By Josh Freeman
Medicine and Social Justice, October 13, 2012
A recurring question for physicians and others in the health profession is what degree of health advocacy is expected or appropriate. For those of us in medical education, the question becomes how much of the training (and evaluation) of medical students and residents should be based on advocacy for their patients or populations.
In the United States, the clearest expression of the role of advocate is in the American Medical Association’s (AMA) Declaration of Professional Responsibility: Medicine’s Contract with Humanity, which contains, as item #8, “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”
Dobson and colleagues propose a parsing of the concept of advocacy into two components. They call these “agency”, working on behalf of the interests of a specific patient, and “activism”, which is more directed toward changing social conditions that impact health, and whose effect is seen on populations more than individuals.
They note that “…several studies have concluded that although physicians generally endorse the idea of advocacy, they rarely engage in it.” They summarize the difference between agency and activism by saying “…whereas agency is about working the system, engaging in activism is about changing the system.”
There are, however, many physicians who do act as social activists, and we need more of them. The source will be medical students who then become residents. Luckily, there seem to be no shortage of entering medical students with this commitment. They demonstrate it by community volunteer work, creating and working in free clinics, volunteering their time to work in schools, and pursuing training in public health, public policy, and community involvement. Sadly, however, along with empathy, which has been shown to dramatically drop as medical students enter their clinical training (Hojat, et al.[2], and this blog, “Are we training physicians to be empathic? Apparently not.”, September 12, 2009), so does volunteerism and commitment to social change.
When we look at the American political landscape, we see a fair number of physicians involved in politics. It could be argued that, in these roles, they are advocating for social, economic, educational, and political changes. What is disconcerting is that the majority of these physician politicians seem to ignore the second half of that sentence, “…that ameliorate suffering and contribute to human well-being”. They are often found among, and sometimes as leaders, in advocating policies that slash the social safety net, decrease funding for public education, and oppose universal health insurance. Too frequently, they act as agents of their own social class than as advocates for those most in need.
That doctors will most often adopt the “agency” role when it comes to issues that most directly affect the health of their patients, that can be arguably seen as “medical”, is very reassuring.
The advocacy role is more complex. Not only are many physicians socially conservative and not, perhaps, in support of policies “…that ameliorate suffering and contribute to human well-being,” physicians are busy people who mostly see themselves in the role of providing direct patient care, not advocating for systemic societal change.
I would like to think that all physicians manifest advocacy in the “agency” sense for their patients. It may be wishful thinking to hope that all physicians will manifest advocacy in the “activist” sense, that they will fulfill the AMA’s Declaration by actually advocating “…for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” But if we do not make this a core value for physicians that is ubiquitously taught in medical school and residency, if we do not select students because of their commitment to advocacy, we will have much less of it.
And we need it badly.
(Joshua Freeman, MD is Chair of the Department of Family Medicine, University of Kansas Medical Center. These excerpts are from his blog and do not represent the views of the University of Kansas.)
http://medicinesocialjustice.blogspot.com/2012/10/physician-advocacy-for-patients-and-for.html
And…
GOP Doctors Caucus, U.S. Congress
True health care reform can only begin with a complete repeal of Obamacare.
The Doctors Caucus is committed to ensuring that all Americans have access to quality health care. Doctors believe that chronic illness and cost are two main barriers between patients and quality coverage. Consumer-driven health reforms that seek to put the patient and their physicians in control of how care is accessed can greatly increase a patient’s access to quality health care.
http://doctorscaucus.gingrey.house.gov/
21 members of the GOP Doctors Caucus:
http://doctorscaucus.gingrey.house.gov/whoweare/members.htm
Comment:
By Don McCanne, MD
What is the disconnect between the activism of physicians who serve in Congress advocating for social, economic and political changes, and physicians in the community who advocate for ameliorating suffering while contributing to human well-being? Didn’t they all enter medical school with the same altruism? Apparently not.
We now have a politically polarized nation. The medical profession has not escaped this dichotomy. In Congress, it is not as balanced as it is throughout the nation. The GOP Doctors Caucus has twenty-one members, whereas there are only two Democratic physicians in Congress and one of those, as a delegate, is not even allowed a vote on the House floor.
When you read the Priorities of the GOP Doctors Caucus, it is loaded with warm, fuzzy, feel-good language. But if you are a student of health policy, you recognize that they support policies that would greatly increase the numbers of uninsured, and would expand a market of “affordable” health plans that really just shift costs to users, making health care access unaffordable for far too many. That might meet the social, economic and political goals of the GOP Doctors Caucus, but at the cost of exacerbating suffering and further impairing human well-being.
We wish that the partisan divide wasn’t a chasm, but it won’t go away. Voters do bear some responsibility for having selected these physicians to be their senators and representatives in Congress, but it is difficult to blame them when the GOP Doctors Caucus stated mission is “Utilizing medical expertise to develop patient-centered health care reforms focused on quality, access, affordability, portability, and choice.” That sounds pretty good. How could the voters be expected to understand the nefarious policy positions behind that statement?
For health care, many would agree that the filter should be at the medical school admissions committee. Medical schools should select students for whom ameliorating suffering and contributing to human well-being is a part of their soul. The problem is that it may be difficult to find enough admissions committee members who can pierce the obfuscating feel-good language used by too many of the applicants – the type of language that is so effectively used by the GOP Doctors Caucus.
(I apologize to Republican single payer supporters who might object to what seems to be a partisan message. In my defense, the message is about physician politicians and health care justice. It is the Republican physicians in Congress who have made it partisan.)