Physician Advocacy

Physician advocacy: what's necessary, how to do it, what are the pitfalls?

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have doctors Monica Peek and William Parker talking about physician advocacy, what's necessary, how to do it, and what are the pitfalls.

[00:00:15] Dr. Parker: This makes me think about the big controversy when the NRA was criticizing doctors for advocating for gun violence policies, and of course, one of the trauma surgeons responded with a tweet of her blood-soaked shoes saying, "This isn't my lane, it's my effing highway." Right? Um, so I do think successful advocacy comes from expertise and good ideas.

[00:00:36] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect, and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors. I'm Adam Cifu, and today I'm joined by doctors Monica Peek and William Parker.

Dr. Peek is a professor of medicine at the University of Chicago. She's the Ellen H. Block professor for health justice and the associate vice chair for research faculty development. Her academic interests include health disparities, particularly as related to chronic disease management and preventative healthcare. She has focused her research on diabetes and breast cancer screening. She is a senior faculty scholar in the Bucksbaum Institute. Monica, thank you for coming by.

[00:01:31] Dr. Peek: Thanks so much for having me.

[00:01:33] Dr. Cifu: And Dr. Parker is an assistant professor of pulmonary and critical care medicine and public health sciences, and assistant director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. Dr. Parker is a critical care doctor, clinical medical ethicist, and NIH funded physician scientist who studies the allocation of absolutely scarce medical resources such as deceased donor organs, life support and crisis scenarios and novel vaccines. Whew. Will, thanks for coming.

[00:02:06] Dr. Parker: Thanks so much for having me.

[00:02:07] Dr. Cifu: Um, so I have a couple of questions for you guys and we can certainly, um, wander off topic, if we want to. Um, I wanted to talk to you guys about advocacy, and I asked you because you have both, I think, been terrifically successful as not just physicians but as physician advocates, and I kind of wanted to ask like, um, why do you feel like it's important for physicians to get involved in advocacy?

[00:02:36] Dr. Peek: Yeah, I think that's a really important question. Um, Will, I'll let you start and then I'll back it up.

[00:02:42] Dr. Parker: Yeah. Adam, you and I were invited to debate this sort of topic in general in front of the med students. Debate frames it as being more contentious conversation than it was, but I think advocacy is necessary because physicians do advocate as professional societies, is sort of the central argument. The AMA is one of the top lobbyists in the country constantly advocating for our interest in a national policy level, particularly by maintaining our salaries to be very, very high or twice our European counterparts. And we work in a system that teaches or treats medical students and trainees in a very caustic difficult manner, and the reason that people undergo this really arduous training is because of this large payoff, both financially and socially. Um, and so if you sort of accept all these facts to be true, combined with our poor health outcomes as a country overall, I think it prompts one to consider what's the structure that I'm contributing to individually as a physician, and do I have ethical obligations to try to advocate for changes to that structure in my daily clinical practice?

[00:03:59] Dr. Cifu: So, interesting, your take is almost that, um, you do your job as a physician, but people are advocating for you, maybe not in the way that you would choose to be advocated for, and so you're almost forced into a position, you know, to advocate, I don't know, you know, let's say for the better.

[00:04:18] Dr. Parker: Yeah, I guess it's more a choice between complicity and staying silent and advocacy and pushing against injustices you see in your daily life, whether it's about our training system, the barriers to entry for foreign medical grads...

[00:04:33] Dr. Cifu: Sure.

[00:04:33] Dr. Parker: ...for example, something that constrains the supply of physicians, harms our patients, keep prices too high. So, you know, you experience all of these things in your daily practice as well as other structural inequities being, um, placed onto our patients' burden, so like one example that strikes me as an ICU physician was during the pandemic, LA County literally had to order hospitals to accept Covid transfers from struggling community hospitals. These are... The hospitals they were ordering were major tertiary care centers, academic hospitals who are trying to keep their ICU bed set aside for lucrative surgeries and, you know, the physicians at those hospitals who are party to those decisions, it's not... These things aren't happening in a vacuum. And while clinical medical ethics is normally focused on this hypothetical encounter where there's one patient and one doctor, and how do you behave, I think we should go beyond that and think about, well, how did that patient in front of you get there in the first place? And do we have ethical obligations for the structure that placed that one patient in front of us? So those are the things I'm interested in.

