AMA Journal of Ethics^®

Case

After finishing another grueling morning of pre-rounding, Rebecca found a moment to grab a cup of coffee with her fellow intern, Samuel. As first-year residents at a competitive internal medicine program in a large county hospital, they were already feeling the much-anticipated burnout just halfway through intern year. “I’m so irritated with some of my patients,” Samuel remarked. “I don’t get how so many of them lack insurance. Most of them don’t even have a PCP!” Not sure what to say, Rebecca pointed to her watch. It was time for rounds with Dr. Myers, the Medicine Team D attending physician for that week.

A couple of hours later, Samuel was about to present the last patient. “So tell me about Mrs. Olson,” instructed Dr. Myers. Samuel began, “She is a 52-year-old female admitted through the ED for community-acquired pneumonia after a 5-day history of productive cough and fever.”

When his presentation was finished, Samuel was surprised by Dr. Myers’ first question. “Why wasn’t she seen by her doctor before the infection got to this point?”

The reason seemed obvious. “She doesn’t have insurance or a PCP.”

Dr. Myers replied, “Well, it looks like you have a job to do. Why don’t you go by her room this afternoon and provide her with some information on insurance options for those with low income? I know she’ll appreciate it. And also, if you wouldn’t mind, go ahead and look up Virchow’s essays on public health for rounds tomorrow. I know we can all learn something.”

Over lunch, Samuel was seething. “I didn’t go to medical school so I could be a social worker. Finding Mrs. Olson health insurance is not my job.” Rebecca realized this probably wasn’t the best time to start a debate, but she couldn’t help but frown at her colleague’s tirade.

Commentary

There is an Irish proverb that says to count your health instead of your wealth. Unfortunately, here in America, a person’s health is largely dependent upon his or her wealth. Life spans can vary by as many as 20 years between the richest Americans and those who are worst off [1]. However, the amount of money a person has in the bank is just one of a slew of factors that influence health and, therefore, have been termed the social determinants of health. These factors, which can have a significant impact on outcomes, include access to health care, education level, workplace safety, environmental cleanliness, the number and type of relationships a person has with the people around him or her, and culturally ingrained dietary and health habits [2].

I saw the true meaning of the social determinants during my first year of medical school, when I spent one afternoon going on house calls with a physician working to increase access to health care. Before the other medical student and I got out of the backseat of his car, the physician asked us how it could be 4 o’clock in the afternoon on a school day and yet not a single child was playing outside. He said that there were two lessons to take from this. The first was that in all likelihood a recent incident of intimidation or violence had driven everyone inside and that we needed to be aware of our surroundings. The second lesson was that, if kids can’t run around outside and get the exercise they need because their safety is threatened, then it isn’t difficult to start to understand pediatric obesity.

As Rudolf Virchow noted more than 150 years ago, health needs to be a social concern—society must promote the health of its members [3]. He argued that the physician stands at the crossroads between the health of individuals and the social conditions that influence it; physicians must not only cure pathologies, they must work harder to correct the social injustices that their patients face.

To speak out about these underlying factors takes courage. At its core, addressing these structural issues is an act of advocacy. While advocacy can be an appealing aspect of the profession, and what ultimately draws many to medicine, this skill set is something that is rarely built into medical school or residency curricula. Since the 2008 presidential election and the subsequent health care reform debate, the role physicians should play in the hospital and in society has been called into question.

Some authors take the position that physicians must become part of the solution by participating in the public dialogue as advocates [4]. Given the trust the public places in the medical profession, those who do so effectively have the ability to become powerful leaders. Others have defined the scope of physician advocacy in broader terms [5]. Being an advocate need not be limited to finding patients health insurance or coming out in favor of a specific policy. It could mean advising local schools on nutrition policy or developing patient safety initiatives. Most physicians are advocates in one way or another.

There is, however, a camp that believes that political advocacy should not be a component of either medical education or medical professionalism [6]. They argue that, since advocacy is inherently political, it is a civic duty and not a professional one; universities and residency programs should not teach advocacy. Given the lack of consensus regarding this higher-level question and the lack of space in current curricula, the likelihood of much time being devoted to teaching advocacy competencies is low. This should not serve as a deterrent to those who wish to bring about change. It is absolutely possible to effect change without formal training. For those looking to become involved, here are four lessons I have learned.

First, find a mentor. Like most things in medicine, having a relationship with someone who is knowledgeable and willing to lead the way makes things easier and more enjoyable. This is especially true when it comes to advocacy activities. Many medical centers have prohibitions on lobbying but not on advocacy, and a mentor can help you understand and walk this fine line. Furthermore, accomplishing things on a large scale is rarely a one-person task, and a mentor can connect you with other like-minded people.

Second, teamwork is key. The hospital is full of nurses, case managers, and social workers who are all striving for better patient care, both inside and outside the hospital. It is a fallacy to think that tackling social issues is solely the domain of the clinician, and it would be counterproductive to reinvent the wheel or duplicate the work of others who are more skilled in these areas. I have found the best way to do this is simple: just communicate with these other caregivers to find out what they can do for the patient and how I can help.

Third, find win-win situations. Advocacy is fundamentally about change, and often change is met with criticism. One of the best ways to obviate this is to find outcomes that are good for both sides. Some of the best advocates are those who can come up with options for mutual benefit. This takes the ability to look at a situation from other people’s perspectives, and that can be enhanced by good mentors and collaborators.

Finally, have appropriate expectations and don’t be discouraged by defeat. Setbacks are inevitable, and can easily lead to burnout if expectations and goals aren’t attainable and aligned. As such, perseverance and building upon small victories is a must. Don’t be willing to accept defeat; no one who has ever accomplished anything ever has.