Ch 23 - Advocacy for Everyone
Laura Haselden, MD, MPM; Hannah Thielmeyer, MD; Brittany CH Koy, MD
Doctors often vote and participate in community service less frequently than other similarly educated professionals – as workers in a helping industry, it’s easy to feel as though our clinical work fulfills our need to serve our communities.1 However, we operate within an incredibly complex health care system in which, perhaps, no specialty sees the challenges of health care more clearly than the emergency physician. In our position at the intersection of all fields of medicine and society, we have a responsibility to ensure that policies that affect us, our patients, and the practice of medicine are informed by evidence and are made with consideration of the needs of everyone.
Where legislation attempts to dictate physicians’ ability to deliver care or promote public health, our responsibilities go beyond the bedside and into the sphere of advocacy.
None of us can engage in direct action, or even invest our emotional energy, in every issue relevant to the health of our patients or our practices. However, the breadth of factors that shape our practice virtually guarantees that an issue exists that’s interesting and accessible to each of us. Advocacy is for everyone; regardless of your politics, interests, subspecialty, or even your bandwidth at any given time, there’s a way you can participate.
Why It Matters to EM and ME
We have all experienced failures of the health care system that have impeded patient care and made our jobs harder. Advocacy gives us an opportunity to address these systemic challenges by using our frontline experience to promote solutions that meet the needs and address the shortcomings of the system.
How We Got Here
A seemingly fundamental part of the human experience is trying to influence the actions of others. The American political arena takes this to a new level, with groups trying to exert control over any number of issues for a wide range of reasons – not all of which align with the ethics of physicians. The advocacy work that we must do can be broadly grouped as physician self-advocacy, health and health care advocacy, and advocacy for the broader social determinants of health. This chapter will explore a selection of topics in each.
Current State of the Issue
Physician mental health stands out as one of the landmark issues in physician self-advocacy over the past several years. Approximately 40% of emergency physicians are estimated to experience high levels of burnout and emotional exhaustion,2 and the rate of physician suicide remains high, although it has declined since the 1980s.3 In response to these rates and the increased stressors of the COVID-19 pandemic, professional organizations, including ACEP, joined forces to facilitate the passage of the Dr. Lorna Breen Health Care Provider Protection Act, in memory of Dr. Lorna Breen.4 This federal law provides grants to promote mental health and access to mental health care for health care workers, and it funds research and development of best practices to prevent suicide among health care workers, lower the barriers to care and treatment, and promote strategies for resilience.4
The passage of this bill represents a success story of combined lobbying and legislative efforts of a broad coalition of health professional organizations. As we have recognized the stressors and demands of our careers, we have leveraged our combined political power to push for federal support for our needs.
Other ongoing issues in physician self-advocacy include the push for pay parity. Doximity reports that emergency medicine has the fifth smallest gender pay gap among medical specialties; however, salaries for male and female physicians remain inequitable, with the average annual salary for men estimated at $360K, but for women at $315K.5 This pay inequity can total nearly $2 million over the course of a career.6 Pay disparity is complicated by the burdens of child care falling disproportionately on female physicians, which exacerbates wage disparity and increases burdens of mental and emotional stress.7 Advocating for pay transparency and equity among individual health care systems, throughout contract management groups, across geographical regions, and nationally will help keep emergency medicine in the top specialties for pay equity.
Similarly, inconsistent policies surrounding parental leave and parental return-to-work support create both financial and emotional burdens on physicians, particularly in the residency setting. Parental leave often requires residents to use vacation time, elective time, short-term disability, or unpaid leave through the Family and Medical Leave Act (FMLA).8 The American Board of Medical Societies requires specialty boards to allow for a minimum of 6 weeks of family or parental leave at least once during residency without extending training or using up all other time away; however, their policy allows for averaging and accrual of vacation time and does not make any recommendations about paid versus unpaid leave.9
Using vacation or elective education time to give birth or adopt a child adds to the stress on new parents and is a disservice to the education of residents, who fundamentally participate in residency programs as an educational endeavor.10 Beyond unclear leave policies surrounding the birth or adoption of a child, many programs and hospitals also do not have a straightforward policy for return to work or support services such as lactation rooms, accessible child care, or flexible coverage policies.11 These systemic failures create barriers to autonomous reproductive decisions and disenfranchise birthing parents from the workforce.
