Many Americans believe that we have the best health care system in the world. Yet that doesn’t square with the fact that the health of Americans is worse than that of nearly all other industrialized counties. Why? Because the huge disparities in income and a host of environmental, social, and other factors powerfully influence our chance of getting sick and of getting appropriate medical care.

Physicians have a special vantage point from which they can see the way that poverty, housing insecurity, a lack of health insurance, and other factors affect health. But most don’t know what to do with this information, or envision how they can make a difference. To create a truly healthy America, we need a new kind of medical training, one that prepares physicians for roles as health advocates.

That’s why we and several of our colleagues developed a rigorous yearlong course in social medicine and research-based health advocacy. It stems from our belief that physician advocacy is a central tenet of medical professionalism.

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Physicians have a long history of advocacy, particularly for the disempowered. Take, for example, Rudolph Virchow, a 19th-century German physician who is considered to be the father of pathology, the study of disease at a cellular and molecular level. Virchow believed that physicians have a responsibility to work on behalf of the poor. When asked to investigate the cause of a local typhus outbreak, he identified poverty, famine, and political corruption as the root causes of the spread of the disease. He later became a German politician and helped develop health care reforms that laid the foundation for the system of universal health care that now exists in Germany.

The hospital in which we work, Cambridge Health Alliance, is a safety net health care system that serves the greater Boston area. It has a rich tradition of health advocacy. Faculty, staff, and trainees have, for example, petitioned the city of Cambridge to de-stigmatize health services for gay men with HIV/AIDS in the 1980s; partnered with local community agencies that serve survivors of domestic violence; provided telemedicine infectious disease consultations to an organization serving a village in rural India; and generated research that measures health disparities due to race and ethnicity in the US health care system.

The major health care challenges the United States faces — from global poverty and disease to HIV/AIDS, health care reform, Ebola and Zika and other pandemics, and the unmet health needs of millions of Americans — require a physician workforce with the passion and skills to advocate for public policies that will improve health and health equity.

Medical education should honor and leverage the ideals that inspire many students to choose a career rooted in compassionately caring for people. Sadly, idealism, empathy, and inspiration wane during training. Teaching physicians-in-training about social determinants of health and providing them with advocacy skills can help reverse that trend and make it more likely that doctors will work for systemic changes to improve health once they complete their training.

In a paper published last week in Academic Medicine, we describe the curriculum we created for Cambridge Health Alliance’s internal medicine residency program. This course, required for all trainees, has become a centerpiece of our residency program.

Through course work, trainees learn about the US health care system, human rights, health disparities, and global health. They also meet with community organizers, policymakers, and media professionals. Health advocates and mentors help them understand what physician advocacy means and explore ways of incorporating advocacy into their careers.

Our trainees put their course work into action by working on a real-world project. They start by thinking of a situation in which they feel an injustice was done to one of their patients. They then identify the social factors that permitted that injustice to occur, rigorously study those factors, develop policy solutions, and advocate to put them in place.

Last year, the residents’ research measured racial disparities in health insurance coverage and access to health services in the US, work that was published in a highly respected academic journal. They spoke to the media and wrote an op-ed about their findings in hopes of influencing the public debate over the Affordable Care Act. Through this process, they learned concrete skills such as study design, biostatics, public speaking, media relations, and writing for the media.

The need for health advocacy has never been greater. Proposals from President Trump’s administration and from Congress include plans to repeal the Affordable Care Act, which could result in 32 million people losing health insurance and translate into more than 43,000 deaths a year. Defunding Planned Parenthood, which provides care for a largely underserved population, could make it difficult or impossible for millions of women to get access to contraceptives and screening for cancer and sexually transmitted diseases. An executive order that aims to block Syrian refugees seeking safety from a devastating war and the greatest humanitarian crisis of our time from entering the US is keeping many from much-needed medical care.

A handful of medical schools and other residency programs, such as the University of California, San Francisco, and Montefiore Medical Center, provide advocacy training. We believe that every medical education institution should weave health advocacy into their programs. We must train future doctors to understand the social factors that affect health outcomes and to work to improve them.

Healing patients bodies and minds is noble and fulfilling work. But doctors have the opportunity to help heal the ills of society as well. Training programs that give young physicians tools to advocate for such changes will be good for them, and for all Americans.

Gaurab Basu, MD, and Danny McCormick, MD, are on the faculty of Harvard Medical School and are attending physicians at Cambridge Health Alliance.

