AMA Journal of Ethics^®

Case

Dr. Jones, a family medicine physician, practices in a community health clinic outside of Oakland, California, in a low-income neighborhood. Dr. Jones works long days seeing patients from the community with illnesses prevalent in groups of low socioeconomic status: tuberculosis, HIV, and metabolic syndrome, among others. He has a wife and one child, both of whom are healthy. He spends part of every weekend making house calls, helping patients get prescription medications, assisting his elderly parents with their needs, and meeting with community and school leaders about health projects. Dr. Jones has become something of an expert in diagnosing and treating lead exposure in children, since many of the housing options in his community are not adequate. Given early diagnosis and treatment, including counseling of the family to try to limit exposure, many children experience minimal symptoms. This week, Dr. Jones saw another child who had symptoms of lead exposure. He would like to help his community correct the root causes of this threat to its children, but, after caring for his family and his individual patients, he is exhausted.

Commentary 1

The case of Dr. Jones elicits feelings of both admiration and concern. While we admire his deeply felt commitment to his patients and their community, we are concurrently concerned that his mode of practice is unsustainable, that his present course will negatively impact his family, and that he will suffer from exhaustion, undermining his career. This case raises many questions: What is the physician's obligation to the patient? What is the difference between a physician's obligation and a physician's aspiration to improve health? And finally, how can one practice and not overextend?

Increasingly, medical professionals are engaging in community and health policy arenas.^1,2,3 This involvement is in direct response to a heightened awareness that many health issues, such as lead poisoning, have their roots in the community. Aspects of modern culture that give rise to these diseases, such as environmental contamination, represent the new vectors of disease.⁴ To address them one must practice both inside and outside of the clinic walls, and physician advocacy is one approach. One definition from the Lancet states "Advocacy only means taking the problems that one faces day to day and pursuing their resolution outside their usual place of presentation."⁵

What is the physician's obligation to the patient?

Physicians have an obligation to work within their own practices and communities to ensure that patients have access to high-quality preventive, urgent, and specialty care that is geographically, linguistically, culturally, and financially accessible.⁶ These noble ambitions frequently clash with the financial realities of a growing uninsured and underinsured population.⁷ Practicing physicians are caught in the debate between the utilitarian notion of distributive justice, which acknowledges finite resources, and the notion of justice as equity where all patients are guaranteed equitable access. This is a crucial debate, and one in which doctors must be heard.

The strength of the link between the policy and the health outcome can guide physicians in distinguishing their obligations from their aspirations when advocating for patients.⁶ For instance, Gruen et al suggest that it is the physician's obligation to work with individual patients and in the larger realm to reduce tobacco use because the health implications of tobacco use are well established. They suggest that physicians may aspire to address factors such as poor educational opportunities and neighborhood safety, since the impact on health outcomes is suggestive but not conclusive. Determining the strength of the scientific evidence can help a physician prioritize his obligations over his aspirations.

How can one practice and not overextend?

Where does this leave Dr. Jones? He is exhausted—and who wouldn't be—after making house calls, helping his parents, and partnering with community leaders on health projects. He would appear to have 3 jobs and be doing them all in isolation. Let's examine each activity to ascertain where obligations end and aspirations begin and then consider where different advocacy approaches would strengthen his work but lighten his load.

Dr. Jones is exceeding his obligation to see that his patients have access to high quality care. Instead of making house calls, might he look upstream to assess why patients can't get to the clinic? Maybe the clinic is too far away, and he could establish a satellite clinic in a location closer to the need. Alternatively, if the practice values house calls, perhaps he could be given time during the work week to make those visits.

Dr. Jones spends time assisting his patients in filling their prescriptions, which is a perennial challenge for many Americans. Luckily Dr. Jones practices in California where a new prescription drug recycling program has recently been signed into law. This surplus medication collection and distribution law approved by Governor Schwarzenegger on September 30, 2005, creates a "…program for purposes of distributing surplus unused medications, as defined, to persons in need of financial assistance to ensure access to necessary pharmaceutical therapies."⁸ It is possible that Dr. Jones is unaware of such recent legislation with all that he is doing. One easy way to stay abreast of such important issues is participation in local organized medicine, where short frequent e-mails alert members to legislative activity.

A compelling part of the story behind this legislation is that it was the direct result of medical students' advocacy for patients just like Dr. Jones's. In 2004 a group of Stanford medical students approached one of California's elected officials with the idea of introducing legislation allowing indigent seniors to obtain medications that would otherwise be thrown away. With this legislation now law, countless California seniors will receive medications where before they would not. Medical students can clearly be extremely effective and unique advocates.

Finally, Dr. Jones aspires to improve the health of the community through various projects with local community groups and schools. Self-care is important, and it appears that he is overextended in his aspirations. One approach to focus his activities would be to examine where his passion and expertise intersect: childhood lead poisoning. This is an area where the scientific evidence for prevention is very strong, thus it is a health topic where a physician is all the more obligated to act.

Regarding his clinic patients, Dr. Jones should recognize that he is one member of a public health team available to address lead poisoning. His role is to provide medical treatment where indicated and then to refer these patients to the Alameda County Public Health Department. He should advocate at the county or state level in favor of lead abatement programs or legislation. As a physician who witnesses the effects of lead, he has a unique and powerful voice to bring to this process. When the next new patient comes in with symptoms of lead exposure he will be heartened with the knowledge of all that he is doing to prevent future cases. By focusing on lead issues he limits his efforts to an area where his impact will be greatest. He must not attempt to solve all of his patients' problems. At some point in the future his advocacy endeavors may shift to address obesity, or any one of myriad topics, but at this point in his career he has one issue and should remain focused. This will prevent overextension and burnout.

No epidemic has ever been halted by focusing on the individual patient, and many of the health issues facing our nation and world today are the same sort of challenges. As physicians learn to advocate for individual patients and beyond, they will improve the lives of many while they improve the quality and enjoyment of their work.