63 Advocacy Given 12 to propose the following 2 necessary. In this article, astoward first building steps a model for competency-based physician advocacy training and delineating physician advocacy in common practice, the authors propose a definition and,the using biographies of actual physician advocates, describe the spectrum of physician advocacy. definition of physician advocacy: Action by a physician to promote thoseeconomic, social, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies throughher his professional or work and expertise. requires working to address the rootof causes the problems they face. Nevertheless,physicians’ all obligations to advocacy are grounded in their professional experience and expertise and their duty topatients. their Each physician’s obligation to advocacy must also include a recognitionthe of limits of his or herexpect expertise an (e.g., adult to ophthalmologist to advocate children’s oral health needs is unreasonable). We therefore build on the AMA’s endorsement their social standing, physicians enjoy an unusual degree of access to policy makers, to local and national leaders,to and citizens; thus, they possess a great deal Physicians’ Unique Capacity for Advocacy and the BarriersMay That Keep Them From It Physicians are uniquely positioned to function as public advocates for health. They understand the medical aspects of issues better than any sector ofand society, they are poised to observedelineate and the links between social factors and health. Public trust of physiciansvery is high; to the public, doctorscredible are source a of information. Acad Med. 2010; 85:63–67. Others 11 and the Accreditation 11 9,10 programs must deliberately train physicians as advocates. Accrediting bodies must clearly define advocacy competencies, and all physicians must meet them at some basicSustaining level. and fostering physician advocacy will require modest changesboth to undergraduate and graduate medical education. Developing advocacy training and practice opportunities for practicing physicians will also be responsibilities, Defining Physician Advocacy Physicians are well acquainted with their roles as advocates for the individual . Most, if not all physicians,taken have extra steps to ensure areceives patient a needed service. Physicians consider advocacy for an individual an accepted component of ethical practice, yet this alone does not meetrequirement the for “public advocacy on the part of each physician.” Advocacy, according to this broader perspective, requires more than helping individual get the services they need; it Despite widespread acceptance of a physician’s duty to advocate, the concept remains problematic because it remains undefined. Although the Pediatric RRC requires advocacy training, the committee does not define physician advocacy, nor does it delineate itsor scope describe its competencies. who have called for professional advocacy have likewise gone no further. Inarticle, this we propose a definition and describe the spectrum of physician advocacy as first steps toward buildingmodel a for competency-based physician advocacy training and delineating advocacy in common practice. Council for Graduate Medical Education (ACGME) Pediatrics Residency Review Committee (RRC) now requires advocacy training and experience for all pediatric residents. 2 Physician Advocacy: What Is It and ; several specialty 3–8 Theirs was not an isolated is assistant professor of pediatrics, 1 is associate professor, Department of is associate professor of pediatrics,

n 2002 the American Board of Internal Academic Medicine, Vol. 85, No. 1 / January 2010 Dr. Federico Dr. Wong University of Colorado Denver SchoolAurora, of Colorado, Medicine, director of school-basedcenters, health Denver Health and ,Colorado, Denver, and physician advocacy fellow,for Institute Medicine as a Profession. Correspondence should be addressed toCampus Dr. Box Earnest, B180, 12631 E.80045; 17th telephone: Ave., (303) Aurora, 724-2248; CO fax:2270; (303) e-mail: 724- [email protected]. codirector, LEADS (Leadership Education Advocacy Development Scholarship) Program, and directormedical of student education in pediatrics,Colorado University Denver of School of Medicine,Colorado. Aurora, Dr. Earnest Medicine, codirector, LEADS (Leadership Education Advocacy Development Scholarship) Program, and director of interprofessional education, UniversityColorado of Denver School of Medicine,Colorado. Aurora, societies now include advocacy in their definitions of professional Numerous authors have also argued for the importance of public physician advocacy and its place in medical professionalism I Abstract Many medical authors and organizations have called for physician advocacycore as component a of medical professionalism. Despite widespread acceptance of advocacy as aobligation, professional the concept remains problematic within the profession of medicine because it remains undefinedconcept, in scope, and practice. Ifis advocacy to be a professionalmedical imperative, schools then and graduate education How Do We DoMark It? A. Earnest, MD, PhD, Shale L. Wong, MD, MSPH, and Steven G. Federico, MD Perspective: Medicine, in its charter on medical professionalism, called for a “commitment to the promotion of public health and preventive medicine, as wellpublic as advocacy on the part ofphysician.” each entreaty. The American Medical Association (AMA) endorses a similar commitment: Physicians must “advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”

