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. Sarah Dobson and colleagues provide a useful formulation of this question in a “Perspective” in the recent Academic Medicine, “Agency and activism: rethinking health advocacy in the medical profession”. They note that “Health advocacy appears in various forms in professional charters and standards”; however, as Canadians they focus on the CanMEDS document. This is “…a competency-based framework developed by the Royal College of Physicians and Surgeons of Canada that describes the core knowledge, skills, and abilities of specialist physicians,” that has 7 core roles including “health advocate”.
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.” Overall, the Declaration is quite an impressive document, the contents of which would surprise many in both the medical and lay communities who think of the AMA as professional advocacy group with no social conscience; sadly, there might be as many unpleasantly as pleasantly surprised by the discovery. Advocacy for patients is generally considered an appropriate role for physicians by physicians, but advocacy for social, economic, educational and political change is far less widely accepted.
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. This is helpful in clarifying different perspectives on the term “advocacy”. While the CanMEDS framework, for example, calls for physicians to “…responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations,” the authors observe that trainees “…have variously described it as charity or as going above and beyond regular duties.” 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.”
The article concludes that there is a distinction to be made between the role and responsibilities of the individual physician and that of the medical profession as a whole. “Physicians and other health professionals witness the effects of the socioeconomic determinants of health every day, made
visible to various degrees in every patient encounter, “ but they question “whether this authority translates into an obligation.”
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., and this blog, “Are we training physicians to be empathic? Apparently not.”, September 12, 2009), so does volunteerism and commitment to social change.
In the US, despite the AMA Declaration, there are no requirements for teaching advocacy included for teaching medical students by the Liaison Committee for Medical Education (LCME), which accredits medical schools, or in training residents by the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs. In the absence of such requirements, it is less likely that advocacy programs will be developed for students and residents, and more likely that, when they are, it will be the students who are already interested in doing such activities who participate. That is great, and programs which allow students to be involved and helps “inoculate” them against from losing their interest and commitment will continue to exist (such as several that we have here at the University of Kansas School of Medicine, including our free clinic and longitudinal elective Community Leadership track). However, if these are not expectations of all students, of all physicians, then only a minority will be involved.
Indeed, 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. I was once at a physician meeting in which a “conservative” state legislator was speaking against a statewide smoking ban. Reassuringly, the vibe in the room was very hostile to the content of her remarks. Sensing that, she turned to a physician from her district who was also very conservative and a political supporter of hers and said “You? Do you agree with this?” To which he shrugged his shoulders and replied, “I’m a doctor!”
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. Even physicians with public health roles may see their advocacy in a much more limited way (for immunizations, smoking cessation, cancer screening, seat belt use, etc.) rather than structural 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.
[1 Dobson S, Voyer S, Regehr G, “Agency and activism: rethinking health advocacy in the medical profession”. Acad Med. 2012;87:1161–1164.First published online July 25, 2012. doi:10.1097/ACM.0b013e3182621c25
 Hojat M, Vergare MJ, Maxwell K, et al, “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”, Academic Medicine, Sept 2009;84(2):1182-91
Advocacy begins at the level of one's practice and one's neighborhood and physicians and students need to understand that from the outset. I was fortunate as a student in Chicago 45 years ago to be "taught" by a community of Latinos that my job was to help them improve their community and that I was going to be a contributor, not the leader. Humility is an essential component for effective advocacy and one concern with much of the student - and the occasional physician - interest in advocacy is that it may still be coming from the sense of noblesse oblige that most of us who are not from the communities we seek to help begin with. "I am here to help you". Advocacy is about "we" and if one wants to learn how to do that on a personal and community level, the recent book by Parker Palmer, the long time teacher of community "Healing the Heart of Democracy" is important reading. It recommends listening and dialogue as the predecessor of advocacy and change - not a radical notion but one that is lost, in my opinion, in the enthusiasm for volunteerism and service that many students begin training with. Dosteovsky put it best, perhaps, in the Brothers when he said "love in reality is a harsh and dreadful thing compared to love in dreams....I worry about myself because it is easier to love mankind in general than love man in particular." Advocacy begins with man in particular.
This article is a good start toward examining some little-known facts about AMA writings and texts for physicians in terms of possibilities or responsibilities for changing social determinants of well-being and for health equity. However, advocacy for groups of people should only be done with the active participation of the targeted group members. Even with the best of intentions, academic or professional experts' speaking for excluded and marginalized groups without their organized, active collaboration is not emancipatory or democratic. The disability community motto is "Nothing about us without us", and perhaps this could be said of experts' speaking for other groups, without their consultation. Yes, it is harder and takes more time. And yes, we can do it anyway.
Thanks so much for this piece, Josh. I think one major point worth adding is that physicians belong to a higher social class and with ever rising tuitions of medical schooling, not to mention the privilege required to have been able to go to undergrad, not work a part time job, and do well enough while also doing volunteer work, often self selects people of higher socioeconomic status. This means that physicians are much less likely to come from a background of marginalization and thereby less likely to see those struggles. This is yet another reason we need to ensure that we provide supports to families and more accessible education on top of teaching activism in medical school to ensure we are bringing people in with a wide experience, and not just people who are from the 1% and will continue to stay in the 1%.
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I hope this email finds you well.
There are things one witnesses that need to be shared.
On February 8, 2018, I along with three other presenters (Dr Everett Allen, an internist who worked for several years at California Pelican Bay State Prison's solitary confinement, a UCSF Public Health and Criminal Justice researcher Cyrus Ahalt, and Steven Czifra who was confined in solitary confinement for 8 years and is now is a U.C. Berkeley MSW intern) presented on the relevance of solitary confinement to community psychiatry to my colleagues at the California Contra Costa County Psychiatry and Psychology monthly meeting.
Another psychiatrist present suggested I write a petition ...so here it is...
I am writing hoping you may assist me in collecting signatures for this petition I wrote to end prolonged solitary confinement in American jails, prisons, and detention centers.
If you are a medical provider of any specialty, a psychologist, a LCSW, a NP or a PA please consider signing.
In a few months I will be sending petition with signatures to the American Psychiatry Association, the American Psychology Association, the American Medical Association, and the American Academy of Psychiatry and the Law, National Association of Social Workers, the American Association of Physician Assistants, and the American Association of Nurse Practitioners.
Mariposa McCall, MD
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