Within emergency medicine, EMRA advocates for a clear, straightforward parental leave policy that emphasizes equitable access to paid leave for both birthing and non-birthing parents, separate from vacation time, with flexibility in accrual of leave time, and with minimal extension of training periods. The American Board of Emergency Medicine (ABEM) developed a parental leave policy that allows for residents to take up to 8 weeks of family leave per year without extending training, from a previous maximum of 6 weeks annually.12 Sustainable and financially supported parental leave may serve to narrow the pay gap and reduce the exodus of parents from the workforce. In our efforts to facilitate the success of physician parents, we should advocate to our governing bodies, and to our individual employers, to work holistically to expand parental and familial leave to the maximal extent possible within the bounds of our accrediting bodies. Parental and familial leave should be offered liberally to both birthing and non-birthing parents without pressure or stigma. Supportive policies upon return to work will help ensure the continued success of parents in the workforce.
To facilitate the cultural shift necessary to destigmatize parental leave policies, programs should begin openly discussing parental leave policies with all prospective residents. A comprehensive and generous leave policy serves as an effective recruiting tool; the precedent set by prioritizing family wellness from recruitment forward will shape the culture of the residency.13 Outside of our own residencies and colleges, we should advocate for national, paid parental leave policies - medicine is certainly not an outlier in perpetuating inadequate parental leave policies. We broadly recognize the benefits of adequate parental leave on the health and wellbeing of both parent and child14 - we must advocate for these benefits for both ourselves, and our society.
Health and Health Care Delivery
Beyond advocating for ourselves and our careers directly, countless opportunities exist to advocate for our patients and the practice of medicine. The health care system has faced legislative threats to the autonomy of care delivery and patient-physician privacy for generations, and evolving political dynamics have exacerbated these threats. From historical restrictions on medication-assisted treatment for opiate use disorder, to ongoing legislative efforts at state and federal levels to restrict abortion access, reproductive health care management, gender-affirming care, and firearm safety - legislation that interferes with our delivery of care has created harm for our patients. Advocacy in these areas is critical and holds the potential for powerful change.
Substance Use Disorder Treatment
Consider the so-called X-waiver. After the initial authorization of buprenorphine under the Drug Addiction and Treatment Act of 200015 for medication-assisted treatment for opiate use disorder (MOUD), its use was restricted under the DATA waiver, or X-waiver.16 This restriction was codified in federal law, which then created systemic barriers to initiation of MOUD, requiring doctors to undergo extensive training and additional licensure to prescribe a medication with similar or lower risks to other opiates, at the expense of patients’ access to this care.17 Physicians from a wide range of specialties decried these regulations and spent years advocating for the removal of the X-waiver in order to improve patient care. Section 1262 of the Consolidated Appropriations Act of 2023 (also known as Omnibus bill) effectively ended the X-waiver, signifying an important victory for health care advocates.
Reproductive Health Care
Similarly, while the provision of elective abortions is generally not within EM’s scope of practice, proposed abortion bans and criminalization have implications for both us and our patients. Our charts carry legal significance, particularly in states that have prepared legislation to criminalize patients and clinicians suspected of undergoing or performing abortions. We, as physicians, recognize “abortion” as the appropriate medical diagnosis for both spontaneously-occurring and induced termination of pregnancy; however, legislation constructed without medical expertise has created environments in which our medical diagnoses pose legal threats to both our patients and colleagues. Abortion bans have also historically resulted in increased morbidity and mortality to our patients.18,19 Regardless of one’s personal opinions surrounding elective abortions, blanket criminalization of medical care that saves lives is unacceptable. Our responsibility to our patients requires that we demand the unrestricted delivery of care, dictated by evidence-based principles and our ethical requirements to our patients and unencumbered by political, personal, or religious agendas.
Moreover, the precedent set when non-medical legislators and politicians dictate medical care without knowledge of the medical evidence behind these policies threatens the integrity of health care delivery. We have already seen this pattern extending into legislative efforts to criminalize gender-confirming health care in states like Texas.20 These legislative efforts to restrict care that is personal, evidence-based, and lifesaving are tantamount to the practice of medical care without a medical license and are entirely in opposition to medical standards of best practice. Our responsibility as physicians is to defend the evidence-based practice of medicine. Where legislative barriers seek to prevent this, our responsibility to our patients and our profession is to take direct action against the restrictions imposed against us — advocacy is our lane.
