The Role of Physician Advocacy in Achieving Health Equity: Where is the allergist-immunologist?

Abstract

As allergists and immunologists many of us have likely worked in the capacity of being an advocate for individual patients. However how many of us are aware of our ability to be effective advocates who address root causes of health issues through policy changes? Physician advocacy is not a core competency medical specialty training (except pediatrics) yet physicians’ clinical and research expertise; and professional experience can be leveraged to shape policy. This rostrum describes the spectrum of activities for a physician advocate, barriers to physician advocacy, and actionable steps to encouraging the training and expansion of advocacy efforts by allergists and immunologists.

Physician advocacy is a critical population health strategy emphasizing individual and collective actions to effect positive change in healthcare delivery and healthcare outcomes^1,2. Some physicians consider advocacy to be a “calling many of us have pursued – one way or another – for many years”, while others do not see advocacy as an essential or even a minuscule part of their role as physician. Regardless of how advocacy is perceived by physicians, a major issue is that physician advocacy is undefined, does not have clear competencies, and there are no formal, minimal training requirements across all medical specialities³. This article will highlight the importance of physician advocacy as a strategy and practice to improve healthcare outcomes, while also encouraging readers to expand their advocacy efforts and skills. We also will describe the spectrum of activities within physician advocacy, facilitators and barriers of physician advocacy, state of advocacy training/experience in medical education, benefits of physician advocacy, and future directions to have physician advocacy integrated into Allergy-Immunology training and practice.

History of Patient Advocacy: Where is the Physician?

Early patient advocates were more likely to advocate for a cause than for an individual and so we provide some notable historical events in advocacy. Nurses worked to advocate for indigent health care notably with the creation of Visiting Nurse Services in 1893 and the Maternity Center Association in 1918^4,5. The nurse advocates behind these organizations were activists in social movements and voluntary organizations such as civic organizations and early disease-specific non-profit organizations, such as the American Cancer Society (founded as the American Society for the Control of Cancer in 1913)⁶ and the March of Dimes (founded as the National Foundation for Infantile Paralysis in 1938)⁷.

Patient advocacy also has roots in community organizing around health hazards in the environment, typically beginning with concerns about perceived clusters of disease. The Love Canal Homeowners Association was founded in 1978 by individuals concerned about high rates of cancer and birth defects in their community⁸. The West Harlem Environmental Action (WE ACT) in the 1980s advocated for environmental justice for low income and minority residents⁹.

The utilization of patient advocates by individual patients continued to gain momentum in the early 2000’s in the United States. As the complexity of healthcare systems increased and as the financial burden of healthcare on patients increased, private professional advocacy began to emerge in the mid-2000’s. During that time several professional organizations were founded to support the activities of professional patient advocates such as the National Association of Healthcare Advocacy Consultants (NAHAC)¹⁰.

Amongst clinicians, nurses have long been at the forefront of patient advocacy as aforementioned¹¹. The American Nurses Association (ANA) includes advocacy in its definition of nursing and its code of ethics for nurses includes language relating to patient advocacy. Their definition of nursing is as follows: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.”

Unlike nurses, there is no universally accepted definition of physician advocacy or similar integration of advocacy into physician core duties¹². There is no blueprint for guiding physicians on how to become physician advocates, defining the scope of what it entails, or defining its competencies. In 2001 the American Medical Association (AMA) stated that physicians must “advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being”¹³. In 2002, the American Board of Internal Medicine (ABIM), and its charter on medical professionalism, called for a “commitment to the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician”¹⁴. Some specialty societies now include advocacy in their definitions of professional responsibilities¹⁵. The Accreditation Council of Graduate Medical Education (ACGME) Pediatrics Review Committee (RRC) requires advocacy training and experience for all pediatric residents since 1996¹⁵. To clarify the concept of physician advocacy Earnest et al. proposed the following definition of physician advocacy: “Action by a physician to promote the social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise”.

