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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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. 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.” 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.