For years, physicians have butted heads with the NRA and similar groups about the role of medicine in advocating for gun control. Over the past several decades, physician gag laws have been crafted to prohibit physicians from talking to patients about firearms and firearm safety, despite medical boards recommending these conversations as best practice.21 These gag orders have been deemed unconstitutional, as they violate physicians’ First Amendment rights; however, attempts to restrict physician’s ability to discuss issues deemed political or controversial persist.22 Physicians also remain poor at asking about, and counseling on, firearms and firearm safety.23 This failure is partly due to misinformation about the physician’s right to legally discuss firearms - while some states have laws that say physicians cannot be specifically required to ask about firearms, in all states, if physicians have good-faith concerns that firearms affect a patient’s medical care or risk, they are allowed to ask and counsel on firearms and safety. For patients at high risk of suicide or interpersonal violence, we are, and must remain, able to discuss safety measures.
Other Public Health Issues
Beyond the right and responsibility to counsel individual patients on their respective risk of harm from firearms, physicians have a responsibility to advocate for public health measures that promote the well-being of our communities. Physicians have long been involved in matters of public health - seatbelts, tobacco, leaded gasoline, to name a few. This involvement is more than a hobby; it is an ethical obligation. We are bound by our oaths to promote and preserve health and well-being when it is within our knowledge and ability to do so. We face frequent legislative interference in public health efforts, driven by financial and politically motivated interests. For example, oil companies have lobbied for legislative restrictions on physician disclosure of the risks of fracking in states where fracking poses a major source of oil revenue.24 Where organizations and industries leverage their power to influence health care out of financial or political motivations, it is the responsibility of the house of medicine to advocate for the interest of our patients, in keeping with evidence-based best practices. Where legislation prevents adequate research, as seen in federal prohibitions on funding firearm research imposed by the Dickey Amendment, it is our responsibility to advocate for the acquisition of this evidence.25 Advocating for the repeal of all legislative barriers to our provision of best care is well within our rights and responsibilities.
In short - it is essential that physicians advocate for our right to practice medicine in keeping with our knowledge, experience, and the responsibilities of our oaths. Where legislation attempts to dictate our ability to deliver care or promote public health - abortion access, gender-affirming care, firearm safety, etc. - our responsibilities go beyond the bedside and into the sphere of advocacy. Forces outside of health care will attempt to restrict our practice; it is the responsibility of each of us to ensure our autonomy and ability to provide effective care.
Social Determinants of Health
While advocating directly for our practices and against interference into our delivery of care is essential, it is also our responsibility to recognize the factors outside of the direct delivery of health care that influence our patients’ health and ability to access health care.
Access and Affordability
We have all seen the effects of high-cost health care on our patients’ ability to access care, leading patients to enter the emergency department late in their disease course and critically ill. We’ve cared for the patients unable to access regular dialysis; we’ve made the stage IV cancer diagnoses. We’ve had parents refuse testing or treatment out of concern for cost. We’ve cared for patients dying of temperature-related illnesses, from exposure, from malnutrition. We must advocate for both financial and physical access to preventative health care.
The social factors that determine our patients’ ability to care for themselves, and to access medical care, often play a far greater role in their overall health and well-being than we do. Promoting the health of our patients requires us to recognize this fact, and advocate for social systems and safety nets that allow our patients to meet their needs. Physicians should consider the implications of access to health insurance, preventative care, housing, mental health and substance abuse treatment, employment training, and food security for our patients, and advocate accordingly. We should consider and screen for social determinants of health in the emergency department, maintain awareness of our community and health systems’ resources to address these needs, and advocate for the expansion of these services.
Racial and Socioeconomic Disparities
Physicians also carry the responsibility of recognizing and working to narrow health and health care disparities that arise from discrimination both within and without the health care system. Racial and socioeconomic disparities within health care access have only become more pronounced as health care resources have been stretched to their absolute limits during the COVID-19 pandemic.