The Spectrum of Physician Advocacy Activities

Although physicians are trained to provide care in the context of a clinical encounter to individual patients, we do have the ability to use medicine as an instrument to effect social and political change¹⁶. Some physicians may resist the integration of advocacy into our practice to avoid becoming “physician activists”¹⁷. However, we must acknowledge that the spectrum of physician advocacy is broad and most if not all of us have participated in some form of advocacy during our educational journey. Some of us have likely taken additional steps to ensure a patient received a particular evaluation, test, medication, etc through interactions with other clinicians, administrators, and insurance companies. Physician advocacy also entails efforts addressing the root causes of patients’ health issues; being a champion for health care reform; working with state and specialty societies to implement change; a coalition builder; and policy advisor to community groups and to legislators; a patient and parent educator; or a liaison to the media. Lastly, physician advocacy is unique in that public trust is high and we are seen as trustworthy sources of information².

Physician advocacy also varies by field of expertise and can be implemented at the community, state, or national level. There are several recent notable examples of physician-led advocacy. Dr. Mona Hanna-Attisha, a pediatrician at Hurley Children’s Hospital and founder/director of Pediatric Public Health Initiative, is a prime example of a primary care physician who was able to utilize her expertise and power to serve as a public health advocate for her patients¹⁸. In 2014, the Flint River became the primary source of water instead of the Detroit Water authority for Flint, Michigan. The untreated, elevated chloride levels in this water caused corrosion and leaching of lead from the pipes and thus contaminating the water. Dr. Hanna-Attisha found that the number of patients with elevated lead levels had more than doubled after the water source switch, with the greatest increases in the most disadvantaged areas. After these results were released in a study, residents were advised against drinking the tap water. Another example is the School-based Allergies and Asthma management program Act (HR 2468) is a bill spearheaded and endorsed by the work of Dr. Robert Lemanske, allergist-immunologist and Professor Emeritus at University of Wisconsin School of Medicine and Public Health and numerous other stakeholders. It was introduced to the House in April 2021 then a subcommittee in June 2021¹⁹.

For some of us, the desire to be a physician advocate is innate as we feel that physicians have a social responsibility to address global factors that affect our patients. For others, physician advocacy is a voluntary or optional aspect of their career. The fundamental issues in this difference of opinion are: what constitutes advocacy?; how much responsibility do we have in advocacy particularly in the context of time constraints and the growing concerns of physician burnout?; and how does one integrate advocacy into a career?.

Advocacy allows us to influence the socioeconomic, environmental, and political contexts affecting our patients’ health outcomes ². Fried et al highlight several benefits of physician advocacy. It allows the profession to be seen as a trusted authority in health and demonstrate a commitment to social responsibility²⁰. Secondly, physicians are intimately involved in a patient’s medical care allowing access to a unique expert perspective on the intersection of policies and patient clinical outcomes. Our position as clinicians overseeing care (physician-led care) give us access to invaluable patient stories and narratives that create a crucial understanding of the impact of these policies²¹.

Although physician advocacy does involve this wide spectrum of activities it is evident that to create sustainable changes in our healthcare system, we need more physicians who are more proximal to legislators through or even become legislators themselves. Physician advocates with advocacy training and protected time are critical for us to create and change policy.

Barriers to Physician Advocacy

Are physicians prepared to embrace civic engagement as part of their professional responsibilities? Most physicians have little or no formal training in advocacy skill development. Moreover, there is little time for physician advocacy and there is no compensation for implementing physician advocacy, much of which occurs outside the clinical encounter. There is lack of protected time for the invested hours of participating in physician advocacy activities, most of which are not contributory to promotion within medical institutions in the United States. (Figure 1).

Figure 1:

Barriers to Physician Advocacy

Some insurance companies and health care systems can obstruct physicians acting in the patient’s best interests through financial and insurance mechanisms. For example, physicians may be penalized financially by some institutions for referring patients outside of their “home” institutions for medical care²². Similarly, physicians may be deselected from certain insurance networks for ordering tests the insurance companies perceive as financially prohibitive, although these tests would be appropriate as a diagnostic and/or management tool.

How Do Physician Advocates Interact With Legislators?