Downloaded from http://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/14/2020 Downloaded from http://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/14/2020 Advocacy of leverage in influencing public those with more junior status, away from Parent education: School board advisor processes and priorities. these activities; the culture of medicine Dr. B recognized an extraordinary rate of and “hard” science may be the culprit as obesity among his school-aged patients Although physicians seem to endorse the well. Few randomized controlled trials while practicing in rural Washington. idea of civic engagement as a professional have tested community health After discussing the issue with several 13,14 responsibility, there is less evidence interventions—much less public policy— families, he concluded that a contributing that physicians engage in these activities. and public decision making may often factor was the poor food choices found The limited evidence available shows that seem a chaotic and ill-informed process. within the local schools. He decided to physicians are more likely to engage Even our grammatical preferences may bring the issue before the local school policy makers on issues affecting their hold a clue here; perhaps a culture that so board, requesting action on the children’s 7,15–18 own economic well-being and that, stubbornly clings to passive-voice-verb behalf. School board members agreed on the most basic measure of civic construction is simply averse to the with Dr. B and felt empowered by his involvement, that is, voting, doctors vote proactive, declarative nature of advocacy. medical expertise to take action. They less often than other professions or the Despite these barriers, doctors do engage encouraged Dr. B to become a member of even public at large.19 Others have in advocacy, and many are very effective the board to follow this project to observed that often a discrepancy exists in that role. Their real-life examples best completion. On the basis of his between the professional values demonstrate the broad range of physician commitment to these children, he agreed. physicians endorse and the behaviors His advocacy successfully effected 14 advocacy. they demonstrate. changes in nutrition policy in the schools.

Little empiric evidence exists to explain The Spectrum of Physician Policy advocate: Coalition building and why physicians have not more fully Advocacy leadership embraced the role of advocate. A number Medical society affiliation: State health of hypotheses might explain it. The gap Dr. L is a pediatrician who oversees a care reform between endorsing and engaging in nonprofit practice. He cares for a largely advocacy may be illusory; because the Dr. L became increasingly concerned uninsured and underinsured population. attitudes cited are socially desirable, about the lack of Frustrated by the lack of insurance for physicians may endorse them in polls coverage available for his patients and the kids and the lack of action on the part of without holding them very deeply. Maybe growing systemic inefficiencies in health policy makers, he worked to build a the admissions process for medical care that he saw eroding access to and coalition focused on expanding access to schools favors academic success to a quality in health care. At a meeting of his health insurance. He helped to organize a degree that admissions committees admit state medical society he stood up, voiced statewide coalition of 40 organizations too few service-oriented students. his concerns, and made a motion that the interested in expanding health insurance Medical training, which is long, intense, members move comprehensive health coverage to all children. Dr. L uses his and isolating, largely removes physicians care reform to the top of their agenda. experience as a clinician to “tell the story” from the community while they attain His action redirected the meeting; 90% of of why more kids need coverage. The clinical competence; perhaps these the membership voted to suspend the collective advocacy and political capital of severed ties are too difficult to rebuild. planned agenda and take up his question. this newly formed coalition have Maybe the contrast between the When the medical society convened its effectively moved policy makers at a state competence and control physicians feel Physician’s Congress on Health Reform, level. Over the course of three years, the in a clinical setting and the uncertainty he joined, and he has since contributed to coalition outlined the necessary steps to and ambiguity they experience in an the processes of health care cover all children in the state, and the advocacy role is too stark for most to improvement. The medical society is now members have, to date, successfully overcome. Physicians have busy, providing leadership and advocating worked to pass several pieces of demanding clinical lives—perhaps their comprehensive health care reform at the legislation leading toward that goal. time is too scarce. Doctors are trained to state level, and Dr. L has taken a keep personal opinion and preferences leadership role in the process. Patient advocate: A health care advisor out of the clinical encounter; they address for a policy maker religion and politics at the bedside with Practice management: Coalition and When Dr. S learned of a bill pending in caution, if at all. Perhaps physicians tend board leadership the U.S. Senate that would adversely to generalize this soft, interpersonal Dr. K reorganized his practice so that he affect her patients, she called the office of clinical boundary and become reluctant could care for more uninsured patients. her U.S. senator and spoke to the to engage in the processes required for When the need grew so great that he was legislative aide who worked on health effective advocacy. As one observer turning away large numbers of patients, issues. The aide noted her concern and noted, leaving “the mountain of he began researching local groups that then asked her advice on another health- equipoise for the valley of advocacy” is were working to improve the plight of the related matter. Dr. S spent several difficult (John F. Steiner, MD, personal uninsured. He volunteered his time with minutes offering a thoughtful opinion communication, 2000). An advocate’s a statewide coalition working to bring and left her number with the aide, agenda may at times conflict with the about state health care reform. He offering to help in the future. Dr. S now priorities of institutions to which he or ultimately joined the organization’s meets quarterly with her U.S. senator and she must be accountable; fear of political board and became one of the group’s his legislative aide, and she has become a fallout may keep physicians, especially leaders. trusted advisor on health-related issues.

