Ep 11. Professionalism, advocacy and public life- when physicians should speak up

Introduction

As a refugee from war-torn El Salvador, the recent developments in the United States have struck a deep, personal nerve for me. The other day, just before the start of lecture, our classmates were talking about current events. During this conversation, we wondered when should we speak out as physicians and when we should hold our personal views back.

To answer these questions I turned to a physician that has shared and defended his views publicly: a belief in a publicly funded healthcare system, in diversity in leadership positions, in equality and inclusivity in medicine and in increased support for rural medicine. Dr Alan Ruddiman is a family physician, who was trained in South Africa (during a time of heavy political upheaval), has worked as a rural doctor in the Okanagan Valley, has served as a board member for Doctors of BC and is the current president of Doctors of BC.

Background Research

  1. Rudolf Virchow was a German physician, historian, writer and politician best known for his work in pathology and public health (Encyclopedia Britannica, 2017). One of my favorite quotes from Virchow: “medicine is a social science, and politics is nothing else but medicine on a large scale.” (Encyclopedia Britannica, 2017).
  2. Professionalism and advocacy are concepts found on the mandate of several medical associations including the Canadian Medical Association (2017), Resident Doctors of BC (2016) and Doctors of BC (2017). In fact, Health Advocacy is one of the pillars we are expected to master as per the CanMED training framework (Royal College of Physicians and Surgeons of Canada, 2017). The definitions for these concepts involve more than just a list of things not to do.
    1. The Royal College (2017) states that as health advocates we are expected to contribute “expertise and influence…to improve health… work with those [we] serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.”
    2. Doctors of BC (formerly BC Medical Association) wrote a policy paper on professionalism in 2013. Highlights (paraphrased):
      1. Physicians have a contract with society that gives the profession the ability to self-regulate. Our part of the bargain is to put the needs of our patients above our own ambitions.
      2. Healthcare is dependent on a series of relationships. We have professional obligations to more than just our patients; to communities, health authorities and the government.
      3. As part of the policy paper, 1809 physicians responded to a survey. Over 63% of survey respondents agreed that the structure of the health care system creates or acts as a barrier to professional relationships between physicians and others.  17% of respondents noted that physician, government, or Ministry of Health goals are misaligned: physicians are care focused, while other entities are fiscally focused. Over 70% of survey respondents agreed that physicians are increasingly being held responsible for the system’s sustainability, as compared to 20 years ago. 59% thought this was inappropriate. On a positive note, nearly 75% of respondents rated their relationship with their patients as positive.
    3. Although physicians seem to endorse the idea of civic engagement as a professional responsibility, there is less evidence that physicians actually engage in these activities. According to a survey of 1662 physicians in the US, more than 90% of respondents overall rated community participation, political involvement, and collective advocacy to be important (Gruen, Campbell, & Blumenthal, 2006). However, the percentage of respondents who reported providing health-related expertise to local community organizations (54.2%), being politically active (other than voting) on a local health care issue (25.6%), and encouraging a professional society to address a public health or policy issue that is not primarily concerned with physician welfare (24.3%) within the past 3 years.
      1. Even in the most basic form of civic engagement, voting, physicians seem less involved. According to Grande, Asch, and Armstrong (2007), the pooled adjusted odds ratio for physician voting across the four elections was 0.70 (CI 0.61–0.81). The authors looked at 350,870 participants in the Current Population Survey November Voter Supplement from 1996-2002, including 1,274 physicians.
    4. Why do physicians not engage? Earnest, Wong & Federico (2010) have a few ideas.
      1. Physicians have busy clinical lives—perhaps time is too scarce.
      2. Doctors are trained to keep personal opinion and preferences out of the clinical encounter.
      3. We are taught to approach political and religious issues cautiously.
      4. Lastly, there is fear of political fallout (and the scrutiny that comes with it- one of my biggest fears).
    5. Physician political beliefs matter.
      1.  Hersh and Goldenberg (2016) linked 20,000 primary care physicians in 29 US states to a voter registration database, obtaining the physicians’ political party affiliations. They then surveyed a sample of Democratic and Republican primary care physicians with politicized health issues like marijuana and abortion. The physicians’ partisan identity was highly correlated with their treatment decisions. For example, Republicans were more likely to discuss health risks of marijuana, urge the patient to cut down, and discuss legal risks. Liberal physicians were more likely ask patients not to store firearms in the home.
      2. Interesting side points from the original data: 67% of surgeons were Republican, 24% of psychiatrists were Liberal and 52% of family doctors were Liberal (Sanger-Katz, 2016).
    6. People trust doctors
      1. In a survey of  1,720 Canadians aged 18 and over, 81% of participants agreed that they would receive the appropriate care if they were to become seriously ill, 81% have a high level of trust in doctors, 90% rate their doctors’ overall knowledge and communications skills as good, 90% agree that family doctors who receive training in Canada have the skills and expertise necessary to provide quality health care (The Association of Faculties of Medicine of Canada, 2011).

Additional Reading

  1. Doctors of BC paper on professionalism https://www.doctorsofbc.ca/sites/default/files/bcma_policy_paper_med_prof_final_web.pdf
  2. Short slideshow of the 50 most influential physicians in history http://www.medscape.com/features/slideshow/influential-physicians-part-1#page=10

Summary

Society trusts physicians. When we speak up, people listen. It’s important to remember that as part of our societal contract, we have an obligation to advocate for patients. Politics does not need to be a dirty word, but rather “medicine, on a larger scale.”

References

The Association of Faculties of Medicine of Canada. (2011). Shifting Public Perceptions of Doctors and Health Care. Retrieved from https://afmc.ca/future-of-medical-education-in-canada/postgraduate-project/pdf/EKOS-Final-Report.pdf

British Columbia Medical Association.  (2013). Working Together: An Exploration of Professional Relationships in Medicine. Retrieved from https://www.doctorsofbc.ca/sites/default/files/bcma_policy_paper_med_prof_final_web.pdf

Britannica. (2017). Rudolf Virchow. Retrieved from https://www.britannica.com/biography/Rudolf-Virchow

Doctors of BC. (2017). Who we are. Retrieved from https://www.doctorsofbc.ca/who-we-are

Canadian Medical Association. (2017). Advocacy: take action. Retrieved from https://www.cma.ca/En/Pages/advocacy-getting-involved.aspx

Earnest, M. A., Wong, S. L., & Federico, S. G. (2010). Perspective: Physician advocacy: what is it and how do we do it?. Academic medicine85(1), 63-67.

Gruen, R. L., Campbell, E. G., & Blumenthal, D. (2006). Public roles of US physicians: community participation, political involvement, and collective advocacy. Jama, 296(20), 2467-2475.

Hersh, E. D., & Goldenberg, M. N. (2016). Democratic and Republican physicians provide different care on politicized health issues. Proceedings of the National Academy of Sciences, 201606609.

Resident Doctors of BC. (2016). Strategic Plan 2016-2019. http://residentdoctorsbc.ca/wp-content/uploads/2016/06/Strategic-Plan2016-2019_FNL.pdf

Royal College of Surgeons and Physicians of Canada. (2017). CanMED framework. Retrieved from http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-health-advocate-e

Sanger-Katz. (2016). Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat. Retrieved from https://www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html

Schickedanz, A., Neuhausen, K., Bennett, H., & Huang, D. (2011). Do medical professionalism and medical education involve commitments to political advocacy?. Academic Medicine86(9), 1062.

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