Before we discuss physician advocate interactions, we wanted to describe the process by which an idea becomes law at the state/national level (Figure 2)²³. The main function of Congress, consisting of House of Representatives (House) and the Senate, is to make laws. Laws start with an idea from a public citizen, a legislator, a recommendation from a department/agency or an advocacy group. A bill is drafted and is introduced in the House or the Senate and then is referred to a committee consisting of Congress members with special interests in relevant subject matter. The committee may hold recorded hearings where public citizens, experts, other public officials, and supporters/opponents discuss implications of the law. Subcommittees (or specialized committees) review and make changes and decide if the bill should be sent back to the committee. The Committee then meets to review and revise the bill, and then recommends the bill to be sent for formal consideration in the House or Senate. In the House or Senate, the bill is debated/discussed and then there is a vote to be passed or note. Of note, the bill most go through both sides of Congress. After being passed it is then signed into law by a state Governor or President on the state and national level, respectively. Both a state governor and president can veto the bill, however the veto can be overruled if the both the House and Senate pass the bill by a two-thirds majority vote.

Figure 2:

Overview of how ideas become law and areas where physician advocates can intervene

Physicians typically will provide expert testimony during committee meetings or public hearings²⁴. Physicians can also communicate with health care legislative assistants on behalf of their senator or congressman or directly with the legislator². These meetings typically occur in-person but are often phone or video calls. Emails or written communications are usually the most effective early in the legislative process. Recently the use of social media could be a powerful tool to ensure action or awareness about time-sensitive issues e.g upcoming vote.

There is limited empirical evidence on how often physicians interact with legislators, issues that are discussed in these interactions, and effectiveness of physician advocacy. Landers et al in 2000, interviewed 120 legislative assistants of Congress members about the frequency of physician and legislator interactions, topics of discussion, and the effectiveness of physician advocacy²⁵. The respondents reported about an average of 4 to 10 meetings with physicians per month. The most common issues lobbied by physicians were: Medicare reimbursement, managed care reform, and medical research funding. Notably in this article, respondents reported a need for more physician input on access to care for underserved populations and improving health outcomes. Regarding effectiveness of physician lobbying, although about half of respondents noted that physician lobbying was effective, it was suggested that physicians lobby less about reimbursement, know more about the legislative process, and to lobby outside of professional societies. Although the authors did not offer reasons why the survey respondents gave the latter comment, we think this suggestion was related to the differences in the issues physicians lobby vs, what voters lobby (making Medicare financially sound, gun control, insurance for the uninsured, managed care reform).

What are the Advocacy Activities of Medical Professional Organizations?

Specialty and subspeciality societies such as the American College of Allergy Asthma and Immunology (ACAAI), American Academy of Allergy Asthma and Immunology (AAAAI), and the AMA work regularly with local, state, and federal government to create opportunities to improve support of bills or legislative efforts. Physicians can engage in advocacy through these medical and specialty organizations by serving as committee members and delegates²⁶. The ACAAI offers state delegate and super-delegate positions open only to College members. These delegates serve as critical liaisons between the other delegates; House of Delegates leadership; and local, state, and regional societies. They monitor local/regional legislation or regulatory issues; and establish maintain contact with legislators, colleagues, and allergic societies.

Similarly, the AAAAI Advocacy Committee works with the AAAAI Board of Directors (BOD), its members, and professional representatives to ensure that the AAAAI mission is brought to the forefront through relevant health policy. Activities include letter writing campaigns, Capitol Hill fly-ins, and organizing support for updated national practice and health systems policies or other niche advocacy organizations’ missions.

Current State of Advocacy Training in Medical Education

As we prepare for individual patient care along the journey through undergraduate, graduate, and postgraduate medical education, we must prepare students and trainees to participate in the complexities of physician advocacy. This complexity was further highlighted with the intersection of the COVID-19 pandemic and the acknowledgement of the United States’ underlying structural racism collided, when there was a re-energized discussion of advocacy training during our educational training and beyond ²⁷. Subsequently there has been greater global interest in improving physicians’ true capacity to be the ideal community advocate and thereby become change agents in the elimination of racial disparities. Fried et al. described advocacy as a team sport where residency programs and specialty societies play an essential role in extending physician advocate competency, particularly by creating training program initiatives and developing physician toolkits.