[00:05:42] Dr. Peek: And that's exactly how I would frame this, um, is that we have to understand the context in which we are practicing medicine and we're here as physicians to treat the patient. And so, uh, my father was a history professor. I was always taught to not be ahistorical or to be acontextual. And so the world in which we live has created an uneven playing field that creates worse health outcomes for some. The healthcare delivery systems in which we work creates even worse, it sort of expands upon that inequity and creates even worse health outcomes for some. And so, what I think a lot of people don't understand, and what Will just pointed out is that physicians are already, we already are making a choice. Um, and the choice that we're making is to be active or to be inactive. Both of those are choices. Both of those are actions. It's just that, you know, one feels more proactive, like we're making a choice but being silent is always a choice. Being inactive is always a choice. And so being politically "inactive" is just aligning yourself with the status quo and saying that these things about inequities that are harming our patients, that's okay with me.

You know, doing nothing allows the system to continue as it is, um, and just roll over entire populations of people who are otherwise deserving of equal care, equal health, and continue in this manner. Or you can say, no, I'm going to choose to push against this status quo, and align myself with forces for justice and equity.

So we, every physician has made a choice whether they realize it or not, every physician is advocating, whether they realize it or not, because of the context in which we are working, we are working in a system that is very active as far as a lobbying force, the amount of healthcare dollars that are spent as part of our economy is huge. And so to pretend that all of this is not very politicized is um, naive. And so to be part of a hugely political system, um, we are making a choice to be silent, um, whether or not we think we have or not.

[00:08:25] Dr. Cifu: I love the way you say that because it parallels something that I find myself often saying in clinical settings when I'm discussing a decision with a patient and a patient is having trouble making a decision or doesn't want to make a decision, and I'm often in the position saying that by not making a decision here, you are making a decision and I just want to make sure that you have control over that.

[00:08:49] Dr. Peek: Yes.

[00:08:50] Dr. Cifu: And it's very much what you are saying that if you sort of sit and do your practice and are happy with your practice, that is a decision you've made and you are in a way, I don't know, maybe negatively advocating by not getting more involved.

[00:09:06] Dr. Peek: Yes.

[00:09:08] Dr. Cifu: Let me ask another question, and this is sort of mostly from watching you guys from the outside, um, what you've done both locally and what you've done on a more national level. I think like every activity that we do in our life from, you know, soccer when we're four years old to being professionals, advocacy can be done very well or very badly, and you guys have had a lot of experience and seem, at least from my eyes, to do it well. What do you think is important in doing it well, or have you had experience...

[00:09:41] Dr. Parker: I don't, I don't know. I mean, I think a lot of times if you're pushing for things you think are right or just in the healthcare system, you find yourself frustrated or tired or falling short, but I do think that knowing what you're talking about and being an expert in that particular area is very fundamental.

I try to stay very much in my lane of somebody who understands the ethics of the allocation of scarce healthcare resources and enough empirical methods to understand how these protocols can undermine some of these key ethical principles like, um, one of Monica's and my big projects together was paired with advocacy, was about the inequitable vaccine distribution in Chicago in particular, was also echoed across the United States. Um, and so we can advocate quite forcefully for different vaccine allocation policies because we're able to quantify the harms of the status quo and point out exactly sort of why or how this happened and how many people died as a result. So I do think successful advocacy comes from expertise and good ideas.

Um, and, you know, it's not necessarily staying in your lane. I mean, this makes me think about all of the... When the big controversy, when the NRA was criticizing doctors for advocating for gun violence policies, and of course, one of the trauma surgeons responded with a tweet of her blood-soaked shoes saying, you know, "This isn't my lane, it's my effing highway." Right? So I think, um, that doesn't mean you... There are areas that are off limits, it means that you have to know what you're talking about and you have to have expertise to be effective.

[00:11:23] Dr. Cifu: I think that is a point that when I've listened to you guys, I think both at Grand Rounds, and Monica, on a podcast I listened to you on, it may have been the depth of knowledge in this subject that was most powerful because it really takes it away from arguing just another opinion to there's something about this topic that I know well from my career and I have something really to bring to the table on it, and I didn't really think about that until you said it in that way.

