AMA Journal of Ethics^®

Case

Dr. Mills and Dr. Ribeira are having a conversation in the hospital break room. Dr. Mills is complaining about another physician, Dr. George, because Dr. George is heavily involved in lobbying his local congressman for patient-centered health reform.

“He’d be doing a lot more good,” Dr. Mills suggests, “if he spent less time following politics and more time reading medical journals. In my opinion, the best way for physicians to provide quality care for their patients is to be competent, careful, compassionate, and spend their extra time learning about the latest treatment recommendations. Not only that,” he adds, “George is so wrapped up in partisan politics, writing and arguing with his congressman. I don’t see how he can remain unbiased and patient-centered in his practice.”

Dr. Ribeira disagrees and, in fact, applauds Dr. George’s patient advocacy, noting that if physicians don’t contribute to an informed discussion of health reform, from whom should legislators obtain information? He expresses a belief that physicians have a duty to advocate for sound health policy. “The Dr. Marcus Welby days are over, my friend,” he says to Dr. Mills. “We have a simple choice today: work to enact policy that will help medicine or have someone else force politically motivated regulations on us.”

Commentary 2

As this case shows, physicians today garner both respect and suspicion when involved in political affairs. A Gallup poll during the height of the health care reform debate showed a high degree of trust in physician involvement. Overall, the poll showed greater public trust in physicians’ ideas for reform than in those of health care academicians, politicians, or commercial groups [1]. Almost three-quarters of Americans expressed confidence in physicians to do the right thing in changing the health care delivery system; only half as many felt that way about congressional leaders.

Physician advocacy is not a new concept. Throughout the history of modern medicine, physicians have acted as political advocates as well as clinicians and scientists. German physician Rudolph Virchow, often referred to as the father of modern pathology, is well remembered by various medical terms named after his work, including Virchow’s Triad, Virchow’s node, Virchow’s psammoma, and Virchow-Robin spaces. In nineteenth-century Germany, Dr. Virchow also ran for and served in political office as a civic reformer, championing the reformation of sewer and water systems, because he recognized that disease did not exist as a pure biological phenomenon, in isolation from its surrounding social context. Noting the similarities between medicine and politics, he said:

Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the answers for their actual solution…. The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction [2].

More recently, Dr. Herbert Abrams, a radiologist who received the Nobel Peace Prize for his work with the International Physicians for the Prevention of Nuclear War, termed physician activism “the fourth dimension of biomedicine.” In addressing graduating medical students at Stanford University School of Medicine in 2007, he spoke of patient care, research, and teaching as the first three dimensions linked by physician activism to the greater outside world. “Activism,” as he explained,

means engagement, involvement, sharing a voice or an activity, individual or joint or cooperative action in an area of need…. It represents an understanding that there are areas beyond our professional work and achievements that link to urgent continental or planetary needs. It stems from the connectivity of all humans and the awareness of that great universal community in which hundreds of thousands of smaller ones coexist. It reflects a sense of values that derive partially from the Enlightenment and persist in religious and secular humanism over time [3].

Only 150 years after Virchow, it is unusual to see physicians engaging in political actions to the degree they once did. While 11 percent of the signers of the Declaration of Independence were physicians, only 1 percent of congressional leaders over the past 50 years have been [4].

The medical profession does not have a union to act on important issues. Instead, it relies on the volunteerism of individual physicians to either become politically active themselves or to electively join and contribute to organizations that will advocate on their behalf. But organizing is inherently challenging in such a tremendously diverse field. Medicine is made up of generalists and specialists, rural and urban practitioners, private and academic practices, small practice groups and large hospital staffs. Any single organization attempting to represent the medical profession as a whole needs to appeal to a multitude of different ideologies, backgrounds, and interests. Then it has the monumental task of identifying issues that a majority of members not only agree are important but also agree on what should be done. Consensus is hard to find, and physicians who care about an issue must often go it alone.

Physicians who engage in political advocacy face many obstacles. The time demands of maintaining a medical practice often prohibit political activity and activism. Physicians must keep abreast of growing amounts of clinical and scientific information, leaving little room for following political issues in depth. The unpredictability of a physician’s schedule, dependent on the demands of patients, presents a challenge for meeting with equally busy political officials and staff members.

Some, like Dr. Mills, may have a general feeling that political activism is futile or even unethical. Often, political advocacy is associated with entrenched or extremely partisan views, but physician advocates need not—and should not—be close-minded, biased, or self-serving. Political advocacy is not the championing of one political party, one point of view or one profession. Political advocacy can be the potential leadership and collaboration with government to ensure that decisions and actions are made in the best interest of society.

The skills required for political advocacy are already important for our profession and the betterment of patient health. The ability to identify a problem, construct a legislative solution, work with others (in this case, legislators) to implement the solution and monitor for potential problems or improvements to the solution is as useful when performing an intubation as it is when writing to one’s elected representatives. Both can lead to the saving of hundreds if not thousands of lives. As physicians, we have the ability to speak on behalf of our patients.

Advocacy may also be important for Dr. George himself. Political apathy in medicine may lead to depression and frustration with forces “beyond our control.” Behavioral science has shown that the cumulative effect of chronic stress coupled with helplessness has negative effects on physical and emotional health. One can only suspect the cumulative toll of viewing the environment in which we practice medicine and the adverse forces against our patients’ health as unchangeable. The consequence of this can be seen in physicians’ growing dissatisfaction with their work. Advocacy provides an outlet for that desire to change things, ultimately improving the physician’s sense of well-being and ability to care for patients with complex medical and social problems.

Physician advocacy has historically been of vital importance for the betterment of the medical profession and improvement in public health. Physicians are trained to both diagnose and treat disease. However, disease encompasses more than a series of biological sequelae, and the treatment requires more than prescriptions and procedures. Political advocacy provides physicians the opportunity to educate legislators on positive systemic interventions beyond the realm of encounters with individual patients. Ultimately, patients are the beneficiaries when physicians like Dr. George bring forth issues that adversely affect their health.