Physician Advocacy: Identifying Motivations for Work Beyond Clinical Practice

Abstract

Introduction

Advocacy is a perceived social and professional obligation of physicians. However, many feel their training and practice environment do not support increased engagement in advocacy. The aim of this qualitative project was to delineate the role that advocacy plays in physicians’ careers and the factors driving physician engagement in advocacy.

Methods

Physicians engaged in health advocacy in Kansas were identified by personal contacts and referrals through snowball sampling. They received a standardized email invitation to participate in a short interview. These interviews were recorded and transcribed using Apple Voice Memos and Google Dictation. Two team members independently identified themes from interview transcripts, while a third member served as a moderator if themes identified were dyssynchronous.

Results

Of the 19 physicians invited to participate, 13 were interviewed. The most common reasons for engaging in advocacy included the desire to change policy, obligation to go beyond regular clinic duties, giving patients a voice, and avoiding burnout. Physicians reported passion for patients and past experiences with disparities as the most common inspiration. Most physicians did not receive formal advocacy training, but identified professional societies and peers as informal guides. Common supports for advocacy were professional organizations, community partners, and employers. Time was the most common barrier to conducting advocacy work.

Conclusions

Physicians have a broad number of reasons for the importance of doing advocacy work, but identify key professional barriers to further engagement. Providing accessible opportunities through professional organizations and community partnerships may increase advocacy participation.

INTRODUCTION

There is increasing support for the idea that advocacy is a core component of the professional obligations of physicians. In 1996, the Royal College of Physicians and Surgeons of Canada recognized “Advocate” as one the seven essential physician roles.1 The perceived social responsibility of practicing physicians was highlighted in the American Medical Association’s Principles of Medical Ethics: “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and betterment of public health”.2 Advocacy has been defined as “action by a physician to promote to 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”.3 Physicians are perceived by society to have a duty not only to improve the health of their individual patients, but also improve the well-being of society as a whole.4

Despite increasing pressure to perform as advocates, many physicians feel that their training and practice environment do not support engagement in advocacy.5 Modernization of the health system, increased administrative demands, and changes in reimbursement structure may serve as barriers to further involvement.6 To promote the idea that advocacy is an integral aspect of modern practice, it is necessary to characterize its definition and scope further. The role of being a physician advocate can be challenging and there are many barriers that must be overcome to engage in advocacy work.

Initially involving oneself in advocacy activities may seem overwhelming.3 Additionally, time constraints can play a role in limiting a physician’s ability to participate in advocacy projects.3,7 Some residency programs have begun requiring formal advocacy training within the curriculum to alleviate these barriers.8–10 In addition, national models exist to fund advocacy efforts surrounding various health issues, for example, in work surrounding HIV.11 Initiatives have been proposed to facilitate involvement of physicians in advocacy work. One such initiative proposed standardizing a portfolio, so that physicians can better quantify the successes of their advocacy and promote them as scholarly work.12

The purpose of this study was to delineate further the role advocacy plays in a physician’s career. Specifically, this project aimed to investigate the driving factors that influence and inspire, as well as the barriers that limit physicians’ decisions to engage in advocacy work.

METHODS

The Institutional Review Board indicated that this project did not require ethics review, as it is educational research, did not involve patients, and posed no risk to the participants.

Participants and Setting

Physicians were identified using a snowball sampling technique, which is a form of convenience sampling that includes members of the population who are available to the researcher. 13 Using this method, an initial list of physicians well-known for their advocacy work in this region was compiled by the researchers. From this list, those contacted recommended other physicians to add to the invitee list. This project was completed during the month of February 2020.

Data Collection

Data were collected through an interview process. Potential interviewees were contacted initially via email, using a standardized template. An in-person interview was preferred. If the physician was not available for in-person interview, a phone interview was conducted. Each participant verbally consented for interviews to be audio-recorded and transcribed. Interviewees were asked not to disclose personal patient information during the interview. Each interview lasted approximately 15–20 minutes, using a structured interview guide of predetermined questions (Table 1). Interview audio was recorded using Apple Voice Memos software on a mobile device. Interview transcription was recorded using Google Dictation. The transcriptions were corrected manually by referencing the audio recording. Interview transcripts then were uploaded to a shared drive for review.

Table 1.

Interview structure.

