AMA Journal of Ethics^®

Since the earliest existence of the medical profession, physicians have accepted a host of ethical responsibilities. Physicians should be truthful, compassionate, and hold confidences. The idea that physicians should be patient advocates doing everything within reason to help their individual patients is also an idea that is woven into the fabric of medical practice. Contemporary medical practice, however, has thrust the profession into some new territory and forced medicine to confront a new range of potential roles and responsibilities, including those of gatekeeper, steward of limited health care resources, administrator, and manager.

Many physicians have indulged the temptation to get involved in more prominent ways, individually or collectively engaging in public debate about how health care is delivered and practiced. Some have argued that medical professionalism includes a component of public engagement.¹ Others go further, claiming that the social contract between the medical profession and society imposes on physicians a responsibility to provide leadership in matters involving the health of the public.

The "Medical Professionalism Charter," a document endorsed by virtually every medical specialty society, embraces the principle of social justice as a value fundamental to medical practice.² It further endorses several specific responsibilities for physicians, such as demonstrating commitment to improving the quality of care, access to care, and just distribution of finite resources. These are realms that are, by their nature, public—not individual—hence the charter constitutes a formidable argument for a broad public role for physicians.

But what does the professional imperative implied in these analyses mean for the individual clinician? Beyond joining a professional organization and participating in its internal policy deliberations, must each individual physician take on a public role? Do I need to run for Congress or set up a hospital in another country to fulfill my professional obligations to society? How do I do this while simultaneously fulfilling my primary obligations to care for my own patients and maintain excellence in the provision of clinical care?

Gruen and colleagues have recently articulated an affirmative answer to these questions of physician advocacy.³ These authors link a public advocacy role to the physician's responsibility to individual patients. The boundaries of the wider responsibilities, they argue, can be understood as a series of concentric circles with obligation at the center and aspiration at the periphery. Those community issues and influences that impact the health of their patients serve to separate the inner from the outer circles—obligation from aspiration. As examples, Gruen and colleagues argue that a dermatologist, in addition to treating skin cancer, should actively endorse programs to prevent skin cancer.³ Trauma surgeons should advocate for seat belts and bicycle helmets. For these authors, activities at the outer reaches of national and international health influences remain "above and beyond" the call of duty.

What are some tangible ways that physicians can meet these public responsibilities? There are many well-known physician advocates whose work seems laudable but out of reach for most physicians. Even the examples of physician advocacy in this issue of Virtual Mentor, while exemplary, should not be expected of every physician. Many achievable activities, however, fall within the concept of the "physician citizen" and represent the kind of activities that any and every physician should be undertaking.³ These achievable goals resemble those of active lay citizens who remain informed about issues of importance to their community and join the community dialogue about them. Ask yourself, as a citizen, Do I go to PTA meetings? School board meetings? Community town hall meetings on homelessness? Do I participate in volunteer work?

Beyond their involvement as lay citizens, physicians should strive to bring their knowledge, experience, and community standing to bear as voices for change. So, for instance, when the PTA is confronting proposed cuts to after-school sports programs, a family physician can offer evidence of the impact of physical activity on childhood and adolescent obesity. When the school board is discussing the school's vending machine policy, a pediatrician can speak from experience and knowledge about the effect of nutrition on the health of children in the community. When the city council takes on homelessness, an internist can uniquely give voice to the public health and social justice dimensions of this urban problem, advocating for solutions that consider these complexities.

If we acknowledge this public role for physicians, we must also recognize that their education and training must clearly communicate this responsibility, providing students with the knowledge and skills that will enhance their effectiveness in advocacy. Examples include curriculum that addresses contemporary models of health care delivery and core principles of public health, as well as practical experiences in public advocate roles, such as participation in service learning activities. A curriculum of this type, coupled with an acceptance of a broad responsibility of contemporary practice, can help individual physicians and the profession fulfill an important role as agents for change.