“Only one rule in medical ethics need concern you — that action on your part which best conserves the interests of your patient.”
– Dr. Martin H. Fischer, German-American Physician and Author
“A physician shall, while caring for a patient, regard responsibility to the patient as paramount.”
– Principles of Medical Ethics, American Medical Association
“I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else.”
– Fellowship Pledge, The American College of Surgeons
Advocating for patients is a core value in medicine, in patient care. Our legacy as patient advocates dates back to Hippocrates in 500 B.C.E., codified in the oath and teachings that have provided the moral and ethical foundation on which the profession has been built. Even the Code of Conduct for the American College of Surgeons includes as its first principle, “Serve as effective advocates of our patients’ needs.”
Physicians fundamentally care for patients, their families, our communities. We advocate on the small, individual scale for each patient, and we advocate on the large scale for the entire population of patients and society.
The physician is the ultimate patient advocate.
The entire purpose of my profession is to learn about humans — their biology and chemistry, their function in health, and dysfunction in illness and injury. We strive to understand the impact of health or illness and injury on the psyche and on social interactions. To learn about and discover treatments and interventions, and to provide compassion and comfort in applying them. To educate both patients and our society in order to prevent illness and injury, promote health. We are called to speak truth to power in order to accomplish these goals.
The foundation of all this is the relationship and trust between the physician and the patient. Central to this relationship, that trust is the role of the physicians as advocates for their patients.
But now the position of “patient advocate” has become ubiquitous among hospitals, insurance companies, and health systems. A patient advocate is a (lay) person/entity whose primary role is to protect the patient and their interests, but also to field complaints, advocate on behalf of the patient/family, and even go so far as to assist in decision-making regarding the treatment plan or course of care. They are supposed to help navigate the often complex and confusing health care system, and the interactions with doctors, hospitals and insurance companies.
Patient advocacy seems a noble pursuit, and often much needed. Patients and their families are distressed and vulnerable, even in good health; add illness, and the ability to navigate the system and the decision-making can be daunting if not impossible.
All well and good, but I wonder why there is this pressing need for an entire different profession, an additional layer, another buffer between the patient and the physician? Has the core principle of advocacy changed in my profession? Have we abdicated our responsibility, or is it something else? If it has not changed, if we have not abandoned our principles, what is it perceived as lacking?
As Voltaire (or Peter Parker/Spiderman’s Uncle Ben) says, “With great power comes great responsibility.” The powerful responsibility physicians have for the care of their patients remains, but the trust on which it is based has eroded. The bond between physician and patient — and between the medical profession and society — has become strained.
Individual patients, the general public, and the government have all become increasingly wary of physicians. Considerable effort and expense are employed to rein in the perceived power and control wielded by physicians, implying that there is little trust in the ethics, oaths, and codes that we have set for ourselves. Hospitals, health care organizations, insurance companies, and various branches of government and regulatory agencies, as well as licensing boards and health departments (not to mention lawyers) have bit by bit surrounded physicians and buried them under mountains of law and regulation, benchmarks and measures and protocols.
Health systems and insurance companies increasingly dehumanize physicians, treating the highly skilled and highly trained professionals like pawns on a chess board, faceless and interchangeable. Physicians drop on and off of “preferred provider” lists in arbitrary and capricious fashion, destroying any relationship and continuity built with the patient. Doctors are presented as interchangeable.
Worse, at times it seems that these groups are driving a wedge in the physician-patient relationship. As a consequence, patient trust and confidence is shaken. It is not much of a leap for the relationship to be framed then as adversarial rather than cooperative. If a doctor is no longer seen as the patient advocate, then of course the void must be filled.
But patient advocates generally haven’t the medical training or expertise. They may be also beholden to the system or entity that employs them. The most common and available advocates are generally working for a hospital or insurance company, whose priorities may not entirely align with patient and physician. This is problematic, of course, because it is often the hospital or insurance company the physician must stand up to on behalf of her patient.
It is imperative that physicians continue to shape our evolving health care system and promote that which preserves and protects our relationship with our patients. We must insist that we not only take a seat at the table among “stakeholders” in the health care system, but show that we are the best and more uniquely qualified to lead the efforts. We must again claim that space between patient and physician and remind not just our patients, but all others that indeed we are their advocates. The physician who fails to serve as an advocate for their patient also fails to serve as a physician to that patient. We must fight for the time we need, fight against the distractions, shore up the trust that has been strained so mightily.
There is nothing in the description of a patient advocate that isn’t already part of what we as physicians commit to do for our patients. We are, therefore, the first and the last patient advocate, their most effective advocate, the ultimate patient advocate.
I advocate for physicians to continue to claim the time and space to be effective advocates for our patients; and to embrace this responsibility, and not abdicate it to others. Taking the lead to work with, but not be replaced by patient advocates.
Kathryn A. Hughes is a general surgeon who blogs at Behind the Mask.