[00:11:55] Dr. Peek: Yeah. That's actually one of the reasons that I came to become a clinician investigator, um, because I initially... There's so many things that are great about medicine, just being a full-time clinician is hugely rewarding. I love that. Um, and I could just do that and be happy, but no one would be knocking on my door, asking my opinion about anything, you know? And so I... but I have lots of opinions and so I know that being an expert in a topic, uh, gives you access to people who want people's opinions who have expert knowledge. And so that was a huge reason for me to think about becoming an expert in health disparities. Maybe the most important thing about being a good advocate is having the facts, being deeply steeped in the facts. And I think, uh, a second thing is being on the right side. And I say that, when I say that, it gets back to my original point is that we as physicians are here to treat patients and so for me, I'm always going to be advocating things that are bettering the health and life and well-being of my patients, so that may be increasing their access to care, including their full reproductive, you know, healthcare, increasing their access to basic human rights that, you know, affect their health, like clean water, thinking about the Flint water crisis, um, stable housing, food insecurity, you know, increasing their life to be free of discrimination based on any kind of their social identity, because we know based on research into discrimination, part of which I do, that that negatively impacts your health and not only makes you feel bad, it restricts your access to goods and services and opportunities and increases your exposure to risk like Covid, but it begins a cascade of pathophysiological changes and epigenetic changes that physically change your body and put you at increased risk for disease. It shortens your telomeres, it causes autonomic dysregulation, does all of these things that puts you at increased risk for heart attacks and strokes and other kinds of things.

I don't want racism, not only because I'm a Black person, but because that harms my patients' health. And if other patients get offended because I'm doing the right thing, you know, for a whole group of my marginalized patients whose health is being affected, I'm not sure I'm the right doctor for those patients.

[00:14:48] Dr. Cifu: That's a great segue into sort of my next question because, um, we're all incredibly busy and an obvious, I don't know, pitfall or danger to, you know, getting involved in advocacy is adding, you know, just one more thing to your plate, right? And we all have to sort of balance, like, you know, how can we do everything we want to do and still be really good at everything we want to do, which is I think probably for any physician listening to this is a struggle that, you know, we're aware of.

[00:15:17] Dr. Peek: Mm-hmm.

[00:15:19] Dr. Cifu: What are the things that sort of, in your experience as advocates, you know, and let's just say, maybe advocates, like outside of, you know, the one patient to one doctor relationship, um, like what are the things that you worry about and what are the things that you say, "Ah, you know, is this causing trouble besides, you know, crazy people on Twitter yelling at you about things?"

[00:15:41] Dr. Parker: Well, yeah. Always a risk or the benefit of Twitter, um, depending on what the comments can be, pretty entertaining, but, um, I think, I mean, there are personal professional risks when you push against... Particularly do sort of micro-advocacy in your particular institution, like if you join a practice that you find is engaging in the practice of surprise billing, which is where if somebody's out of network, you still charge that patient full price and they're... Fortunately there's been legislation to address that passed over the objections of the AMA.

You know, as a doctor you have to say, am I going to stir up trouble for this job I just got and say, "Hey guys, what we're doing is wrong." You know, and I think overall you can't, you know, win all of those micro battles, but if you pursue what appears to be obvious and right in your life, you'll sort of flourish in your career and the benefits overall will lead you to be a better doctor and better person.

So I think it's hard to always have your foot on the gas, I guess. And that's one of the big pitfalls and you certainly get tired and you let things slip that you shouldn't.

[00:16:47] Dr. Cifu: Yeah.

[00:16:47] Dr. Parker: Um, but overall the benefits, you know, seem to outweigh the risks. Particularly if you are at a place like UFC that really, you know, protects your academic freedom to sort of go on a podcast like this and say controversial stuff and not be worried.

[00:17:01] Dr. Cifu: Right. Right. We'll see. It hasn't come out yet.

[00:17:04] Dr. Parker: Yeah. Yeah, you're right. That's true.

[00:17:06] Dr. Peek: I was going to say, I think that, I think that's the biggest risk that people worry about, um, real or perceived is their job security. Um, and I think that keeps a lot of people from being more engaged in doing what they feel is the right thing to do, because they have a mortgage and they have kids. And that has been the case with all kinds of social justice movements, that people are concerned about the direct impact on their lives and the lives of their family. Um, and what I will say as a Board-certified physician is that in the back of my mind, I always tell myself, I can get a job anywhere.

[00:17:58] Dr. Parker: Yeah.

