also a type of advocacy as is knowing where and when and how to make appropriate referrals to other who can advocate for the patient.

  3. RobH

    John,

    I appreciate the sentiment that academic physicians should use their “status” to influence matters of public concern about which they have some expertise or special understanding. David points out that it’s not clear that academic physicians are any better positioned than those in private practice to do so. I would add that something else is missing missing from the idea — that (academic) physicians have a professional obligation to participate in public advocacy — you are presenting. What is it about the medical profession that distinguishes it from others? Are you suggesting that doctors have a unique obligation to participate in advocacy different from other professions? And academic doctors have an obligation to participate in public advocacy different from others who enjoy the benefits of public subsidies or support? Are you distinguishing physicians from other citizens, or advocating a robust form of citizen-advocacy, and arguing that physicians are citizens too?

    As David points out, advocacy that amounts to “spitting in the ocean” is not a very effective use of one’s time and skill. Your response to David suggests that all physicians have the ability to be effective advocates. Such an assertion cries out for further explanation. Is there something in the training or backgrounds of (academic) physicians to support your view that, as a class, they are likely to be effective advocates? And isn’t the point of “advocacy” to make the lives of as many people as possible better? Are you suggesting that the physician who concludes that, given her particular set of skills, the best way to make the lives of as many people as she can better is to be an excellent doctor for her patients, and to devote all of her time to meeting the needs of her patients, is somehow failing to meet her full professional obligations? Returning to the first point I raised, it is one thing to say that such a person is failing in her obligations as a citizen. It is quite another to say that she’s failing in her obligations as a doctor.

    Finally, you may wish to consider whether “advocacy” is the best use of the physician profession’s “status,” in light of the possibility that the result of entering the realm of political controversy may be nothing more than a change in the “status” of physicians in society, and not for the better. Is the “status” of the profession, and academics within the profession, important for some other purpose uniquely connected to the job of being a physician? If so, then rushing into activities that may squander that “status” may prove unwise.

    Rob

    • glasshospital

      I definitely am arguing that physicians are citizens, and that citizenship differs among doctors by practice arrangement. I am being intentionally self-righteous in challenging all academic docs to step outside our ivory towers at least a little to work to address the so-called social determinants of health care.

      As for the risk of squandering our “status” (whether righteously earned or reputationally attributed), I think it well worth it. There are many prominent examples, including Jack Geiger, Paul Farmer, Fitzhugh Mullan, Steve Miles, Barry Zuckerman, even old Leon Kass, just to name a few.

  4. Kohar Jones

    Hear hear for physician advocacy!
    And I think it’s great to encourage students to engage in civic society, at the same time they are beginning to define their roles as doctors.
    Teaching on the family medicine clerkship, I find many students shaken by the psychosocial needs of the patients they meet on their monthlong rotation. “What can I do?” they ask themselves. As students, they are learning the one-on-one dynamics of the doctor-patient relationship. They want to meet their patients’ health needs (the role of the doctor). They see lack of housing, lack of insurance, poor education, no jobs–the social determinants of health–and they feel overwhelmed in the 15 minute doctor-patient encounter.
    Reminding them that they are citizens of a democracy as well as doctors, and can participate in the debates that shape policies that shape the determinants of their patients’ health seems to relieve their feelings of helplessness in the face of needs that go far beyond the boundaries of the clinic room.
    Every doctor finds their own balance between direct patient care, and caring for their patient population.

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