The consistent theme in the literature is the need for standardizing the advocacy curricula for teaching and competency. Specifically, Howell et al highlighted the non-standardized range of educational methods and experiences to implement and maintain this training experience, which naturally prompted a few questions²⁸. What is the necessary role of physicians in community advocacy? And how do we amplify, almost perfect, the social contract of advocacy within the physician profession?

As ACGME requirements for pediatric trainees include advocacy, pediatricians are regularly preparing and participating in advocacy training and activities. Within several other specialty residences, such as family medicine, internal medicine, and emergency medicine and orthopedic surgery, there are unique strategies evolving to establish effective learning experiences in advocacy, without establishing concise standards. In 2020, Scott et al, reviewed postgraduate medical education health advocate core competencies with a focus on Canadian training²⁹. They identified participating residency programs beyond pediatrics to include psychiatry, obstetrics and gynecology, preventative, internal and emergency medicine and neurology³⁰. The various teaching methods described were classroom-based interventions, clinical placements/practicums, role play, and “observerships or field trips” all of which varied widely in duration and outcomes evaluation²⁹. Therefore, creating and maintaining consistent methods of teaching beyond the individual patient-centered advocacy needs to focus on health systems, population-level, legislative/health policy and grassroots/community engagement. The importance of unambiguous advocacy skill set experiences in dissolving health disparities and actively addressing the social determinants of health are vital to this framework.

However, there have been advances, such as the American Academy of Pediatrics Community Pediatrics Training Initiative, which supports advocacy grant training and visiting professorships to spread advocacy curriculum development and adoption³¹. Additionally, elective seminars/modules and mentored community engagement projects are becoming more common. Canada has created formal regulatory guidelines for teaching health advocacy and published their revised CanMEDS Physician Competency Framework which introduces the Health Advocate role²⁹.

Brender’s recent review of over 100 medical schools’ curricula showed greater than 75% offered at least one advocacy course, but the Liaison Committee on Medical Education (LCME), the accrediting body for educational programs at schools of allopathic medicine in the US and Canada, does not list advocacy as a requirement³². Their evaluation revealed an extensive variation in content of elective courses, a large focus on pediatric advocacy, and the absence of any content for reducing health disparities.

How will we train for this vital competency of local, state, and federal advocacy to elevate the current work of allergist-immunologists in health policy to achieve health equity? We provide practical steps to support the development of physician advocates and how those who are interested can get involved.

Actionable steps in Physician Advocacy (Table 1)

Table 1:

Actionable Steps in Physician Advocacy

Actionable Steps in Physician Advocacy	Examples
Fellows-In-Training advocacy curriculum and opportunities (eg. workshops, electives) with projects focused on equity	AMA Medical Justice in Advocacy Fellowship The Commonwealth Fund Fellowship in Minority Health Policy at Harvard University
Protected time/Awards for advocacy	HMS Equity, Social Justice, and Advocacy Award
Community engagement through collaboration with established leaders	Not One More Life (NOML)
Collaborative lobbying amongst medical professional organizations	Section on Allergy Immunology of AAP
Direct contact with legislators	https://www.house.gov/representatives/find-your-representative https://www.senate.gov/senators/senators-contact.htm
Advocacy liaisons in specialty organizations and institutions	AAAAI-COU liaisons ACAAI delegate and superdelegate positions
Approval of Advocacy Projects for Maintenance of Certification in A/I	The American Board of Pediatrics
Supporting legislation to actively dismantling structural racism and addressing equity issues	S.203 Healthy Food Access for All Americans Act HR 666 Anti-Racism in Public Health Act of 2021 HR 5030 DIVERSE Trials Act

1. Training in residency and in fellowship

ACGME Residency core program requirements include residents learning how to be advocates within the context of the health care system, but fellowship program requirements do not include this. Programs have incorporated advocacy education in their curriculum through various methods including use of workshops and the development of advocacy core rotations or electives²¹. Unlike resident physicians, subspecialty fellows do not have the core competency requirements for advocacy training.

