Safety of care
The physician voice: When advocacy leads to change
Originally published June 2014 / Updated May 2017
Advocacy is typically 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 well understood. Numerous definitions and various interpretations of the term can make it difficult for doctors to determine what advocacy approaches will be effective and considered appropriate.
A deep tradition
Advocacy has a long and deep tradition in medicine. Dr. Rudolf Virchow, one of the most prominent physicians of the 19th century and known as the father of modern pathology, said physicians were "natural attorneys of the poor."1 Recognizing the credibility associated with the medical profession, physicians have traditionally been called upon to speak up on behalf of patients or others in need, and to influence policy or program changes.
Advocacy is imbedded in many aspects of the medical profession, and as a result, medical associations or organizations have identified 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."2 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. As well, many Colleges 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.3
Advocacy at many levels
While advocacy is intrinsic to a physician's role, the approaches to fulfilling this responsibility may sometimes be a cause of difficulty. Ambiguity about what is the appropriate level of advocacy and the general 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'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 within it. Prior to 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. 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, while others avoid doing so. Some doctors may back patients in their quest for new healthcare programs, or encourage new disease treatment options, or promote innovation at the point of care. 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.
Learning about advocacy
Medical students and doctors 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 increasingly exposed to a wide spectrum of patients including refugees, the homeless, and other disadvantaged patient groups.
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.
Advocacy plays a larger role in the new edition of the CanMEDS Framework, which will be used to guide both residency training and education for practising physicians. The Health Advocate role in CanMEDS 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."4
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 meeting members of parliament, an overview of how government works, media training, and communicating key messages.5
Colleges have also made efforts to guide or clarify how physicians can advocate effectively. For example, the College of Physicians and Surgeons of Alberta signaled its intention to help physicians understand how, when, and under what circumstances they can advocate effectively. In Ontario, the College has a policy on Physician Behaviour in the Professional Environment that recognizes advocacy as an important component of the doctor-patient relationship.6 In Québec the advocacy role is embedded in the 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."7
Advocating in institutions
Physicians working in private practice may feel more at ease to advocate for patients or for changes. Meanwhile, physicians working in healthcare institutions may face more complexity. For example, doctors working in facilities may have to channel their recommendations for change through committees, or chiefs of divisions/departments. Hospitals or health regions may have guidelines on how to advocate for improvements. There may be organizational bylaws or policies that outline how to advocate on behalf of patients or health system issues. In some instances, this has led to disagreements between individual doctors and hospitals or health authorities.
As healthcare providers and leaders, physicians can help 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 must demonstrate recognition of competing demands. Physician advocacy should be accompanied by evidence of that awareness.8
When advocating within their institutions, the CMPA recommends doctors:
- Approach the issue with transparency, professionalism, and integrity.
- 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 happen at once; be patient.
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 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, physicians can show leadership by remaining engaged and seeking to advance their viewpoints in a professional and appropriate manner. Members with questions or concerns about advocacy should contact the CMPA to discuss these with a physician advisor.
- Arya N. Advocacy as Medical Responsibility. CMAJ. 185(15):1368.
- Canadian Medical Association [Internet]. The Evolving Professional Relationship between Canadian Physicians and Our Health Care System: Where Do We Stand? 2012 [cited 2013 Nov 27] p.14. Available from: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD12-04.pdf
- Alberta Medical Association [Internet]. Physician Advocacy. 2016 [cited 2017 Apr 28]. Available from: https://www.albertadoctors.org/advocating/physician-advocacy
- Royal College of Physicians and Surgeons of Canada [Internet]. CanMEDS. [cited 2017 Apr 28]. Available from: http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-health-advocate-e
- Canadian Medical Association [Internet]. Advocacy skills training. [cited 2014 Feb 20]. Available from: https://www.cma.ca/En/Pages/advocacy-skills-training.aspx
- College of Physicians and Surgeons of Ontario [Internet]. Physician Behaviour in the Professional Environment. Policy number #3-16 [cited 2017 Apr 28]. Available from: http://www.cpso.on.ca/Policies-Publications/Policy/Physician-Behaviour-in-the-Professional-Environmen
- Collège des médecins du Québec [Internet]. Code of ethics of physicians. [cited 2017 Apr 28]. Available from: http://www.cmq.org/publications-pdf/p-6-2015-01-07-en-code-de-deontologie-des-medecins.pdf?t=1493046300365
- Wasylenko E. Jugglers, tightrope walkers, and ringmasters: Priority setting, allocation, and reducing moral burden. Healthcare Management Forum (summer 2013). Vol. 26, no. 2 p.79