[00:17:59] Dr. Peek: I will always be able to practice. So if I get fired, I can always eat, you know? And thankfully, um, you know, it has never been a problem, you know, no one has ever tapped me on the shoulder and be like, "Can you tone that down? I saw what you wrote." You know, but I know that this happens across the country. Not everyone has the same kind of freedoms and flexibilities that I do. And I'm always like, one day it's going to, you know, as Marshall said today, bite me in the behind. I don't know why you pronounce it that way, but I have to live my life in a way that aligns with my moral principles.

Um, and what keeps me from a lot of hand ringing is just that I know I can always get another job, that keeps me sort of pushing forward in the moment. And in the long run, it always works out. It has worked out for me.

[00:18:55] Dr. Cifu: Right, and certainly historically, advocates have taken significantly more risks, exponentially more risks, right? Than a physician who has, you know, so much sort of privilege and backup behind them.

[00:19:10] Dr. Peek: Yes.

[00:19:11] Dr. Cifu: So when you compare it to a lot of the people who've gone before, right, the risk is very small.

[00:19:17] Dr. Peek: Exactly. And that's another reason is that I feel like that for me as a person of color, um, me, my sister and brother being the first ones in our family, born with all of our rights that I have an obligation to all of the people who came before me. My grandmother was a domestic, my parents were the first ones in their families to go to college, the first generation of college that all of the people who came before me, I owe them a debt of gratitude to fight every day. And so, that is who I'm working for.

[00:20:00] Dr. Cifu: So maybe my final question is, you know, when I go through my day, I could come up with 50 things that might be worth trying to change, from the length of my clinic visits to the variation in the look of a practice between say, the residents and a senior faculty member, and I could probably have a podcast naming all the other things that come to mind just from this.

[00:20:30] Dr. Parker: Yeah.

[00:20:31] Dr. Cifu: How do you sort of choose like what's the right thing to go after, because you can't...

[00:20:37] Dr. Parker: And of course, you're not sure if like, it's the thing that you get most interested in that fires you up and that's not really where the money's at from an equity perspective too. That's something I worry about, you know, particularly obsessing about load-sharing during pandemic surges and ICU transfers, and being kind of an iconoclast or just being really dogmatic about that in my section and like... And then sometimes pointing out like, well, maybe this isn't really where you're supposed to be spending most of your energy because there are other lower hanging fruit in terms of combating structural inequities that your group is party to, but I think, the first step is recognizing, like recognition that we have to think beyond the individual doctor-patient relationship, we have to think about the way our structure in which we're practicing is affecting a group, a larger group of people. And that's sort of the first step, and then, you know, sometimes you're going to miss and spend too much energy on something that's not that big of a deal but it's part of the process, I think.

[00:21:37] Dr. Cifu: Right. And it's also, I guess, what both of you said that, so much of this is becoming expert, which takes work.

[00:21:43] Dr. Parker: Yeah.

[00:21:43] Dr. Cifu: It's finding something which is important and which you are enthusiastic about, passionate about, yes.

[00:21:49] Dr. Peek: That's right.

[00:21:49] Dr. Cifu: So you can sort of put that energy into it because none of us do a good job working on something that we're not really into.

[00:21:55] Dr. Peek: Absolutely.

[00:21:56] Dr. Parker: And I would say it's not something that just academics should be doing. I mean, my wife's a private practice ophthalmologist in a large group, and they have decisions all the time about are they going to charge people who don't have insurance? How much free care are they going to do, are they going accept the county care?

[00:22:12] Dr. Cifu: Yeah.

[00:22:12] Dr. Parker: You know, and all these micro decisions add up to potentially a more equitable practice. They're still going to... They may make marginally less money, they're still doing fine , right? But they'll probably at the end of the day, feel better, be better, you know, be better people overall, you know, in the sort of Aristotelian virtue-based sense, and then also combat structural inequity. So I think a call to more awareness is sort of the first step. And then ultimately organization at the physician level is the only way I think to really overcome these deep barriers which we're still a long ways away from.

[00:22:48] Dr. Cifu: I think what you're saying is different organization.

[00:22:50] Dr. Parker: Yes. Different organization. Yeah, not the ones we currently have. You know, some that, that's goals are more explicitly about the interest of patients than the interest of physicians, which do not always align. Right?

[00:23:03] Dr. Cifu: Guys, thank you so much for joining us for this episode of The Clinical Excellence Podcast. This was really interesting and I think thought-provoking and hopefully people enjoy it. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.