Primum non nocere, or “first, do no harm,” is a fundamental principle in the practice of medicine. Physicians vow to do as much when taking the Hippocratic Oath on their first day of medical school. But where does the buck stop? I posit that we in the medical community harm patients when we fail to engage in political advocacy.
Why should physicians care?
Health care accounts for just ~20% of the modifiable determinants of health. This compares to 40% from socioeconomic factors and 30% from health behaviors. Zip code is a more accurate predictor of patient health than genetic code. When you consider patient wellbeing through this lens, it becomes clear that all policy is health policy, and health care alone cannot fully address patient needs. These factors have been underscored by COVID-19, where patients face unprecedented food insecurity, housing insecurity, and the worst hit are poor minority communities. The same communities that have been short-changed and, at times, abused by decades of federal policy. Ultimately, public policy dictates patient access to health care and shapes patients’ health in countless other ways.
Imagine a trainee presenting a heart attack patient. The resident proudly proclaims that he gave the patient aspirin, and is recommending discharge. The resident has given 10-20% of available treatments and is satisfied with the modest improvement in the patient’s outcome. However, he has neglected to provide life-saving interventions. The attending physician immediately recommends cardiac catheterization for the patient, reprimands the resident, and demands he remediate.
Here the resident represents the physician that refuses their role in the other 80% of modifiable health determinants. Just as a physician that witnesses unsafe medical practices and does nothing is guilty of malpractice, the physician that turns a blind eye to poverty, systemic racism, and environmental health cannot claim innocence against the standard of non-maleficence. These factors are at the heart of what cause disease. Physicians who decry political advocacy to address the social determinants of health or throw their hands up and say “not my job” are directly harming patients.
What physicians are called to
If physicians are to live up to their oath, they must exercise their passion for patient care in the political arena through policy advocacy. Physicians already practice aggressive advocacy when pushing against resistant insurers for coverage of life-altering treatments. Full commitment to the principles of non-maleficence and beneficence demands that these sharpened advocacy skills be applied to influence the public policies producing patient health.
Notably, powerful physician-led lobbying organizations, such as the American Hospital Association (AHA), spent just under a combined $100 million in 2019. The AHA and American Medical Association were the 5th and 7th largest spenders on lobbying in 2019, respectively. Of further note, physicians and their lobbying groups have primarily focused their political advocacy on affecting reimbursement and malpractice law. Conversely, physicians have rarely lobbied for public goods such as access to health care for the uninsured, tobacco control, or domestic violence prevention. Organizations such as the Chamber of Commerce and Blue Cross/Blue Shield lobby to dismantle key portions of the Affordable Care Act, largely unopposed by physician-run organizations. Through both action and inaction, physicians support policies that harm patients by increasing the costs of care, removing patient protections, and decreasing health care access.
Physicians have a responsibility to wield their influence in opposition to harmful anti-patient lobbying, while working to steer their special interest groups towards health-promoting policies. If we measure continued inaction against advocacy, there is indisputable harm done to patients in the former and a clear surplus of benefits in the latter.
Beneficence benefits physicians
The American health care system is due for a reckoning. Failure to provide high-quality care on average while spending more per capita than any other nation has led to record-high public support for single-payer reform. In a single-payer system, it is likely that fee-for-service reimbursement will give way to quality and outcome-based models. At their worst, physicians’ commitment to reimbursement will prompt them to resist these changes. Clinging to fee-for-service harms patients by perpetuating a system that incentivizes quantity over quality. As the scales tip toward single-payer inevitability and reimbursement models shift to an outcome basis, the realization that advocacy for health-effecting policy financially benefits practitioners will come. At their best, physicians can be a part of advocating for this change, adding their voices to those that will safeguard patient interests when this legislation is drafted and debated. Whether a form of Medicare-for-all comes in the next 4 years or 4 decades, physicians will be at the table when building and implementing this policy. It is up to medical practitioners to decide which side of history their advocacy will put them on.
But I already work 80 hours a week
It is well documented that physicians are overworked. We are currently experiencing a global pandemic at a time when the physician shortage is projected to balloon from ~30,000 to over 100,000 in the next 10 years. Physicians are overloaded with bloated documentation and crippling student debt. With all this in mind, some may reasonably argue that physicians cannot be expected to dedicate what little time they have left towards policy advocacy. Policy advocacy is surely a time and energy-consuming endeavor, with little personal gain for the physician that takes up the mantle of patient interests. How can anyone so busy caring for others be expected to consider the interests of relative strangers in every action or inaction?
The answer lies once again in patient interest advocacy. An understaffed health care system filled with overworked physicians is deleterious for patient care, physician wellbeing, and hospital bottom lines. In our model of health care, everyone is someone’s patient. To be sure, physicians should advocate for their personal patient panel. But, by virtue of the Hippocratic Oath they have taken, there is a moral obligation to take pause and consider whether the measure or change they are advocating for is what is best for every patient.
Michael Kitchin is a medical student.
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