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  • Resonating with Dr. Basu and Dr. McCormick’s concern about decreasing levels of empathy among medics, I think implementing health advocacy training into the residency program is not the correct approach to reverse this effect. It might seem like learning about health advocacy skills allows medics to engage more in social change and thus overturning the trend of decreasing empathy levels. Yet, the article fails to acknowledge factors that are considerably more influential, which are intrinsically diminishing medics’ empathy. The authors’ approach would be much more holistic if they had considered factors like medics’ internal drive for pursuing the medical field and their unhealthy stress levels caused by the nature of the profession.
    First, empathy cannot be taught (Berkhout & Malouff, 2016). It is an intrinsic characteristic established far before the time an individual enters the medical field (Stratta et al., 2016). Though studies have shown that empathy can be enhanced through learning, the room for improvement is nevertheless highly limited to the individual’s baseline and the outcomes are short-lived (Berkhout & Malouff, 2016). Thus, it is unreasonable to rely on training to increase medical trainees’ empathy levels. Instead, it is more important to clearly identify the internal motivations of each applicant before admission and go through a rigorous student selection process with the consideration of their empathy levels (Hegazi & Wilson, 2013).
    Besides, decreased empathy is closely related to stress caused by the infamous working conditions in the hospital (Chen et al., 2012). Research has shown that increasing demands on medical accountability are causing physicians-in-training to empathize less with patients (Stratta et al., 2016). Playing a significant role in decreasing empathy, negative stress puts medics into survival mode, where the sole focus is not making the society a better place but pushing it through the day of treating incoming patients (Park et al., 2015). According to Dr. Park, 80% of medical professionals experience at least one distress, including depression, sleepiness, and low quality of life (2015). The hospital is indeed a mentally challenging environment, so most doctors choose to protect their own mental wellbeing by detaching from the patients. Some even objectify their patients to show emotional competence (Stratta et al., 2016). Being in that mindset, they are less likely to spend time communicating with their patients or getting to know how social determinants have caused their illness, let alone taking initiative in social change pertaining to that situation. Therefore, it is unreasonable to impose more responsibilities, such as health advocacy, on these already burnt out individuals. It is more effective to target hospital’s environment, which directly affects an individual.
    Similarly, since being empathetic requires high emotional engagement from the physicians, it is extremely difficult to reach such level in a setting that encourages the exact opposite. In fact, expressing feelings openly is stigmatized and associated with weakness in the medical field (Kerasidou & Horn, 2016). This unhealthy atmosphere is causing medical professionals to withhold from empathizing with patients in the fear of criticism and embarrassment. Thus, skill based classes are useless if the fear of expressing one’s emotion is not being discussed. Instead of piling up more responsibilities onto a saturated profession, it is more effective to maintain empathy levels by focusing on the intrinsic motivation of each individual and building safe space within the hospital for medics to openly engage in showing empathy. Just like the article mentioned, most medical students who pursue this field are fueled by their innate passion for caring people and the society. They don’t need more mandatory trainings on something they already understand. Instead, medics just need more space to unfolded their potentials and be their true selves.

    • This article focuses on when medical ethics and empathy are learned – way before hospital training. Probably high school. And I agree with 90% which means an A.

      Good for Ashley C.

  • Just a friendly amendment! Nurses, physician assistants, and public health practitioners need to be trained to promote social change as well as doctors!

  • Perhaps the most effective approach would focus on behavior change.. starting with eating behaviors and exercise behaviors with a goal of weight maintenance.

  • At a point in time the MD/President of Amherst College offered me Harvard Medical School (Fall 1963), but I choose Northwestern Medical School to go back home to MidWest ethics. At Northwestern I was the leader in reviving a free clinic so some 400 medical school people participated – all free = zero budget. Later it was continued within the War on Poverty and there are 13 pods still going – all with Erie Street in their name and being near Chicago.

    That was my ethic in 1967-68 from which I can now tell Harvard to shape up – this effort being good but atypical (at risk of being Alt’ Left rather than really tied to patients urban AND RURAL). I was a more radical Peacenik that you can imagine – so get over thinking Conservatives are just rich folks; I live on social security as Hippocrates predicted – IT IS ALL ABOUT HONOR.

    Harvard must take on the Real World: 1) adopt the Hippocratic Oath and stop thinking each class can write their own – ridiculous; 2) come out against medical record tampering – West Coast all the way to East Coast – a crime of theft so GO TO JAIL; 3) turn down any Kaiser FF bribes to give the Kaiser cult an academic halo (the “chair” money you accepted for years); 4) come out against all pill splitting – unequal pieces with fragment powder – AWFUL but worth some $200 billion; 5) publish the for profit incomes of MD folks hiding behind non-profit names of enabling charities (Kaiser), religious names (Saint Agnes Medical Group), etc.); 6) stand up for the 700 rural ERs closed since 1983 – no tear lost by the urban elites;

    7) don’t pretend abortions will stop in blue states of Roe v. Wade is overturned – even in Texas will go to county hospitals up until week 13 (then fly free to a late abortion state); 8) Obamcare changes only affect 13 million not 33 million because the children issues will continue as will the young up to age 26; and 9) avoid any such Fake News to make your cases. Stay close to the poor as I have done for 45 years – now age 74 and writing for the poor.

    Charles Roy Phillips, MD – aka Rural Doc and/or Hospital Cop – elected Senior Class Orator 1964 but obviously more “right wing” this eight years now than most of my class – took incoming SCUD missiles in Riyadh in 1991 while many of you med students were … about to be born. I live in Asia where they actually listen to elders. If you do not, you don’t stand a chance of making a real difference to the big problems. You will just be quasi-depressed with world appearing like a jilted lover to you – once full of so many ideals (read Camus). At age 30 with kids to pay for you will be bribed to hurt the poor – 90% of you charging too much or doing too little.

  • Kudos for doing this. Don’t forget some of the health disparities and environmental exposures we tend to overlook, such as mold in housing, mercury in dental amalgam, low grade dental infections, and materials in medical devices. Varying genetic susceptibilities and the range of exposures need to be taken into account.

  • Excellent article. As we develop risk stratification criteria in population health management programs… behavioral and social risk and protective factors can be incorporated into treatment plans….. meeting the goals of the tripe Aim and assist in improving patient health outcomes. Let’s get patients into reduced risk through recognizing social contributors to health outcomes. Great article. Allyson Mayo.

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