Advocacy for change: An important role to undertake with care

As seen during the COVID-19 pandemic, many physicians may be unclear on their role in advocating for additional healthcare resources, appropriate allocation of existing resources, or countering clinical misinformation spread through social media.

Advocacy is generally defined as support or argument for a cause or a person. Physicians are advocates for their patients and for healthcare improvements, but this dimension of medical care can be challenging if the role of physician advocacy is not clear. Numerous definitions and various interpretations of the term can make it difficult to determine what advocacy approaches will be effective and considered appropriate.

A deep tradition

Advocacy has a long and deep tradition in medicine. Recognizing the credibility associated with the medical profession, physicians have traditionally been called on to speak up on behalf of patients or others in need, and to influence policy or program changes. In particular during the COVID-19 pandemic, many organizations and authors highlighted the important role physicians play in countering medical misinformation and advocating for vulnerable patients and regulatory or policy changes to ease the burden on the healthcare system.^1-5

Advocacy is embedded in many aspects of the medical profession, and as a result, medical associations/federations or organizations have developed programs, policies, and statements that define the role of physicians in advocacy.

The Canadian Medical Association states doctors "must be able to freely advocate when necessary on behalf of their patients and should do so in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the healthcare system."⁶

Health advocacy is also one of the core roles for physicians as outlined by the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada in the CanMEDS Framework.^7,8 In the Royal College document, the health advocate role states "…physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change."⁷

As well, many medical regulatory authorities (Colleges).^9-12 have indicated it is generally appropriate for doctors to advocate responsibly, and advocacy should not interrupt the safe provision of care. Jurisdictions such as Alberta have developed detailed resources to support physicians in their advocacy work.¹³

Advocacy at many levels

While advocacy is intrinsic to a physician's role, the approaches to fulfilling this responsibility vary and may sometimes cause difficulty for physicians. For example, ambiguity about the appropriate level of advocacy and the accepted approaches can lead to misunderstandings or conflicts between physicians, or between physicians and other individuals or groups. This uncertainty can also lead to accusations of overstepping bounds, irresponsibility, or inappropriate behaviours and actions. Failure to successfully influence change through advocacy can lead to frustration, cynicism, and complacency.

Healthcare advocacy by physicians can occur at many levels and can take different forms. For example, doctors often advocate for individual patients by requesting timely diagnostic tests, access to certain treatments, or referral to a specialist. Physicians may advocate at the regional level or for groups of patients, for example by supporting an expanded community health centre or by seeking funding for a health provider to join a hospital. At the system level, physicians may advocate for a provincial medical association/federation’s strategy or activities to improve healthcare overall. Advocacy can also be global, for instance, when physicians support health-related environmental protection.

Advocacy strategies can vary from one-on-one discussions with those in authority, to letter writing and social media campaigns. Physicians will want to consider the appropriateness of the campaign, and their role in it. Before engaging in any public advocacy activity, physicians should consider whether it is necessary or appropriate to discuss the planned activity with parties who may be affected (e.g. patient/family, other members of the care team, clinic, hospital, health authority, etc.). While it is generally a courtesy for physicians working in hospitals to notify the hospital administration in advance, some hospitals may require that express permission be obtained before a physician embarks on activities that could be interpreted as directly involving the hospital. Hospitals, institutions, and health authorities may have policies or guidelines on the role of physicians in advocacy activities, including media or social media campaigns. Colleges may also have policies or guidelines concerning social media use by physicians, which may apply to advocacy conducted through a social media platform.^14,15 When speaking publicly, physicians should be clear when their comments are made in a personal capacity or on behalf of a third party.

The CMPA recognizes there may sometimes be ambiguity regarding what constitutes appropriate advocacy. The Association believes physicians should remain engaged in healthcare decision-making and advocate in a professional manner for the interests of patients and the healthcare system. For example, many physicians strongly support health promotion initiatives such as influenza vaccines. Some doctors may back patients in their quest for new healthcare programs, encourage new disease treatment options, or promote innovation at the point of care. Others may speak out in support of restrictions imposed by public health when dealing with a pandemic or public health emergency.

All of these activities are appropriate as long as physicians act professionally, provide an informed perspective, and offer constructive input and recommendations to the appropriate groups or individuals. Even advocating in a personal capacity or repeating the comments of others can lead to scrutiny by regulatory authorities and/or hospitals, particularly when the advocacy is perceived to reflect negatively on the reputation of the medical profession. For example, physicians who retweet misinformation about purported cures or treatments for illnesses can expect questions from their College or hospital.

Learning about advocacy

Medical students may be attracted to medicine because of the impact that medical care, including advocacy, can have on individuals and society. Trainees and new physicians are often particularly exposed to patients with diverse backgrounds and circumstances, including refugees, the homeless, and marginalized patient groups. Involvement in the care of such patients can generate an interest in advocating for the healthcare needs of vulnerable patients.

Doctors are well-positioned to identify areas for health system change and to recommend improvements. While many physicians are very skilled advocates, these abilities are not necessarily natural for all doctors. Most often, advocacy is a learned skill.

