Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The Necessity of Being an Advocate


Clinical care and advocacy are intertwined. In every clinical encounter, we should think about ways that we can advocate for our patients.

| September 26, 2019 | 3 min read

By Zackary Berger, MD, PhD, Johns Hopkins Medicine

Nowadays being an advocate feels necessary to the very survival of ideals we hold dear. Perhaps every age, for some people and in some places, gives rise to that feeling. Being a healthcare professional gives rise to a conflict with that impulse to advocacy. Here I want to talk about that conflict, its sources, how it can be described, understood, finessed, and perhaps ways in which the very exploration of that conflict can enrich our lives, strengthening both our ideals as advocates and our commitments as clinicians.



First, let’s talk about what advocacy is. I take a broad approach, in keeping with the word itself. It means making your voice heard. There are many ways to do this. There is physical speech—putting your body on the line. There is speech by action—not by immediate physical action but by using one’s position, one’s role, to actuate the good. And, of course, there is rhetoric as action: leading to greater action through setting the terms of the debate and inspiring oneself and others.



There is a conflict between advocacy and clinical care. One might think that the difference is relatively simple: advocacy, one might say, deals with broad topics of societal and political-economic importance, but clinical care deals with a narrower sphere. This is not actually the case, however, as we all know. Clinical care can consider questions as broad as “what brings meaning to your life” and “how is your sleep,” and advocacy can consider very narrow slices of experience, like the prisoner who is unable to obtained the buprenorphine she needs to treat her opioid use disorder. Rather, I think the difference is between how advocacy and clinical care view the overlooked and forgotten, whether those are overlooked diagnoses or overlooked people.



By and large, clinical care concerns itself with the everyday, the usual, and the normal. (Yes, clinical care must deal with the rare and unexpected, but it is not part-and-parcel of usual healthcare to treat only rare conditions.) Advocacy, largely, deals with the overlooked, the disadvantaged.



Though the etymology of advocacy has to do with voice, it helps me to think of advocacy and clinical care both as kinds of seeing. The poet Carolyn Forche said:

“You have to be able to see the world as it is, to see how it is put together, and you have to be able to say what you see.”

Unfortunately, few of us have eyes that can see in multiple realms at once. As clinicians, we tend to think of the individual patient when they are in front of us—and less about the system with its imperfections and injustices. Similarly, when we are in a place to advocate for system changes, we do not keep a particular patient and our responsibility to them in mind at that moment.



That overlap is broader than it might appear. There are many areas where the system view and the individual-, patient-centered view might overlap. Our patients should not be sued for unpaid medical bills, their housing should not be substandard, and they should not be made to paid for medications they cannot be afford. We cannot fix each of these issues for each patient, but we can pull  more levers, talk to more people up and down our chains of command, and make more noise at an institutional level for a greater proportion of our patients.



Paying attention to the ways in which our systems —the very ones we work in—make things more difficult for the patients we care for should make us more attentive to both systems and individuals, sharpening both kinds of vision. This mindfulness is difficult, but should accompany us in every clinical encounter.