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

Author disclosure: No relevant financial affiliations.

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.

LevelsTopicsExamplesResources
InterpersonalCommunication skills
Clinical practices
Interpreters
Clinical protocols
Nondiscrimination
Mindfulness4
Social determinants57
OrganizationalMission
Values
Services
Teamwork
Define population
Community service
Scope of practice
Interdisciplinary actions
Anchor institutions8,9
Quadruple aim10
Health systemAccess
Quality
Relevance
Coordination
Clinic hours
Emergency access
Quality metrics
Collective impact framework11
World Health Organization12
PolicyAffordability
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

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 rather than pushing others away who may have different backgrounds or points of view. For instance, physicians could design education programs for health care professionals to recognize implicit bias; to work effectively with medical interpreters; and to provide respectful care to lesbian, gay, bisexual, transgender, and queer patients.

ORGANIZATIONAL

Organizational affiliations—places of employment, education, professional memberships, worship, and recreation— provide opportunities for family physicians to serve as leaders. By advocating for organizations to become anchor institutions that hire and invest locally 8 and that adhere to fair policies such as paying all employees a living wage and ensuring access to affordable, high-quality health care services, family physicians help communities. Organizations can be encouraged to embrace a mission of community service and to leverage resources to invest in and strengthen local communities.9

HEALTH SYSTEMS

Family physicians know that many social and economic factors strongly influence the health of patients. They have unique opportunities to observe and to influence conditions that promote health and that decrease risks of disease. Family physicians are experienced in working across traditional disciplinary boundaries to create teams focused on shared goals. By promoting systems that improve access to affordable and high-quality child care, healthy foods, public education, housing, and recreation, family physicians are able to expand opportunities for educational and economic advancement, to reduce structural inequalities, and to aid patients who may be disadvantaged.7 Family physicians can reach beyond individual organizational affiliations to create multisectoral partnerships and to create conditions for collective action.11 The social determinants of health can be addressed by working across institutional boundaries.12

POLICY

Family physicians can serve as credible champions for policies that support robust health care systems, financing mechanisms, and public health infrastructure. Family physicians can best fulfill their professional obligations when all patients can access affordable, comprehensive health care services. Family physicians can express their support for health-promoting policies through communications with political leaders and the public.16 Public opinion can be influenced through community outreach, writing, public speaking, and editorials. Patients' stories can be shared to highlight the effect of policies, while still maintaining confidentiality. Family physicians can identify and question policies that could harm patients, limit patient choices, or restrict patient access to health care services. They can advocate by recruiting, preparing, and supporting potential future leaders, training students and residents to become more effective advocates,17 and even by running for public office.

The keys to effective advocacy are to identify an issue of concern, gather information, commit to action, collaborate with others, mobilize resources, and sustain the effort. The American Academy of Family Physicians recommends that medical residents build skills for legislative advocacy.13 The American Academy of Family Physicians, the Society of Teachers of Family Medicine, and the Association of American Medical Colleges have assembled advocacy resources, conferences, and tool kits.10,14,15

It is important to remember that self-care remains an essential component of advocacy for others.18,19 Family physicians must remember how much time and effort we can devote to advocacy beyond personal and clinical responsibilities. Caring for physical, mental, and spiritual health enables physicians to remain strong, focused, and capable of handling challenges.4 This includes reflecting on what can and cannot be controlled and preserving time for rejuvenation to recharge for the work that lies ahead.

Returning to the case scenarios, how could family physicians respond?

The family physician seeing the child who was overweight noted that he had seen many other children with similar conditions. The physician met with the local elementary school nurse and learned that she and the teachers had also recognized that many children were overweight. The doctor encouraged and then joined teachers and parents in organizing a community health initiative to promote healthy school lunches, family exercise programs, and healthy lifestyles.

The family physician of the grandmother of the young man who had accidentally overdosed on narcotics recognized that many of her patients could not access treatment for opioid use disorder. The physician advocated for her health system to support primary care physicians to complete the buprenorphine training program. She and several colleagues completed the training and launched a new community-based program to treat patients with addictive disorders.

The family physician of the patient who lost her job encouraged the patient to meet with the clinic's financial specialist. The financial specialist helped the patient complete her application for insurance, and she received coverage through the Patient Protection and Affordable Care Act. Additionally, the physician joined with others to advocate for state policies to expand affordable health insurance options for persons living on low incomes.

Although each category of advocacy is distinct, each depends on the others to function most effectively. Physicians have a unique palate of knowledge, skills, interests, patients, and contexts. Family physicians can influence the lives of patients, communities, and health care systems. By carefully choosing actions from personal to political levels, family physicians can effectively advocate for changes needed to promote the health of communities and society.

Editor's Note: Dr. Haq is currently at the University of California-Irvine.

Authors are full-time faculty members of their respective institutions, and the opinions expressed are their own and are not official institutional policies. They received no outside support for this work.

The authors appreciate thoughtful review and feedback from Dr. Caroline Wellbery and Ms. Danielle Jones.

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.

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