Selected examples of training:

AMA Medical Justice in Advocacy fellowship:

Offers a 14 month-long program open to residents, fellows, and faculty interested in health equity and advocacy aimed to enhance advocacy leadership skills through the understanding of inequities, various advocacy models, and ways to engage resources³³.

The Commonwealth Fund Fellowship in Minority Health Policy at Harvard University:

This one year and full-time fellowship prepares physicians to improve the health of vulnerable populations through academic coursework (MPH or MPA), leadership training in health policy and management, mentoring, and networking³⁴. Applicants must have completed residency; therefore, fellows and faculty are eligible to apply.

George Washington University Residency Fellowship in Health Policy:

This 3-week elective provides residents and fellows from any specialty aims to prepare physicians with health policy knowledge and the skill set to be physician-leaders in systems-based practice. The elective entails lectures, interactive seminars, site visits with policymakers and policy analysts, and participants making presentations with policy recommendations. The program was associated with increased knowledge of health policy³⁵.

American Academy of Pediatrics (AAP) Advocacy Conference: This annual conference entails an entire curriculum dedicated to educating, training, and preparing attendees (trainees and faculty) for congressional meetings³⁶.

Next step(s): We encourage our specialty organizations AAAAI and ACAAI to create programming during Fellows-In-Training (FIT) sessions and longitudinal learning sessions that engage fellows in advocacy projects. These projects can be co-created between the Advocacy Committees, lobbying groups, and the trainees and entail equity as a fundamental principle. If the institution of a particular Allergy-Immunology fellowship program has an advocacy elective, fellowship trainees should be encouraged to participate. Also, we propose the expansion of fellowship scholarly project options to include advocacy.

• 2.Protected time and promotion/acknowledgement for physician advocacy activities

As discussed above a significant barrier to conducting advocacy activities is a lack of protected time. Similar to grants for research training and activities, grants for advocacy activities should be created and/or offered as part of faculty packages. Moreover, acknowledgement of physician advocacy activities could be recognized by awards from professional organizations and institutions. For example, Harvard Medical School created the Equity, Social Justice, and Advocacy award in 2021 to recognize staff, students, trainees, and faculty who impact marginalized populations through community engagement, expert testimony, position statements, curriculum development, research, clinical care.

Next step(s): We encourage our specialty organizations AAAAI and ACAAI to create awards to recognize the advocacy efforts of staff, trainee, faculty members. Consideration can even be given to create awards to recognize the advocacy efforts of committees.

• 3.Partnerships with community-based organizations as advocacy

Community engagement and collaboration with established community leaders/members can be considered a form of advocacy as mutually beneficial relationships can be cultivated particularly in research partnerships and as mechanisms to improve health outcomes.

Not One More Life (NOML), subsidiary of the Allergy and Asthma Network³⁷:

NOML was created by Dr. Leroy Graham, a pediatric pulmonologist, after being inspired by the death of a 10-year-old Black child due to an asthma exacerbation. NOML partnered with Black ministers to promote health and social justice of Black people in Atlanta, Georgia, who were able to provide insight into the barriers to respiratory health and utilized their established connections to engage other Black clergy and patients. Through these relationships NOML focused its efforts on providing respiratory assessments, asthma education, counseling, and referral options. NOML has spread to more than 20 cities and now includes public schools.

Next step(s): We encourage our specialty organizations to provide funding to support community engagement projects by their members; and to continue to foster partnerships with nonprofit organizations centering equity in allergic and immunologic conditions such as the Elijah-Alavi Foundation, Food Equality Initiative (FEI), and Alerje.

• 4.Collaborative lobbying amongst allergy-immunology and other medical professional groups (e.g. AMA, AAP, American Thoracic Society), non-profit organizations (Food Allergy Research & Education, FEI, Asthma and Allergy Foundation of America) and coalitions on specific issues e.g cost of inhalers, biologics access, telehealth equity, food insecurity

The AAP Section on Allergy and Immunology has worked closely with several allergy immunology groups to advocate for improved pediatric device and drug laws such as the Pediatric Research Equity Act and the Best Pharmaceuticals for Children Act³⁸.