While physician advocacy is increasingly discussed in undergraduate and postgraduate medical curricula, medical students and physicians may wish to seek out other sources of information and training. The Canadian Medical Association offers an advocacy skills training program that includes tips for building successful relationships with elected officials and building an effective advocacy campaign.¹⁶

Medical regulatory authorities (Colleges) have also made efforts to clarify how physicians can advocate effectively. For example, the College of Physicians and Surgeons of Alberta helps physicians understand how, when, and under what circumstances they can advocate effectively.^9,10 In Ontario, the College has a policy on Physician Behaviour in the Professional Environment that recognizes advocacy as an important component of the physician’s role.¹¹ In Québec the advocacy role is embedded in the College’s Code of Ethics of Physicians. The Code indicates that a "physician must collaborate with other physicians in maintaining and improving the availability and quality of the medical services to which a clientele or population must have access."¹²

Advocating in institutions

Physicians working in healthcare institutions may face additional hurdles when advocating for patients or system changes. For example, doctors working in facilities may have to channel their recommendations for change through committees, or chiefs of divisions/departments. In some instances, there have been disagreements between individual doctors and hospitals or health authorities where the hospitals or health authorities had guidelines, bylaws, or policies on how to advocate for improvements.

Despite these challenges, as healthcare providers and leaders, physicians play a much-needed role in helping improve and sustain the health system. This may include being involved in structural changes, priority setting, resource allocation decisions, quality improvement projects, or initiatives to improve patient safety, among other matters. All who advocate within the system should demonstrate recognition of competing demands. Physician advocacy should be accompanied by evidence of that awareness.¹⁷

When advocating within their institutions, the CMPA recommends doctors:

• Approach the issue with transparency, professionalism, and integrity. Keep that approach when on social media. For example, use appropriate language, and review the entire thread of a conversation or any embedded links before retweeting.
• Work within approved channels of communication.
• Discuss concerns, suggestions, and recommendations calmly.
• Provide an informed perspective, and seek the perspectives of patients and other healthcare professionals.
• Use evidence to help persuade others.
• Remain open to alternative suggestions or solutions, and try to build on areas of consensus.
• Be cognizant that not all good ideas can be implemented at once; be patient.

Final thoughts

The challenges facing physicians in today's practice environment are growing at the same time that patients face a complex and shifting healthcare system. As a result, patients will continue to look to you, their doctor, as a trusted source for healthcare information and support. Consequently, it is likely advocacy will only increase in importance. While the definition of appropriate advocacy in healthcare is evolving, you can show leadership by remaining engaged and seeking to advance your viewpoints in a professional and appropriate manner. If you have questions or concerns about advocacy, contact the CMPA to discuss them with a physician advisor.

References

1. Tang B, Zhou LL. COVID-19: An Accidental Catalyst For Change In The Canadian Health Care System. BCMJ. 2020 Sep [cited 2020 Oct 26];62(7).
2. Royal College of Physicians and Surgeons of Canada Newsroom Announcements. RCPSC;2020 Apr 9. Canada’s doctors launch new campaign to bring health information about COVID-19 to Canadians [cited 2020 Oct 26].
3. HealthLeaders. HealthLeaders media; 2020 Jun 1. Physician Advocate: Coronavirus Pandemic Shows Need to Ease Regulatory Burdens [cited 2020 Oct 26].
4. American Medical Association Patient Support and Advocacy. AMA; 2020 Sep 22. COVID-19 misinformation: What physicians can do to stop it [cited 2020 Oct 26].
5. Health Affairs Blog. Project HOPE; 2020 Aug 19. No Longer An Elective Pursuit: The Importance Of Physician Advocacy In Everyday Medicine [cited 2020 Oct 26].
6. CMA Policy. Canadian Medical Association;2012 p.14. The Evolving Professional Relationship between Canadian Physicians and Our Health Care System: Where Do We Stand? [reviewed 2019 Mar 3; cited: 2020 Oct 26].
7. Royal College of Physicians and Surgeons of Canada. RCPSC;2015. CanMEDS Role: Health Advocate [cited 2020 Oct 26].
8. Shaw E, Oandasan I, Fowler N, eds. CanMEDS-FM 2017: A competency framework for family physicians across the continuum. Mississauga: The College of Family Physicians of Canada; 2017.
9. College of Physicians and Surgeons of Alberta. AMA;2015. Code of Conduct, Expectations for Alberta Physicians [cited 2020 Oct 16].
10. College of Physicians and Surgeons of Alberta. AMA;2017. Advice to the Profession: Professional Courtesy [cited 2020 Oct 26].
11. College of Physicians and Surgeons of Ontario. CPSO;2007. Physician Behaviour in the Professional Environment [reviewed and updated May 2016;cited 2020 Oct 26].
12. Collège des médecins du Québec. CMQ ; 2015. Code of ethics of physicians [cited 2017 Apr 28].
13. Alberta Medical Association. AMA. Physician Advocacy [cited 2020 Oct 26].
14. College of Physicians and Surgeons of Ontario. Social Media- Appropriate Use by Physicians [cited 2020 Oct 26].
15. College of Physicians and Surgeons of Alberta. AMA; 2020. Advice to the Profession: Social Media [cited 2020 Oct 26].
16. Canadian Medical Association. Advocacy skills coaching [cited 2020 Oct 26].
17. Wasylenko E. Jugglers, tightrope walkers, and ringmasters: Priority setting, allocation, and reducing moral burden. Healthc Manage Forum (summer 2013);26(2):79. DOI: https://doi.org/10.1016/j.hcmf.2013.04.006

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.