64 Academic Medicine, Vol. 85, No. 1 / January 2010 Advocacy

She uses the opportunity to advocate services and assist them in overcoming exceptional. For this to occur, solutions to the needs she sees in her barriers in accessing the services. This physicians and medical educators must practice and community. simple change dramatically improved become thoughtful and deliberate access to social services for the clinic’s about training advocates. If left to physician: Leader in injury patients and also led to the identification chance, the charge to serve as public prevention of a new layer of unmet patient needs. advocates rings hollow and will not be Dr. R was sickened by the number of Dr. W is now organizing a system to met. Furthermore, if advocacy is a emergency department visits of children facilitate legal referrals for patients to professional imperative, its suffering injuries related to falls from help them address many of the competencies must be well defined, and high-rise windows. She sought a small nonmedical barriers to health, such as all physicians must meet them at some grant to place window guards on housing and environmental risks. basic level—these competencies must apartment building windows in the not be relegated to a new specialty Physician advocates—Discussion surrounding neighborhood. When she called “advocacy.” Whereas a minority demonstrated the dramatic decrease in The examples above illustrate some of the of doctors practice cardiology, every injuries, the city council passed a law skills and competencies (e.g., identifying physician must understand the requiring protective guards on all high- a problem amenable to advocacy, circulatory system and its place in his rise windows. This initial effort led to a defining the problem and its scope, or her clinical area of expertise. So it national change in laws promoting injury identifying and engaging strategic should be with advocacy. prevention from falls. partners, developing a strategic action plan, communicating an effective What would medicine need to do to Patient advocate: Liaison to media and message) necessary for effective advocacy. achieve this? What would advocacy health reporter All of these physicians grounded their training look like? We believe that advocacy in their professional experience sustainably fostering physician advocacy Incensed by the injustice he saw in his and work life. Each sought and developed requires some modest changes to both daily care of patients without health critical strategic relationships that undergraduate and graduate medical insurance, Dr. M felt that change would leveraged his or her own expertise and education while also developing advocacy come only if the public, too, could see experience to achieve broader effect. In training goals and opportunities for what he saw. One particular patient’s these examples, the physicians all acted practicing physicians. story seemed to perfectly illustrate some locally—working with partners who of the problems faced by the uninsured. served their own communities and Historically, both undergraduate and With the patient’s permission, he institutions. None of these physicians graduate medical education have focused contacted a reporter who covered the changed jobs or moved. Most devoted purely on developing clinical story. Dr. M began gathering illustrative only a few hours a month to their competence. Advocacy training would stories and pitching them to media advocacy work. These examples illustrate require that training reliably occur in a outlets which then covered many of the the powerful effect physicians can have if broader context. Medical students and stories. He also wrote and published they, as collaborators and leaders, residents would gain a basic frequent opinion pieces, editorials, and strategically share their expertise with the understanding of the world beyond the letters to the editor on health matters. In community. They also illustrate the fact clinical encounter. Ideally, this would the process, he developed relationships that every physician has a contribution to begin in undergraduate courses with with the local media and advocacy make and that, in all likelihood, a place instruction in both the determinants of communities. He began coordinating his exists in the physician’s own community health and the production of health efforts with local health care advocates to where those contributions would be both from an ecological perspective. link media coverage with their policy- meaningful and welcome. Residents would develop competence in change and organizing efforts. He also the preventive and population health became an advisor on health matters to a While each of these examples illustrates perspectives that relate to their number of local reporters. an instance of effective physician specialty. Training in the theories and advocacy, each, to some degree, practices of both leadership and social Practice management: Reallocation of developed accidentally. None of these and organizational change would be resources individuals received special training to new areas for competency, but this Working in a hospital-based ambulatory take on these roles, and in many cases training would be closely related to care clinic, Dr. W recognized that the these physicians learned by trial and error training in systems-based practice. majority of her patients were not the processes required to be successful as Physicians-in-training would develop successfully accessing the social services advocates. Because of the current paucity the interpersonal and leadership skills they needed. When she voiced her of formal physician advocacy training, needed to work collaboratively in teams observations, her colleagues confirmed successful physician advocacy tends to be in order to participate in, develop, and her experience. Dr. W collected basic exceptional. lead groups and coalitions. They would information documenting the magnitude practice basic skills in developing and and impact of these unmet needs. She delivering clear messages and using the then proposed a redistribution of social Training Physician Advocates media effectively. Training in the work services within the hospital to If the profession of medicine considers processes of policy making within provide a full-time social worker to the advocacy a professional imperative, trainees’ own institutions as well as clinic who would direct patients to social then advocacy must cease to be institutions in the community and the

