Curbside Consultation

Effective Advocacy for Patients and Communities

 

Am Fam Physician. 2019 Jan 1;99(1):44-46.

Case Scenarios

How can family physicians advocate for their patients and communities?

Case 1: A nine-year-old boy presented for a well-child visit. After reviewing the growth chart, the physician noted that the patient's body mass index was above the 95th percentile. The patient's mother was also morbidly obese. The mother was worried that her child could not keep up with his peers in physical education class.

Case 2: A 70-year-old woman presented with symptoms of anxiety and insomnia. Her 21-year-old grandson had recently been hospitalized for an unintentional narcotic overdose. His insurance covered alcohol and substance use treatment programs, but all local programs had long waiting lists. The patient was worried that her grandson's life was in danger and that he would not be able to access rehabilitation services soon enough.

Case 3: A 56-year-old woman presented for a follow-up visit and for medication refills after she had been laid off from her job. She has a history of type 2 diabetes mellitus, hypertension, and breast cancer. She was worried that she would not be able to afford access to health care after losing her employer-based insurance.

How can physicians learn from these visits to become effective advocates for solutions that often lie outside the clinical encounter?

Commentary

Family physicians play diverse roles in society, often bridging individual and community perspectives. Family physicians' ethics require providing care to all persons regardless of their geographic, economic, political, racial, religious, or sexual orientation status. Although family physicians may differ in geographic locations, political affiliations, and approaches, they are unified by the shared goal of providing the best possible care for patients.

Physicians' organizations and medical educators agree that advocacy is a core component of medical professionalism.1,2 Family physicians have access to evidence regarding what works to improve the health of their patients, including children, families, older persons, and communities. For example, physicians know that immunizations are one of the most cost-effective public health interventions and that affordable health insurance coverage increases patients' access to health care and saves lives.

This commentary offers a framework based on the social-ecological model of public health3  to describe distinct yet interrelated categories of advocacy (Table 1415) for patients at interpersonal, organizational, health system, and policy levels.

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TABLE 1.

Advocacy Levels, Topics, Examples, and Resources

LevelsTopicsExamplesResources

Interpersonal

Communication skills Clinical practices

Interpreters Clinical protocols Nondiscrimination

Mindfulness4 Social determinants57

Organizational

Mission Values Services Teamwork

Define population Community service Scope of practice Interdisciplinary actions

Anchor institutions8,9 Quadruple aim10

Health system

Access Quality Relevance Coordination

Clinic hours Emergency access Quality metrics

Collective impact framework11 World Health Organization12

Policy

Affordability Inclusion/exclusion Political action

Insurance Coverage/limitations Legislation

American Academy of Family Physicians13,14 Association of American Medical Colleges15 Society of Teachers of Family Medicine10


Information from references 4 through 15.

TABLE 1.

Advocacy Levels, Topics, Examples, and Resources

LevelsTopicsExamplesResources

Interpersonal

Communication skills Clinical practices

Interpreters Clinical protocols Nondiscrimination

Mindfulness4 Social determinants57

Organizational

Mission Values Services Teamwork

Define population Community service Scope of practice Interdisciplinary actions

Anchor institutions8,9 Quadruple aim10

Health system

Access Quality Relevance Coordination

Clinic hours Emergency access Quality metrics

Collective impact framework11 World Health Organization12

Policy

Affordability Inclusion/exclusion Political action

Insurance Coverage/limitations Legislation

American Academy of Family Physicians13,14 Association of American Medical Colleges15 Society of Teachers of Family Medicine10


Information from references 4 through 15.

INTERPERSONAL

A physician's primary circle of influence includes family members, friends, patients, staff, colleagues, students, neighbors, and community members. Family physicians should maintain equanimity and compassion, treating patients with respect, empathy, and dignity regardless of status or affiliations. Family physicians can address behaviors or policies that could harm patients through speech, actions, or inactions.5 By listening carefully, family physicians can hear patients' concerns to be able to effectively advocate for patients' health and social needs.6

Family physicians can be advocates in several ways. One way is having no tolerance for disrespectful speech or materials in clinics and hospitals. Family physicians can demonstrate understanding

Author disclosure: No relevant financial affiliations.

Address correspondence to Cynthia Haq, MD, at chaq@uci.edu. Reprints are not available from the authors.

References

show all references

1. Earnest MA, Wong SL, Federico SG. Perspective: physician advocacy: what is it and how do we do it? Acad Med. 2010;85(1):63–67....

2. Hansen H, Metzl JM. New medicine for the U.S. health care system: training physicians for structural interventions. Acad Med. 2017;92(3):279–281.

3. Centers for Disease Control and Prevention. The social-ecological model: a framework for prevention. Updated February 20, 2018. https://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html. Accessed November 5, 2018.

4. Epstein R. Attending: Medicine, Mindfulness, and Humanity. New York, NY: Scribner; 2017.

5. Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health. 2000;90(8):1212–1215.

6. Paul EG, Curran M, Tobin Tyler E. The medical-legal partnership approach to teaching social determinants of health and structural competency in residency programs. Acad Med. 2017;92(3):292–298.

7. Bourgois P, Holmes SM, Sue K, Quesada J. Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Acad Med. 2017;92(3):299–307.

8. Democracy Collaborative. Building community wealth. Anchor institutions. https://democracycollaborative.org/democracycollaborative/anchorinstitutions/Anchor%20Institutions. Accessed November 8, 2017.

9. Zuckerman D. Going all-in: why embracing an anchor mission is how health systems benefit their communities. Health Prog. 2016;97(3):64–66.

10. Society of Teachers of Family Medicine. Advocacy toolkit. https://www.stfm.org/about/advocacy/advocacytoolkit/. Accessed July 24, 2017.

11. Kania J, Kramer M. The collective impact framework. http://www.collaborationforimpact.com/collective-impact/. Accessed July 9, 2017.

12. Solar O, Irwin A; World Health Organization. A conceptual framework for action on the social determinants of health. Social determinants of health discussion paper 2 (policy and practice); 2010. http://apps.who.int/iris/bitstream/handle/10665/44489/9789241500852_eng.pdf;jsessionid=CB90DEA2B33B83967701F898A18B2E37?sequence=1. Accessed November 5, 2018.

13. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents: leadership. Updated June 2017. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint292_Leadership.pdf. Accessed July 24, 2017.

14. American Academy of Family Physicians. AAFP advocacy toolkit. https://www.aafp.org/advocacy/involved/toolkit.html. Accessed July 10, 2017.

15. Association of American Medical Colleges. Health equity research and policy. https://www.aamc.org/initiatives/research/healthequity/. Accessed December 6, 2017.

16. Avorn J. Engaging with patients on health policy changes: an urgent issue. JAMA. 2018;319(3):233–234.

17. Crump C, Arniella G, Calman NS. Enhancing community health by improving physician participation. J Community Med Health Educ. 2016;6(5):470.

18. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576.

19. Rabatin J, Williams E, Baier Manwell L, Schwartz MD, Brown RL, Linzer M. Predictors and outcomes of burnout in primary care physicians. J Prim Care Community Health. 2016;7(1):41–43.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

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