Demographics Collected	1. Specialty of practice
	2. Number of years in practice
	3. Gender
Questions Asked	1. What does physician advocacy mean to you and how it is incorporated in your practice?
	2. What inspired you to engage in advocacy work?
	3. Tell me about any formal or informal advocacy training that you had.
	4. What support have you found for doing advocacy work?
	5. What barriers have you found for advocacy work?
	6. What suggestions do you have for physicians wanting to get involved in advocacy work?

Data Analysis

From these transcripts, themes were developed using thematic analysis methods. Each transcript was reviewed independently by two researchers, who both listened to and read the text to become familiar with the interview. They coded the interview, by selecting key words, phrases, and motifs from the transcripts. The research panel, consisting of five coders, then convened to compare the transcripts. Motifs that were mentioned in multiple interviews were felt to reflect an over-arching theme.14 Following identification of the most prevalent themes, each theme was characterized further by identifying direct quotes from the interviews to be included in discussion.

RESULTS

Invitation to participate was sent to 19 physicians. Four physicians did not respond, 2 did not respond in time to participate, and 13 responded within the study time frame. Of these 13 interviewees, 10 were male (76%) and 3 were female (23%). These physicians practiced in a variety of areas, including Obstetrics and Gynecology, Family Medicine, Pediatrics, and subspecialists including Hepatology, Otolaryngology, Pulmonary Critical Care, Maternal-Fetal Medicine and Palliative Care. They had been in practice for ranges of 1–5, 6–10, 20–29, and 30+ years. Their areas of practice included academic, community, and rural medicine.

Question 1: What does physician advocacy mean to you?

Most participants (8/13) reported that the meaning of advocacy was working to change policy, with one saying “if I’m not in the legislators’ face and telling them about what is important to me, they’re not knocking on my door to find out.” Eight physicians also reported that advocacy was going above and beyond clinical duties. One physician expressed, “So really advocacy is a many faceted kind of word, it starts with the individual patient but it also spreads out to the whole to take every opportunity you can to improve the opportunities for your patients to be healthy and to be safe”. Another echoed, “I think that just everyday as a physician you try to do those things to advocate for each individual patient, but to be able to expand upon that further is identifying a passion or purpose beyond your clinical duties.”

Beyond these two major themes, a few interviewees discussed helping others using “our” stronger physician voice. It was mentioned that advocacy can be used in practice as a means to avoid burnout. Overall, the meaning of advocacy to these physicians was reflected in this statement by one, who said “I think it’s just trying to advocate, speak up, whatever the definition of advocate is. Speak up, argue for, improving patient care above and beyond the examination room.”

Question 2: How is advocacy incorporated into your practice?

Nine physicians discussed their involvement in politics or policy work in response to this question. One expressed, “if you care about something in health care, maybe it’s your specialty and access to your specialty, or access to certain medicines. If you’re not going to talk to your representatives, then it kind of feels like you’re not being a full health care professional, and I think that was a really big frame shift for me to see that is easy to do and it slowly moves the needle.” Beyond political work, some physicians discussed advocacy being incorporated into their practice on a day-to-day basis, helping patients beyond their clinic visit. An example one physician gave was “calling the medical director of an insurance company that has denied a claim is advocacy. It’s personal, it’s one-on-one advocacy, fixing one problem at a time, but I don’t think it has to be getting legislation done. That’s a full-time job. If you’re going to do that you really have to settle in. But there are lots of ways. Calling someone at WIC (Women, Infants, and Children program) saying no this baby really needs this formula not this, that’s advocacy.”

Overall, physicians discussed incorporating advocacy into their practice both in and out of the direct patient care setting. One recalled, “it’s not like seeing a patient in the comfort of an exam room or hospital room, you’re not really among peers but you’re out in the community.” Fewer physicians identified serving in leadership organizations, or training physicians in ways that they act as advocates.

Question 3: What inspired you to engage in advocacy work?

Physicians interviewed drew inspiration from a variety of factors. At the center of this inspiration, was the patient. About half (6/13) of physicians identified passion for both patients and their specialty as inspiration for their involvement, saying “I think it can be so rewarding as a physician that you’re helping patients you’ll never even see”. Others discussed their experience with vulnerable populations. “So what inspires me? People in vulnerable positions. That’s what inspires me, whether it’s financial, physical, whatever, and so I can’t help myself. When I see people like that I get involved and do things.” Expressed less often were involvement in a professional society, a sense of responsibility, interest in public education, and mentorship.

