Virchow 2.0 and physician advocacy

Effectiveness in physician advocacy

In exploring the effectiveness of physician advocacy efforts, we propose to examine 2 questions:

• What activities are considered “high-level” physician advocacy?

• To what extent do these activities need to objectively advance health outcomes?

The RCPSC’s high-level definition leaves open the possibility that “effectiveness” in physician advocacy might range from a physician simply having spoken up for a cause to objective success in driving large-scale societal changes. If we base effectiveness simply on the act of engaging, then instances in which physicians simply take a stand without broader objective change might be considered effective, as seen in recent efforts of US-based physicians advocating for stricter gun control measures.⁸ However, if we accept that many physicians will often engage in advocacy as a moral imperative, we might instead define effectiveness as being measured by the observed outcomes achieved by the advocacy efforts, rather than simply amplifying a specific position.

In focusing on outcomes, the next question asks to what extent physician advocacy should objectively and ultimately advance health in order to be considered effective. One example is Canada’s long-standing debate around 2-tiered health care, with physicians on both sides of the issue arguing for and against greater private sector involvement in health care. Evidence from other countries largely favours those who defend Medicare, although proponents of for-profit medicine are persuasive with some quarters in justifying how their position will improve health care outcomes.⁹

Perplexingly, the Royal College definition might suggest that both sides are engaged in effective advocacy through supporting a call for change and speaking on behalf of others in using their expert credentials to advance their cause. We propose, however, that physician advocacy cannot truly be effective if it is not done with the aim of objectively advancing health. Evidence suggests that Medicare-supporting physician advocates more closely meet the definition of effectiveness.

All things considered, these points suggest that measuring effective physician advocacy must be predicated on how well such efforts ultimately drive improved health outcomes, the latter being measured indirectly through metrics such as implementation of optimal health policy or programs.

Providing attribution in physician advocacy

Accepting that effective advocacy must be linked to improved health outcomes through measured changes in context, the next step is to clearly define scope and attribution around physician involvement.

Here, the Royal College’s definition again presents challenges owing to its breadth. As an example, one of the described goals is for physicians to promote health equity, prevent disease, and protect and promote health.⁶ This, in fact, is the mandate of the entire governmental public health system, which leaves one wondering how best a single physician advocate might bring his or her efforts to supporting goals already being worked on by whole public health agencies and community organizations.

The definition adds further confusion by clarifying that “advocacy often requires engaging other [stakeholders]” but stating that physicians might “support or lead the mobilization of resources ... on small or large scales [emphasis added],”⁶ which risks role confusion. The reality is that, in many instances, a physician’s contribution is one among those of many stakeholders acting within a complex interplay between many factors such as timing, context, governmental goals, and the work of other interested parties.

If we return to the 2-tiered health care debate in Canada, the importance of scope and attribution in effectiveness is well illustrated in the published biography of a recent award recipient from the Canadian Medical Association, which states that the physician’s singular influence “probably prevented two-tier models of care from developing in several provinces” through the mid-2000s.¹⁰

Such a statement presents several challenges. It ignores contemporaneous context—the 2004 federal 10-Year Plan to Strengthen Healthcare¹¹ provided billions of dollars to increase access to priority medical services while obscuring the contributions of myriad stakeholders such as Canadian nurses, the labour movement, and nonphysician non-governmental organizations.¹² For other physician advocates, the statement also paints somewhat unrealistic expectations for what their own efforts might achieve.

Unlike advocating for individual patients, effectiveness in broad-scale physician advocacy requires recognition of how one’s role intersects with that of other stakeholders as outlined in the “partnership” aspect of the Royal College definition. Physician advocates are often effective because they employ their privilege to speak on behalf of many invisible hands and voices on the ground. Effective advocacy thus requires careful introspection about the physician’s role while ensuring credit for successes in changing contexts is fairly given to all partners involved.

On stretching the limits of physician expertise

Having discussed scope and attribution, we turn then to expertise. In considering effectiveness, to what extent do physician advocates have to possess knowledge and authority on the topic at hand?

Physicians are experts in many topics that they might advocate for, often related to health care and the biomedical sciences, but many topics lie outside of physicians’ training and experience, which we argue limits the credibility and effectiveness of their efforts. One recalls the old adage about the “triad” that physicians engage in out of medical school without formal training: teaching, research, and running a business. This situation, however, extends to many other topics and activities outside many physicians’ traditional knowledge base.

An example: In fall 2017, proposed changes to Canadian-controlled private corporation tax regulations brought out 2 opposing physician advocacy camps, for and against the changes.^13,14 This debate quickly devolved into the typical realm of tax economists and financiers, and while some physicians might share that expertise, outsiders likely saw the 2 camps as self-serving and overreaching, respectively. Simply stated, while all physicians are taxpayers, not all physicians are necessarily experts in taxation.

Another example concerns climate change, where physicians should definitely speak on the potential health effects to justify mitigation. However, absent additional training, physicians speaking to the evidence and details of specific mitigation measures (eg, carbon-capture technologies) could be trespassing on areas otherwise better addressed by experts such as engineers and climate change professionals.

Effective advocacy requires physician advocates to determine if their expertise on a topic allows them to speak as an expert versus as a member of the general public. This is in keeping with scope-of-practice boundaries that are fundamental to many other aspects of physician practice; you would not typically find a general surgeon doing psychotherapy or an emergency physician practising public health leadership and epidemiology without undergoing retraining and assessment.

Hence, a final rule of thumb for effective physician advocacy might be best summed up in a question: Can I speak expertly on this topic? This would allow physicians to determine if they might be best placed to lead, support a coalition of advocates through bringing a medical perspective, or, in certain instances, hold back an uninformed opinion but provide general support to the cause.

Bringing it all together

As it turns out, the commonly used rallying cry based on Virchow’s statement often misses the second half of his thoughts, which state: “Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”⁷ Viewed in this fuller context, we interpret this to mean that Virchow did not intend for physicians to become the sole advocates for all the ills of the world.

In naming politicians, the quote also recognizes that the ultimate exercise in decisions within democracies exists in elected office and the will of the people. It also makes clear that physicians are not meant to lead and engage in every issue of interest but, specifically, are meant to identify and hypothesize on problems salient to the “science of human beings.”

One can hence argue that Virchow’s words describe to some extent the scope of effective physician advocacy as advanced in this paper: a focus on positive health outcomes, with physicians as health experts who inform decisions and solutions, leading where their expertise permits and partnering with key stakeholders where the considerations extend beyond medicine alone.