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.
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.