In particular, medical and systemic racism have been demonstrated to exacerbate nearly every issue described herewith – historically disenfranchised communities experience increased rates of gun violence,26 more air pollution and heat trapping (causing worse health outcomes),27,28 higher maternal morbidity and mortality rates (increasing the risk of restriction of abortion access and maternal health care),29-31 and increased police brutality.32 If we intend to advocate for progress on these issues, we must acknowledge their intersectionality. This includes recognizing our own cognitive biases and implicit racism and working to unlearn them, in addition to advocating for systemic changes and policy solutions. This should include a culture that directly and immediately corrects harmful behavior and biases, systems that pay appropriately qualified minority educators to assist in formal diversity and equity training, and continuing medical education throughout our careers on the social determinants of health and health disparities. It should also include the recognition of challenges that our minority colleagues face at the hands of a specialty that is still predominantly white, with systemic interventions to make EM more diverse at all levels of practice and leadership.
We must also recognize the implications that our practices have on the health of our environment. American health care is one of the industries that contributes most to carbon emissions and climate change; simultaneously, our patients are dramatically affected by the evolving challenges of a changing climate.27,28
Physicians can take a range of actions to help fight climate change, including advocating that hospitals provide a plant-forward menu, selecting medications and dosing strategies with lower carbon footprints, conducting research into the link between climate change and health, and direct lobbying for regulation of supply chains and emission standards.33
Even outside of our direct delivery of health care, our commitment must remain to public health. The barriers to public health are ever-changing - we continuously witness the evolving threats of infectious disease, police brutality, gun violence and other interpersonal violence, racism and xenophobia, climate change, and substance use disorder. It is functionally impossible to meaningfully engage in direct advocacy on every issue that’s relevant to our practices while maintaining our clinical acumen and well-being. However, we must acknowledge that all aspects of our society are interconnected. The challenges faced by our patients are driven by the effects of social policies; awareness of these challenges is the sine qua non for advocating for change.
Organized advocacy groups like ACEP and EMRA provide an excellent place to start — for those less interested in politics, these organizations function as an extensive repository of knowledge and organized lobbying power and are a convenient first step into advocacy. However, organized medicine should be seen as neither necessary nor sufficient – there is an avenue for advocacy for everyone, of any political affiliation or sentiment, at any stage of your career. Our responsibilities are to our patients and our practices. None of us can do everything, but everyone should do something.
- Emergency medicine is a frontline specialty uniquely positioned to identify the needs of a diverse population of patients and the shortcomings of the system.
- We can advocate for ourselves, the health care system, and the social determinants of health that affect our patients and communities.
- Self-advocacy includes mental health access, pay equity, and supportive parental leave policies throughout residency and our careers as physicians.
- Health care advocacy should prioritize basing health policies on evidence and best practice rather than political or individual agendas.
- We have the responsibility to advocate for our patients’ ability to live healthy lives, which includes acknowledging and combatting social determinants of health.
- The issues facing our careers and our patients encapsulate a broad variety of areas for advocacy, and there is space for every physician to contribute in a way meaningful to themselves and their patients.
- Ahmed A, Chouairi F, Li X. Analysis of Reported Voting Behaviors of US Physicians, 2000-2020. JAMA Netw Open. 2022;5(1):e2142527.
- Zhang Q, Mu MC, He Y, Cai ZL, Li ZC. Burnout In Emergency Medicine Physicians: A Meta-Analysis and Systematic Review. Medicine (Baltimore). 2020;99(32):e21462.
- Duarte D, El-Hagrassy MM, Couto TCE, Gurgel W, Fregni F, Correa H. Male and Female Physician Suicidality: A Systematic Review and Meta-analysis. JAMA Psychiatry.2020;77(6):587–597.
- 117th Congress. H.R.1667 - Dr. Lorna Breen Health Care Provider Protection Act. https://www.congress.gov/bill/117th-congress/house-bill/1667. Published 2022. Accessed June 4, 2022.
- 2020 Physician Compensation Report. Doximity.com. https://www.doximity.com/2020_compensation_report. Published 2022. Accessed June 4, 2022.
- Whaley C, Koo T, Arora V, Ganguli I, Gross N, Jena A. Female Physicians Earn An Estimated $2 Million Less Than Male Physicians Over A Simulated 40-Year Career. Health Aff (Millwood). 2021;40(12):1856-1864.
- Frank E, Zhao Z, Fang Y, Rotenstein LS, Sen S, Guille C. Experiences of Work-Family Conflict and Mental Health Symptoms by Gender Among Physician Parents During the COVID-19 Pandemic. JAMA Netw Open.2021;4(11):e2134315.
- Magudia K, Bick A, Cohen J et al. Childbearing and Family Leave Policies for Resident Physicians at Top Training Institutions. JAMA. 2018;320(22):2372.