Academic Medicine, Vol. 85, No. 1 / January 2010 65 Advocacy government would also be necessary. as their highest priorities. They fund Open Society Institute, and the Center for Finally, students and residents would community-based organizations, and Medicine as a Profession for their support during need the opportunity to practice these many would welcome productive the time they developed and wrote this article. skills through service learning, and they partnerships between those organizations They would also like to extend their thanks to Dr. and the medical community, providing David Rothman for his early critique of the would also need to see their mentors concepts and to Dr. M. Douglas Jones for his effectively use and truly value these opportunities for funding and strategic reviews and comments on the manuscript. skills. partnerships. Funding/Support: While writing this paper, the The medical community itself could do authors were supported by the Colorado Health For training like this to develop and much more to foster advocacy as an Foundation, the Health Resources and Services thrive in academic medical centers, an expression of professionalism. Attorneys Administration, and the Center for Medicine as a infrastructure must be available to Profession (S.G.F.). have long recognized the importance of support it. Accrediting bodies like the pro bono work. Many law firms allow Other disclosures: None. Liaison Committee on Medical their members to devote hours to Ethical approval: Not applicable. Education and ACGME must endorse community service as part of their advocacy competencies as necessary practice. Medical practices could do the components of medical training. Just like same, encouraging their physicians to References any area of competence, some physicians offer their services as volunteers in the must devote a significant portion of their 1 ABIM Foundation; ACP-ASIM Foundation; community for a few hours each month. European Federation of Internal Medicine. time and effort to practicing the skills. Even small practices could afford this Medical professionalism in the new Campuses would need to develop level of investment. Larger, multispecialty millennium: A physician charter. Ann Intern stronger, more productive partnerships groups and staff-model organizations Med. 2002;136:243–246. with their communities. Deans and other could even sponsor rotating fellowships, 2 American Medical Association. Declaration administrators would need to encourage and doctors in the organization who have of Professional Responsibility: Medicine’s and reward faculty advocacy activities. Social Contract With Humanity. Available at: more ambitious goals could apply for http://www.ama-assn.org/ama/upload/mm/ Neither developing partnerships nor funding to support a project that might 369/decofprofessional.pdf. Accessed rewarding faculty advocacy is likely to involve a more significant time September 8, 2009. occur if funding is not available to investment. 3 Gruen RL, Pearson SD, Brennan TA. support advocacy. Although the National Physician–citizens—Public roles and Institutes of Health (NIH) has recently The advocacy training that is currently professional obligations. JAMA. 2004;291: begun to emphasize the importance of available to practicing physicians is 94–98. 4 Cruess RL, Cruess SR. Teaching medicine as a translational work,20 to date there has largely available through professional societies. Often local, state, or specialty profession in the service of healing. Acad been little investment in supporting Med. 1997;72:941–952. translation from clinic to community. medical societies will offer some basic 5 Flynn MB. Power, professionalism, and Advocacy is fundamentally a translational training in lobbying and will organize . Am J Surg. 1995;170:407– activity. The application of preventive trips to the state capitol or to 409. 6 Ludmerer KM. Instilling professionalism in strategies in populations, the practice of Washington, DC, for the opportunity to apply those skills. These efforts are medical education. JAMA. 1999;282:881–882. community-based participatory research, valuable, though limited. Expanding 7 Rothman DJ. Medical and the use of process improvement and professionalism—Focusing on the real issues. the training and broadening the agenda outcomes research in community health N Engl J Med. 2000;342:1284–1286. to better include the concerns of those are all methods that translate 8 Stern DT, Papdakis M. The developing in the community while seeking broad interventions from individual patient physician—Becoming a professional. N Engl partnerships with patient groups and J Med. 2006;355:1794–1799. health to broader public wellness. community leaders and advocates 9 Snyder L, Leffler C. American College of Effective advocacy may require seeking would create robust new opportunities Physicians Internal Medicine Ethics Manual. resources and regulations from the same 5th ed. Available at: http://www.acponline. for physicians and their communities. political bodies that fund medical schools org/running_practice/ethics/manual/ and traditional research. These activities If advocacy is a core element of ethicman5th.htm. Accessed September 8, can become politicized, so academic professionalism, it should not become the 2009. 10 American Academy of Family Physicians. institutions and practices must consider parochial concern of a subspecialty. If we The Future of Family Medicine Project. and prepare for the political ramifications intend to train physicians as advocates, Available at: http://www.futurefamilymed. of advocacy activities. we must create a home for these activities org/x24878.html. Accessed September 8, in academic medicine and in medical 2009. Although federal funders have not practice. Funding for advocacy research, 11 Accreditation Council for Graduate Medical training, and activities is required to Education. Pediatrics program requirements. supported the activities we call advocacy Available at: http://www.acgme.org/ in their funding priorities, private make advocacy a sustainable activity. acWebsite/RRC_320/320_prIndex.asp. funders have. In a time of diminishing Successful advocacy is achievable with Accessed September 8, 2009. dollars from the NIH, the growing both a clearer understanding of its 12 Harris Interactive. The Harris Poll #37: resources and influence of private health components and deliberate practice from Doctors, dentists and nurses most trusted foundations represent an opportunity for committed physicians. professionals to give advice, according to harris poll of U.S. adults. Available at: http:// advocacy activities. Many of these www.harrisinteractive.com/harris_poll/ foundations espouse health promotion Acknowledgments: The authors would like to index.asp?PIDϭ661. Accessed September 29, and the elimination of health disparities thank the Colorado Health Foundation, The 2009.

