Why doctors must be advocates

The federal government recently announced the Chief Public Health Officer – the physician at the head of the Public Health Agency of Canada – should no longer set the agency’s own budget, leaving this task to a soon-to-be appointed administrator. While the risks and benefits of this approach continue to be debated, a widely cited column by the editor of a high-profile Canadian weekly magazine noted that public health should “stick to their needles”.

This sentiment is not new. Hon. Jason Kenney, during his tenure as the Citizenship and Immigration Minister, countered an op-ed calling for restoration of the Interim Federal Health program, penned by physicians, by arguing that doctors serve patients best when their focus is on disease treatment. You may ask, naturally: why should physicians advocate? Why should they be involved in shaping health policy?

As two trainees in the profession, we firmly believe our patients are why.

More than a century ago, Rudolf Virchow, a doctor considered as the father of modern pathology, famously stated: “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Our diseases, both in Virchow’s era and now, are as much a product of social arrangements – including housing, income, education and employment – as they are a consequence of biology.

As diseases become less and less infectious and more and more chronic, direct solutions such as John Snow taking the handle off the Broad Street pump to stop the spread of cholera in London will become increasingly rare. Medicine alone cannot stop the rising tide of obesity, the continued scourge of lung cancer or the persistent shadow of depression. From our experience with tobacco control, individual education or intervention is not enough to effect change. Only population-level policy and legislative changes, like banning smoking in public places or raising tobacco taxes, can produce lasting impact.

As trainees, we spend most of our time with our physician supervisors focused on individual patients – we are taught to diagnose, treat, communicate with and motivate our patients, and rightly so. When we advocate, it often takes place at the point of care – how to get an urgent MRI more quickly, or how to fight for access to an expensive medication. But when we take a step back, we realize that these are symptoms of a wider health and social system that needs improvement, and that our voices are needed more than ever. Indeed, we can become much more effective in our role when the economic and political powers also strive to keep people from becoming patients.

For example, during our pre-clinical training, we are taught to encourage exercise and healthy eating as first-line treatment in a variety of chronic conditions. As we progress to clinical rotations, however, we are increasingly confronted with questions beyond the individual level: how effective is prescribing exercise in practice when these motivated, hard-working patients are the same individuals who disproportionately live in our neighbourhoods that are not walkable? How meaningful is it to tell patients to consume healthy foods when we have “food deserts” in the very area they live? Physicians cannot stay outsiders to policy, because they bear witness to the resulting inequity in social determinants of health that drive patients to their offices each day.

Our compassion for patients drives our passionate advocacy efforts. Some have asked – and many will undoubtedly continue to ask – why advocacy is still relevant for physicians and trainees today; why we need to be involved in policy when increasing funder scrutiny, rising administrative burden, and exploding medical knowledge are more than enough to keep us busy. To them we humbly suggest the deep convictions with which we entered this profession: advancing equitable access is why. Promoting healthier community is why. Empowering vulnerable population is why. Our patients are why. Where we can join our voice with those in the shadows, there is nowhere else we would rather be.