- American Board of Medical Specialties Policy on Parental, Caregiver and Medical Leave During Training. American Board of Medical Specialties. https://www.abms.org/policies/parental-leave/. Published 2022. Accessed June 1, 2022.
- Stack S, Jagsi R, Biermann J et al. Maternity Leave in Residency. Acad Med. 2019;94(11):1738-1745.
- Juengst S, Royston A, Huang I, Wright B. Family Leave and Return-to-Work Experiences of Physician Mothers. JAMA Netw Open. 2019;2(10):e1913054.
- Policy on Paternal, Caregiver, and Medical Leave. ABEM.org. https://www.abem.org/public/docs/default-source/policies-faqs/policy-on-parental-caregiver-and-medical-leave.pdf. Published 2022.
- Kraus M, Reynolds E, Maloney J et al. Parental Leave Policy Information During Residency interviews. BMC Med Educ. 2021;21(1).
- Daniel H, Erickson S, Bornstein S. Women's Health Policy in the United States: An American College of Physicians Position Paper. Ann Intern Med. 2018;168(12):874.
- samhsa.gov. https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine. Published 2022.
- Pergolizzi J, LeQuang J, Breve F. The End of the X-Waiver: Not a Moment Too Soon!. Cureus. 2021.
- Whelan P, Remski K. Buprenorphine vs Methadone Treatment: A Review of Evidence in Both Developed and Developing Worlds. J Neurosci Rural Pract. 2012;03(01):45-50.
- Coble Y. Induced Termination of Pregnancy Before and After Roe v Wade. JAMA. 1992;268(22):3231.
- Latt S, Milner A, Kavanagh A. Abortion Laws Reform May Reduce Maternal Mortality: an Ecological Study in 162 Countries. BMC Womens Health. 2019;19(1).
- Boulware S, Kamody R, Kuper L et al. LGBTQ+ Youth. Child Study Center: Policy. https://medicine.yale.edu/childstudy/policy/lgbtq-youth/. Published 2022. Accessed June 1, 2022.
- McCourt A, Vernick J. Law, Ethics, and Conversations between Physicians and Patients about Firearms in the Home. AMA J Ethics. 2018;20(1):69-76.
- Parmet W, Smith J, Miller M. Physicians, Firearms, and Free Speech — Overturning Florida’s Firearm-Safety Gag Rule. New England Journal of Medicine. 2017;376(20):1901-1903.
- Weinberger S. Curbing Firearm Violence: Identifying a Specific Target for Physician Action. Ann Intern Med. 2016;165(3):221.
- Weinberger S, Lawrence H, Henley D, Alden E, Hoyt D. Legislative Interference with the Patient–Physician Relationship. N Engl J Med. 2012;367(16): 1557–1559.
- Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018;108(7):865-867.
- Martin R, Rajan S, Shareef F, et al. Racial Disparities in Child Exposure to Firearm Violence Before and During COVID-19. Am J Prev Med. 2022;63(2):204-212.
- Ebi K, Balbus J, Luber G, et al. (2018) Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II [Reidmiller D, Avery C, Easterling D, Kunkel K, Lewis K, Maycock T, and Stewart B (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 572–603.
- (2016) The impacts of climate change on human health in the United States: A scientific assessment. Crimmins A, Balbus J, Gamble J, Beard C, Bell J, Dodgen D, Eisen R, Fann N, Hawkins M, Herring S, Jantarasami L, Mills D, Saha S, Sarofim M, Trtanj J, and Ziska L, Eds. U.S. Global Change Research Program, Washington, DC, 312 pp.
- MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017. Am J Public Health. 2021;111(9):1673-1681.
- Saluja B, Bryant Z. How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States. J Women's Health. 2021;30(2):270-273.
- Redd S, Rice W, Aswani M, et al. Racial/Ethnic and Educational Inequities in Restrictive Abortion Policy Variation and Adverse Birth Outcomes in the United States. BMC Health Serv Res. 2021;21:1139.
- Ross CT, Winterhalder B, McElreath R. Racial Disparities in Police Use of Deadly Force Against Unarmed Individuals Persist After Appropriately Benchmarking Shooting Data on Violent Crime Rates. Soc Psychol Personal Sci. 2021;12(3):323-332.
- Salas RN. The Climate Crisis and Clinical Practice. N Engl J Med. 2020;382(7):589-591.