In a shift, physicians embrace a new role: advocacy

The other night while having dinner with my father, an oncologist, I mentioned that I was taking a health advocacy class as part of my medical residency at Cambridge Hospital. The elective, now in its second year, is designed to teach young doctors and medical students how to bring about social change -- a role doctors haven't historically embraced.

"This is part of residency training these days?" my father asked. It was clear from his sarcastic tone that he didn't approve.

A generation ago, doctors were taught to take care of patients and conduct research. For the most part, advocacy was left to others.

But attitudes are changing. According to a survey of physicians published in the Nov. 22 Journal of the American Medical Association -- and conducted, in part, by researchers from Massachusetts General Hospital -- 90 percent of doctors now believe participation in community activities, political involvement, and healthcare advocacy are an important component of their jobs.

Perhaps this shift is not surprising: doctors work directly with some of the most vulnerable and oppressed members of society -- the uninsured, the homeless, victims of domestic violence, and victims of human rights violations.

Despite their good intentions, however, over the last generation doctors haven't done enough to bring about social change, according to several of the speakers who came to our class. In fact, they said, most healthcare reform has been passed by politicians with little input from doctors.

Part of the problem is that doctors have attempted to address social injustices and make change happen primarily by doing research.

"Don't get mad, get data," one physician told our advocacy class.

If you think you have a better way to treat heart attacks, we were instructed, prove it by comparing your method with existing treatments in a formal study.

Dr. Paul Farmer at Brigham and Women's Hospital, for instance, has used research to show that treating HIV/AIDS in the developing world is not only possible but much less expensive than many had thought.

But even Farmer admits that progress in response to such research projects has been too slow. Something more is needed to get the attention of policymakers, who don't respond as readily to evidence-based medicine as doctors.

We "will have to learn more about advocacy and about which levers to pull in Washington" and in the international policy community," Farmer said in a speech at the American Public Health Association's annual convention in early November.

This is starting to happen because of pioneer physician advocates such as Farmer himself, who has brought life-saving medications to the developing world by working closely with policy agencies including the US Congress and the United Nations. Other examples of successful physician advocacy include work by Physicians for Human Rights, which won a Nobel Peace Prize a decade ago for its efforts to ban land mines worldwide; and a group of doctors in the Southwest who recently helped persuade Congress to compensate Americans harmed by radiation from Cold War nuclear experiments.

More important, for the first time health advocacy is becoming an accepted career pathway for all doctors.

In addition to the program at Cambridge Hospital, a group of students at Boston University School of Medicine have recently developed an advocacy elective. And the pediatric residency program at Boston University includes a module on community-based health advocacy.

At Cambridge, the monthlong course that just ended consisted of daily lectures from progressive health policy experts, about half of whom are doctors.

Each medical student and resident also developed a project with an advocacy component. One of my classmates, for example, wrote a proposal to provide housing to homeless patients after they leave the hospital. The program, if approved by the hospital administration, could get many of these patients off the streets permanently.

Because of rising costs and demographic pressures -- most notably an aging population -- our healthcare system is going to change considerably in the years ahead. Without strong advocacy on their behalf, the most vulnerable members of society are at risk of losing access to life-saving medical care.

As doctors, we have an important opportunity to serve in this advocacy role, even if our training in this arena is less than ideal.