Advocacy in Academic Medicine

Physicians have a long tradition of advocacy, particularly for the disempowered. Dr. Rudolph Virchow, a 19th-century physician investigating a typhus outbreak, identified poverty, famine, and political corruption as the root causes of disease spread. He outlined a revolutionary program to address the economic, social, and cultural factors contributing to the epidemic and helped develop policies leading to public health reform, believing in “medicine as a social science.” ¹ Considering the daily assaults our patients face, from access to basic health care and reproductive health services to insurance challenges, the type of advocacy Virchow implemented is no longer an optional component of medical care provision.

Advocacy is not a single practice. Rather, it requires incorporation at every level of medical education and area of potential provider impact, from the exam room to the legislator’s office, to gain ground against the onslaught of legislative and policy initiatives aimed at removing access to care and functionally widening gaps in health care disparities. Additionally, advocacy efforts act as a proactive measure against burnout by providing a sense of agency and empowerment for shared concerns in systemic situations, allowing individuals to collectively and actively address issues that contribute to frustration, leading to a more rewarding professional experience. ²

Health care providers are uniquely situated to share patient stories and data to amplify key messages and simplify complex medical information. Providers hold the unique position as keepers of lived patient experience, expertise, and public ³ and policymaker trust. Providers also have a rich base of proofreaders in academic departments and communications teams in national professional organizations to hone their messages. Purposeful advocacy, though, requires intention, strategy, and communication preparedness. Providers require training to utilize their voices and stories to speak to issues, whether in writing, public speaking, or social media engagement. ⁴

Academic medicine has a crucial role to play in the ways advocacy education and scholarship are not only integrated into graduate medical education curriculum but also that they are regarded in a similar fashion to historically respected laboratory, translational, and clinical research. ⁵ Dedicated time and resources for faculty, residents, and staff to develop advocacy interests are essential. An advocacy portfolio, like an educator portfolio, has been suggested as a model by which academic institutions could formally acknowledge the efforts required for physician advocacy, including teaching and engagement. ⁶

Advocacy serves a crucial role for trainees and attending physicians in promoting a complementary, parallel pathway to clinical and surgical care. The Accreditation Council for Graduate Medical Education (ACGME) residency program requirements mandate “advocating for quality patient care and optimal patient care systems.” ⁷ This is in keeping with medical student and resident desires for advocacy training. Residents overwhelmingly believe that government policies will affect their careers and that formal training in advocacy and policy should be a part of residency training but cite “time, stress, and lack of knowledge” as barriers. ⁸ Not surprisingly, the degree to which residents experience dedicated curricula or experiences in advocacy, however, is highly varied. A 2024 survey of internal medicine residency programs showed that more than half of the programs that responded (148/276, 53.6%) did not offer any formal training in public advocacy skills, citing primarily a lack of faculty expertise. ⁹

Similarly, the Educational Objectives of the Council on Resident Education in Obstetrics and Gynecology (CREOG) state that obstetrics and gynecology residents should “[a]dvocate for the patient, for all individuals in need of obstetric and gynecological care, and for the field of obstetrics and gynecology.” ¹⁰ However, an evaluation of an obstetrics and gynecology residency program showed that the majority of their attending physicians (69%) reported they were not currently involved in health advocacy activities, even though 43% participated in advocacy activities during their residency training. Of the attending physicians exposed to advocacy during their formative years, the majority reported they were influenced by role models (68%), suggesting the importance of faculty advocacy mentorship. ¹¹

When medical schools and residency programs do offer advocacy curricula, it is most often during elective courses or as a component of a particular course curriculum rather than required. ¹² Any meaningful advocacy curriculum must address both the basics of health care policy and navigation of social determinants of health. In a systematic review of advocacy curricula in graduate medical education, only 20% taught general health care policies; most programs focused on specialty-specific policy topics. ¹² Programs that are most successful focus on longitudinal advocacy with “spaced repetition” and active, experiential learning opportunities. ¹³ Initial training and curriculum focus on advocacy knowledge acquisition and establishment of a skill set in communication and stakeholder engagement, ideally with competency progression. ¹⁴

Integration of advocacy training throughout medical school and residency curriculum not only provides the skill set required for meaningful communication with the media and legislators but also facilitates experiential advocacy efforts at local, state, and federal levels.

At the local level, advocacy can play a role in focusing resources on community needs and aligning values of medical trainees with those of the community. Examples at the local level include the use of annual events as a springboard for highlighting local statistics. Events that have been successful include the American College of Obstetricians and Gynecologists (ACOG) Maternal Health Awareness Day ¹⁵ and Black Mamas Matter Day ¹⁶ and unite providers and trainees with nursing leadership to run sponsored events in the hospital and/or labor and delivery unit. Other local strategies have included physician advocates working with their hospital administration and legal teams to align on policy when reproductive health legislation serves to limit access to care or places physicians at risk of criminal prosecution in the provision of basic care standards. In these settings, medical trainees must understand not only how to navigate the complexities of translating these restrictions to medical practice but also documentation to protect them from liability. ¹⁷

At the state and regional level, advocacy may require coalition building to optimize synergy in communication among community and provider organizations for policy and legislative navigation. Inter-specialty legislative committees within state medical associations, representing each of the medical societies, meet regularly to discuss health-related legislation in an effort to present a unified voice in response to legislative actions. ¹⁸ Medical association, community, and legal partnerships have been successful in optimizing patient-supportive policies (e.g., extensions in postpartum coverage and amendments enshrining access to reproductive health care) and highlighting the uncertainty and medical harm that comes from legislation limiting health care access (e.g., septic abortion in a state that has criminalized abortion access). Furthermore, state agencies can serve as platforms for physician advocacy. Graduate schools and departments of public health can be pathways for provider and trainee involvement. Cooperation between physicians and public health agencies has included assessments and initiatives to improve water quality, seat belts, tobacco use, maternal mortality, and syphilis transmission rates. ¹⁹ The utilization of email listservs, committee membership, and teaching positions are some of the ways that physicians can leverage their expertise outside of the clinical setting.

At the federal level, advocacy efforts can address national policy. In June 2022, the American Medical Association (AMA) House of Delegates updated AMA policy to acknowledge that “voting is a social determinant of health and significantly contributes to the analyses of other social determinants of health as a key metric.” ²⁰ Several programs have been implemented across the country combining health care delivery with voter registration. Most notably, the nonpartisan Vot-ER program partners with health care professionals to reach historically underrepresented communities and empower civic engagement. Vot-ER has distributed more than 60,000 scannable badges to approximately 700 clinics and hospitals across the United States to connect patients with state and federal voter registration information. ²¹

Involvement of medical and resident trainees within these organizations is oftentimes dependent upon physician champion involvement. Some programs offer advocacy electives for medical students and residents, approved as independent study by the local medical school and coordinated by faculty champions. Just like learning how to suture, take a complete history, or perform a major operation, the examples of advocacy discussed require teachers (faculty champions), dedicated learning opportunities (curriculum and time preserved for experiential learning), and practice (opportunities for advocacy in medical school and residency) in order to achieve not only competency but also successful strategy. Learning how to identify a problem, work with diverse groups, and present solutions is a leadership skill that should be nurtured for our learners to become the stewards of health care we need them to be. At its core, advocacy allows health care providers to leverage their experience and compassion, helping their patients inside and outside of the exam room. It involves coordinating multiple stakeholders, forging alliances, crafting strategic messages for diverse audiences, and researching the policies and practices that will realistically make communities safer and healthier. Advocacy is a long-game effort and will require dedicated academic support to effect lasting change.