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13 Gruen RL, Campbell EG, Blumenthal D. Public experience of financial incentives in 18 Sharfstein JM, Sharfstein SS. Campaign roles of US physicians: Community participation, managed-care systems. N Engl J Med. 1998; contributions from the American Medical political involvement, and collective advocacy. 339:1516–1521. Political Action Committee to members of JAMA. 2006;296:2467–2475. 16 Landers SH, Sehgal AR. Health care lobbying Congress—For or against the public health? 14 Campbell EG, Regan S, Gruen RL, et al. in the . Am J Med. 2004;116: N Engl J Med. 1994;330:32–37. Professionalism in medicine: Results of a 474–477. 19 Grande D, Asch DA, Armstrong K. Do national survey of physicians. Ann Intern 17 Pellegrino ED, Relman AS. Professional doctors vote? J Gen Intern Med. 2007;22:585– Med. 2007;147:795–802. medical associations: Ethical and practical 589. 15 Grumbach K, Osmond D, Vranizan K, Jaffe guidelines. JAMA. 1999;282:984– 20 Zerhouni E. Medicine. The NIH Roadmap. D, Bindman AB. Primary care physicians’ 986. Science. 2003;302:63–72.

Did You Know?

In 1970, faculty at Ohio State University College of Medicine and Public Health created the nation’s first independent study curriculum for medical school education.

For other important milestones in medical knowledge and practice credited to academic medical centers, visit the “Discoveries and Innovations in Patient Care and Research Database” at www.aamc.org/innovations.

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