Question 4: Tell me about any formal or informal advocacy training you have had

Most (8/13) physicians reported having no formal training surrounding advocacy. They became involved in advocacy work after having been in practice. Some (6/13) felt they had received informal advocacy education through large medical organizations. Two expressed learning from specific peers or mentors. Only one received formal training through their residency program. One discussed working with medical students in his training, saying he was “actually working at the level of individual students, trying to inoculate values of advocacy for these patients”.

Question 5: What support have you found for doing advocacy work?

Eight physicians identified either community partner or professional organization support, with one noting that “most of my support has always come from professional associations”. Another saying that “there are a lot of community resources that are looking for a physician on certain issues to be there, and they’re more than willing to help in any way they can”. Six discussed support for advocacy from employers, peers, or family members. One discussed “having other peers who are doing it that you can talk to”.

Question 6: What barriers have you found for doing advocacy work?

Professional time was the barrier identified most often by physicians, mentioned in seven interviews. One discussed that advocacy work has “evolved into a requirement of a lot of work that has to occur outside of regular work hours”, and with a “pretty significant clinical obligation, it’s sort of hard to carve out free time for this”. Physicians also identified conflict of opinion as being a barrier to getting involved in advocacy work, as well as fear of damage to personal or professional reputation. One physician stated there are many circumstances that can “probably make some people more reticent to speak out openly for fear that it will reflect poorly on them, their associates, or their organization. So there has to be a way to allow the community, the physician community in particular, to use their voice without fear of repercussion or without concern of misinterpretation in a way that could have a potential negative impact on their reputation or their career.” Barriers identified less often were money and unfamiliarity with advocacy work.

Question 7: What suggestions do you have for physicians wanting to get involved in advocacy work?

Ten interviewees discussed working with and learning from mentors. Advising physicians to “look at people that are doing this and learn from both the good and the bad”. Another expressed, “Don’t reinvent the wheel. There are people who know what they’re doing, and you need to find them.” Seven physicians advised, “just do it”. Five physicians expressed the importance of finding a passion, saying “Identify your passion, because you can’t advocate for something that you don’t really believe in”. In summary, to get involved in advocacy work, identifying a passion, connecting with a mentor who is involved in that area if possible, and jumping right in is the best possible way to get started.

DISCUSSION

This project elucidated physician attitudes towards advocacy and further characterized the role advocacy plays in their careers. This case series of physician perspectives helped illustrate what advocacy means to them and how it can be incorporated into practice. Most echoed the idea that going above and beyond clinical practice is an important role of physicians. This project explored barriers that exist as well as advice for those wanting to overcome these barriers. The barriers that these physicians identified in this study included professional time, conflict of opinion when it comes to policy making, as well as fear for damage to a personal or professional reputation. This was echoed in other literature. Luft et al.3 expressed that “financial and time pressures in practice may make it difficult for practicing physicians to take on anything more than the pressing clinical problem at hand”. They also noted that “fear of being ostracized and straying from guideline, and evidence-based medicine may also impact the willingness of physicians to be strong advocates”.

A strength of this study was conducting open-ended interviews with physicians from a variety of backgrounds and experience levels. One limitation of this study was recruitment bias. The snowball sampling technique unintentionally may have included physicians who have similar views when it comes to advocacy. The majority of interviewees in this study represented the researchers’ home institution. Through this method of sampling, female physicians were under-represented. Another limitation was that the nature of the questioning may have prompted interviewees to think about advocacy in a positive way, and answered accordingly.

A similar future project could be conducted to question physicians who are not involved in advocacy work. In presenting this analysis of physicians’ perspectives, it may help learners in the medical field and practicing physicians identify ways to engage in work beyond clinical care. More formal training may need to be implemented to educate physicians about their role as advocate. Systems should work to remove time barriers, to allow maximal time available for advocacy work to achieve results. Physicians identified working with a mentor as an important way to learn. A platform to help physicians to connect and network specifically surrounding their advocacy work could prove beneficial.

CONCLUSIONS

Advocacy work in practice can look different for each individual physician. Physicians in this study had a number of reasons to participate in advocacy work. Many had an understanding of the barriers that patients face and acted to eliminate socioeconomic and policy pitfalls through advocacy initiatives or policy work. They felt overall that advocacy meant going above and beyond your clinical duties to patients. They identified key professional barriers to furthering advocacy work. There were still many lessons to be learned moving forward regarding the meaning of advocacy, and how it might benefit both patients and healthcare professionals alike.