A Call for Advocacy in Medicine

The turmoil in our society this year due to the COVID-19 pandemic and the unjust killing of Black Americans has highlighted truths that have been ignored for too long. One such truth is that systemic racism is prevalent in all aspects of American life, including our healthcare system.

The pandemic is disproportionately affecting racial and ethnic minorities. These individuals are more likely to be infected, hospitalized, and die from the virus than white Americans. However, the effects of racism on health aren’t a new phenomenon—we know that people of color receive poorer quality of care than their white counterparts. Black Americans also face inequities regarding education, prison burden, insurance, housing, and safety—all factors that contribute to negative health outcomes.

Physicians as public servants

It’s time to redefine the role and duty of today’s physicians. In a society that facilitates a better life for some, not all, Americans, and a healthcare system that prides itself in identifying disparities but seldom implements adequate reforms, physician advocacy should be a requirement of the medical profession. As a future doctor, I want to hold the medical profession and my mentors, teachers, and colleagues to a higher standard. We can no longer hide behind the idea that physicians are simply diagnosticians who create and manage treatment plans. Clinicians must do more. A physician is a public servant who took an oath to do more good than harm, an advocate for her patients, and a promoter of physical and mental health for all people.

Working toward systemic change

A doctor’s primary goal is to improve the health of her patients. However, if clinical care only accounts for 10-15% of preventable mortality, how can physicians improve patient health? The solution is through advocacy. Doctors can no longer allow structural determinants of health, like food and housing insecurity, to contribute the other 85-90% of health status. Clinicians must screen for these determinants, as recommended by the American College of Physicians (ACP), refer patients to accessible social services, and address barriers by working toward systemic change. This is especially important as health disparities are often a result of systemic racism, classism, sexism, and ableism.

Advocacy as a core tenet of medicine

Several professional organizations agree that advocacy must be a core tenet in medicine. The American Medical Association (AMA) calls for a commitment to public advocacy and the Accreditation Council for Graduate Medical Education (ACGME) requires all pediatrics residency programs to train their residents in advocacy. In order for all physicians to participate in advocacy, the medical profession must agree on the basic principles that all members must honor, like supporting universal healthcare, which the AMA and Physician’s Charter on Professionalism already require of physicians. The Physician’s Charter also lists social justice as a fundamental principle, emphasizing that advocacy is critical for medical professionalism and clinical excellence.

Opponents of requiring physician advocacy argue that doctors shouldn’t be political and that the medical profession and its institutions must remain neutral. If we hold a political belief at the core of our medical system, the right to healthcare, then we’re an inherently political institution. And if advocating for a basic human right is now a politicized notion, then it’s our duty to be political and fight for change.

The desire to remain neutral reflects our privilege and is based on the failure to recognize the medical profession’s history and previous grievances. Considerable medical progress has been made by the exploitation of Black Americans and other marginalized groups. Two examples include J. Marion Sims practicing fistula repair on enslaved Black women without anesthesia and the cells of Henrietta Lacks being used for a multi-billion dollar research industry without her consent. To be neutral requires silence—silence is compliance and the language of the oppressor. We can no longer be silent. We must stand firm in our beliefs, dismantle the power structures that allow systemic racism to permeate our halls, and advocate for patients and their health.

Promoting physician advocacy

If advocacy is to be an integral component of medicine and a requirement of all doctors, how do we foster this ideal? We must start with education, at the level of undergraduate medical students. It’s not enough for medical students to simply receive a few lectures on the structural determinants of health. Medical students must be trained in advocacy—what it is, why it’s important, and how it can be used to promote change. We must also have access to opportunities to engage in advocacy work and be encouraged to seek these opportunities.

Many students enter medical school with a passion for advocacy. However, in a hierarchical paradigm that prioritizes efficiency and deliverable outcomes, this passion is often pushed to the side in favor of other pursuits, like research and studying for board exams. Advocacy work must be given the same priority as other endeavors so students can be free to pursue it without worrying about being less competitive for residency applications.

This requires a cultural change in medicine at all levels. The physicians and mentors we look up to should set the example by incorporating advocacy in their daily activities and teaching trainees to screen for all patient needs (like food and housing) and make appropriate referrals. Administrators and other leaders in our institutions must encourage and promote physician advocacy. Numerous doctors already engage in and promote advocacy every day—however, we must stop relying on these individuals to do all the work. We must all take on this shared responsibility for our patients, our healthcare system, and ourselves. The time for change is now, and we cannot afford to wait any longer.