Next step(s): We acknowledge that there is collaboration amongst organizations that is not obvious to the public. We encourage our specialty organizations to highlight these collaborations and be more transparent. We suggest joint Advocacy events and conferences for members that support education and training, similar the aforementioned annual AAP advocacy conference.

• 5.Consider direct contact with legislators independent of your institution or professional society

See Table 1 for ways physicians can directly contact their legislators. The websites included allow users to find legislators by inputting a zip code. Physician advocates can utilize many means to contact legislators. Social media can be particularly effective as one can garner support and increase awareness amongst colleagues, too. The timing of contact is important as legislators are more interested in hearing from constituents on days leading up to votes. The voting calendar and voting record are accessible on legislators’ website. Some of the authors of this article, have worked with non-profit organizations to provide written and oral testimony during legislative hearings; clinical and research expertise during legislative briefings, and policy statements³⁹. This direct contact facilitates communication of issues that not necessarily represented by our institutions or specialty organizations.

Next step(s): We encourage our readers to find your local town, city, and/or state representative(s) and review their voting history and schedule to see if they are in alignment with issues important to you.

• 6.Facilitate knowledge transfer to the policymaking process by creating dedicated teams within professional organizations and medical institutions to identify medical evidence to support current legislation

In 2020, AAAAI president Dr. Mary Beth Fasano supported the creation of liaisons between the Advocacy Committee and Committee on the Underserved. This unpreceded partnership between AAAAI committees aimed to ensure that critical legislations regarding racial equity were identified and supported by the AAAAI. The siloed nature of medical culture of institutions leads to decreased cross talk and collaboration. The Advocacy-COU Liaisons is an example of making intentional efforts to enhance partnerships, make effective change, and tackle inequity in unprecedented ways. As aforementioned, the delegate and superdelegate positions within the ACAAI are critical positions to allowing effective transfer of key legislative matters across the organization and efficient mobilization.

Next step(s): Continued support and creation of Advocacy liaisons and delegate positions in professional organizations and within institutions.

• 7.Allow opportunities for faculty to participate in advocacy by including it in ABAI Maintenance of Certification (MOC)

One of the modules of ABAI MOC includes Practice Assessment/Quality Improvement which are activities that board-certified allergist-immunologists need to complete every five years entailing examining their patient care approaches and critiquing the literature to improve one’s clinical practice. Other certifying boards such as the American Board of Pediatrics allow advocacy projects for MOC Part 4 credit (25 points).

Next step(s): We propose that adding an opportunity to participate in an advocacy project and/or activity would fulfill this requirement and bring substantial long-lasting change to our field. Projects could include writing an op-ed; providing an allergy-immunology educational curriculum to community partners e.g school nurses; participate in a lobby event by your medical institution or specialty organization; draft a petition on a specific issue and get others to sign and send to a legislator; conducting research analyses investigating the impact (harms and benefits) of certain policies on health outcomes

• 8.Dedicated Advocacy for Health Equity

An integral component of physician advocacy as an allergist-immunologist should include intentional efforts to achieve health equity for groups that have been historically marginalized and are disproportionately affected with worse outcomes for allergic and immunologic conditions. There must be dedicated effort, as those who are experiencing hardship and disadvantage will typically not be in a situation to have contact with a policymaker. We must apply the biopsychosocial model to our understanding and management of allergic disease⁴⁰, and utilize this is a way to convey the importance of social determinants of health including the role of structural racism in our discussion with legislators. We need to convey that addressing these issues are paramount to achieving good health outcomes and reducing cost.

Next step(s): We encourage our specialty organizations and partners to advocate for legislation targeting racial equity and racism. Several current priority topics include: the intersection of food insecurity and food allergy (Bill S.203); physician and researcher workforce diversity (Bill HR 801); access to clean, affordable housing (Bill HR 1501); consistent and accurate race/ethnicity data collection across all sectors (HR 5030, HR 1370); anti-racism efforts (Bill HR 666).

As we focus on improving our patients’ societal wellness and subsequently the community at large, it is vital that we are part of the solution for improving healthy patient outcomes beyond the immediate clinical experience. Being a physician advocate is a way to be a part of that solution.