Advocacy plays a vital role in medicine, especially primary care. It means differently for different people in health care. Health advocacy is defined as “the processes by which the actions of individuals or groups attempt to bring about social and organizational change on behalf of a particular health goal, program, interest, or population.” In an article by Mark Ernest et al., they propose the definition of physician advocacy as action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that they identify through their professional work and expertise.

Health advocacy is being formalized as a professional activity for physicians across North America, but the accommodation of this activity into conceptions of daily practice has been controversial and confusing. There appears to be a lack of clarity around what a physician should do as a health advocate and how this should manifest in daily practice.

My advocacy journey began when I realized the power physicians have in articulating the needs of patients and bringing forth the systemic barriers that affect the health of people. Often, the lawmakers making decisions on major health issues do not have enough knowledge of the issues and the impact their decisions can have on the community. They are open to learning more if we, as physicians, can find the time and patience to make an effort to educate.

In this article, we will explore a) the two components of advocacy in medicine, b) the barriers that primary care physicians face in championing the health needs of their patients and communities, and c) potential ways to overcome them.

In the article, “Agency and Activism -Rethinking Health Advocacy in the Medical Profession,” Sarah Dobson and colleagues have proposed dividing advocacy into two components, which they call “agency” — working on behalf of the interests of a specific patient — and “activism,” which is directed toward changing social conditions that impact health, and the effects of which are seen in populations more than in individuals. The difference is that “whereas agency is about working the system, engaging in activism is about changing the system.”

In general, physicians consider it part of their job to advocate for their patients by coordinating care with other specialists, providing appropriate referrals, assessing needs for home health, etc. But, advocacy for social, economic, educational, and political change is far less widely accepted, although in my opinion and experience, change is beginning to happen.

The barriers

Holtrop, Price, and Boardley found that the most commonly perceived barriers to public policy involvement reported by health educators include “lack of time,” “other priorities,” “frustration with the process,” “lack of money/other resources,” “policy makers’ attitudes/ values,” “lack of access to key individuals,” “can’t be involved due to employment,” “confronting others with opposing viewpoints/large funds/influence,” lack of support,” “takes too long to see a difference,” and “probably won’t make a difference.”

In Verma and colleagues’ study, residents appeared to take for granted the responsibility for patient advocacy (agency) but felt unprepared to take on the responsibility for going beyond the care of an individual patient and into their communities (activism). Similarly, clinical faculty members appeared to feel that they satisfied the mandate of the health advocate simply by behaving as agents in their daily practice and, in so doing, may have undermined the promotion and teaching of the activities associated with the activist sub role.

In a national survey of family medicine program directors (PDs), only one-third of responding PDs reported a mandatory advocacy curriculum, most focusing on community advocacy. The largest barrier to implementation was curricular flexibility. Having an advocacy curriculum was positively associated with faculty experience and optimistic PD attitudes toward advocacy. All of these studies were done before the pandemic, and we need more studies to gauge the current weather pattern of physician involvement in advocacy.

In my residency program, I am working on creating a formal curriculum for advocacy. The main focus of that is to teach residents the skills of letter writing, ways to reach out to legislators, and writing resolutions, to name a few.

What can we do?

While some of the barriers mentioned are real, some can be related to a lack of preparedness, training, and fear of uncertainty. It is vital to explore and demystify these barriers and concerns so that future and current health care advocates can begin or expand their participation in advocacy activities.

Here are some ways physicians and trainees can get involved in advocacy:

1. Medical society affiliation. State or local chapter medical societies have committees on health policy and advocacy that meet periodically and together speak up for issues that matter most to the group and their patient population.

2. Become the key contact for the local policymakers. A key contact is a physician member who is interested in legislative issues. As a key contact, we agree to interact with state and federal lawmakers on public policy development, including attending meetings, sending letters/e-mails, and testifying before legislative committees. The state legislature website or medical organization website will usually have more information. Eventually, if interest and opportunities arise, one can become a health care advisor for policymakers.

3. If you want to significantly impact health policies and implementations, it’s important to seek out leadership opportunities within your own institution. As the saying goes, “If you are not at the table, you are on the menu.” This means that those who hold higher leadership positions tend to have more influence on patient care within their organizations. Even though getting to a leadership position can be challenging, it is one of the ways to make a stronger advocacy-related impact on patient care.

4. Liaison to media and health reporters. Writing opinion pieces, editorials, and letters on health matters and using social media to amplify voices and support bills and trends.

5. Other ways to engage lawmakers. Reach out to them via phone, write letters, and schedule meetings.

Some of the obstacles to advocacy are genuine. As practicing physicians, we have limited time and must choose our activities wisely.

Many of us have learned to advocate on the job as the need arises. However, we need to prepare the next generation of physicians and equip them with the tools to continue the work.

Manju Mahajan is a family physician.