On Physician Advocacy

Should physician advocacy be a mandatory part of physician education and practice? If so, what does that mean? Does it mean that every resident and medical student must develop and demonstrate advocacy skills? And does it imply an expectation that advocacy must be a part of every physician's professional practice? Or does it mean, instead, that the topic of advocacy should be integrated into curricula for residents and medical students to facilitate their understanding of advocacy principles and practices, with the expectation that some may choose to engage in advocacy while others may not? These questions are part of an important discussion that is unfolding on the pages of this journal. In March 2011, Huddle1 presented a reasoned argument that physician advocacy, while a noble pursuit for some, “must remain an occasional and optional avocation in academic medicine, not a universal and mandatory commitment.” This argument stands in sharp relief to various professional organizations' charters, statements, and codes, released over the last decade or so, that call for mandatory physician advocacy and argue that it must be an integral part of medical professionalism and medical education. In this issue of the journal, you will find eight Letters to the Editor that respond to different aspects of Huddle's argument, along with Huddle's reply. Also, you will find two articles that offer additional insights on these topics. The first, by Dharamsi et al,2 presents a concept analysis of the notion of social responsibility to gain a more complete and nuanced understanding of the idea itself and its implications for medical education and practice. Does the notion of social responsibility mean that a physician must engage in political advocacy? Or does it imply that a physician should continually learn about the interactions between social conditions and health, apply that knowledge when making decisions about patients or populations, and pursue new knowledge about social determinants of well-being? The second article, by Meili et al,3 discusses advocacy as part of a program to implement the social accountability vision advanced jointly by Health Canada and the Association of Faculties of Medicine of Canada. If you are new to the physician advocacy argument and want to learn more about the basic issues, you may wish to consult the article by Earnest et al4 published in the January 2010 issue of Academic Medicine, which offers the following definition of physician advocacy: Action by a physician to promote those 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. You may also want to read the charters and statements of various professional organizations (e.g., the American Board of Internal Medicine's “Physician Charter”5 and the American Medical Association's Declaration of Professional Responsibility: Medicine's Social Contract With Humanity,6 among others). These documents provide an excellent foundation to appreciate Huddle's argument and the related Letters to the Editor in this issue. If you want to dig even more deeply into the physician advocacy argument, you may wish to tackle some of the more challenging questions. For example, is politics “nothing else but medicine on a large scale,” as Rudolph Virchow7 wrote some 150 years ago? (For a more extensive version of this quote, see Dharamsi et al2 in this issue.) Or is Huddle1 correct that if the medical profession becomes politicized, even on behalf of ends such as social justice or health care access for all, the world will not thereby be a better place—as the medical profession has no special authority or insight into what is demanded by justice or how far societal resources should support communal health rather than other priorities[?] Huddle identifies another key tension embedded in the notion of physician advocacy when he notes that “whereas the scholar seeks truth,” the advocate seeks change. This, of course, raises questions such as: How do the quest for knowledge and the quest for change relate to one another? When are they synergistic? When can one harm the other? What are the implications for physician education and practice? And what are the tensions between professionalism and advocacy? What are the potential consequences for medical schools and university hospitals? As you ponder these and related questions, please know that this journal welcomes submissions of manuscripts, including Letters to the Editor, that further advance knowledge about physician advocacy, the role it plays—or should play—in medical education and practice, and the ways in which it interacts with the pursuit of new knowledge. Steven L. Kanter, MD

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