How does a doctor best act as an advocate for their patients?
Name: Dean K Wright
Year of Study: 5th Year Medical Student
Medical School: University College Dublin
An ‘advocate’, is defined as: ‘a person who publicly supports or recommends a particular cause or policy.’1 As doctors, our ‘particular cause’ is our patients and we can publicly support them in many ways.
The nature of the medical profession is such that doctors are frequently exposed to the most vulnerable people in their most vulnerable moments. Because of this, it is not long into a doctor’s career that they are get an opportunity to act on behalf of a patient when said patient lacks the resources to do so themselves. In the everyday setting, this can be a routine process. Anyone who has ever been to a Multidisciplinary Team Meeting (MDT) in any speciality has seen first-hand the hard work put into managing the care of patients with the goal of keeping their best interests at heart. Doctors, nurses, pharmacists, physiotherapists, occupational therapists and social workers convene with one overall objective – to provide the best possible patient care while also respecting the wants and needs of the patient and their family. In the MDT, an everyday occurrence, the voice of the patient is projected through multiple viewpoints so that he/she can best be heard. This is 21st Century patient advocacy at its simplest.
Another well-known example is in the case of potential child abuse. In these emotional and often disturbing cases, it is generally the doctor or nurse that first notices the red flags that indicate a shocking revelation. It is up to them therefore to be the ultimate advocate for the child. It is a testament to the progress we’ve made in that the National Guidance for the Protection and Welfare of Children (2011) gives us direct guidelines on how to act in such a situation2
It would be incorrect, however, to assume that patient advocacy is always a straightforward process. There are times when certain medical issues appear to put the best interests of the patient into conflict with patient autonomy; making patient advocacy a challenging ordeal. An example of this would be a case where a patient with full capacity exercises their right to refuse life-saving treatment. In this instance, doctors may feel that their knowledge and experience justifies them being strongly opposed to the decisions being made and may struggle to advocate for their patient. Some may view this as dangerously paternalistic which undermines the privilege of patient advocacy. In any case, it is a barrier to effective patient care.
There are many instances where doctors may find it challenging to advocate for their patients’ rights and/or needs:
1. Do Not Resuscitate orders: where patient and family wishes differ
2. Confidentiality: when divulging private patient information is in the public interest
3. Complicated pregnancies: where there are not one but two lives at stake.
4. Cases of reduced capacity: where the patient may not be able to make decisions in their own best interest
Fear of negative legal and professional consequences can also be a barrier to a doctor acting in the role of advocate. The modern sequelae of ‘defensive medicine’ can cause some doctors to distance themselves from their patient’s affairs as they try to avoid situations where they may leave themselves vulnerable to litigation. Others simply feel they lack the necessary skills and competencies to fulfil the role of advocate.
Legislation can also aid the advocacy process however. Doctors can also use new legislation to aid them in providing optimal care. The Assisted Decision-Making (Capacity) Act 2015 will soon abolish the idea of ‘wards of court’ and introduce new supports for decision-making in patients with reduced capacity. In terms of advocacy, this will allow physicians to tailor care to the wants and needs of the nation’s most vulnerable individuals.3
Technology is now influencing patient advocacy. With the emergence of the ‘Google’ era, the doctor-patient consultation has become a different experience, with many patients now having multiple resources to educate themselves on potential diagnoses. While this can be seen from both positive and negative perspectives it is, regardless, a new hurdle for practitioners to jump. Doctors must now reassure patients of their proficiency to guide them through treatment and acknowledge that medical care is not something to be done to patients but with them. Patients that look to medical professionals to guide them in this way deserve to be fully informed about the options, risks and benefits of treatment. Indeed, this is exactly what doctors strive to outline in every consultation and consent for procedure. The information should not be limited to medical treatments alone however. Effective advocates will actively give advice or referral for advice in non-medical issues such as social welfare, citizen rights as well as legal and financial issues. While not directly affecting their care, helping patients in this way contributes to overall improved patient wellbeing. The idea is that it is not just about giving the best possible medical care, but treating the patient in a holistic manner and empowering them in their decision-making.
How can medical practitioners overcome these challenges and best act as advocates for our patients?
A key factor here is the strength of the doctor-patient relationship i.e. the level of trust between them. Dealing with difficult situations (such as those mentioned above) requires expert communication skills. However, even the most charismatic of practitioners will find it difficult to achieve the best outcomes for their patients if there is a lack of trust present. Effective advocacy in these situations requires that the doctor is informative, assertive, empathetic, understanding and supportive. These are qualities that require conscious effort and work but no doubt go a long way to improving patient care. Aiding us in these efforts is the recently updated ‘Guide to Professional Conduct and Ethics for Registered Medical Practitioners.’4. This document sets out standards that every medical practitioner should uphold and aspire to and can be used as an adjunct to clinical decision-making.
Outside of the doctor-patient relationship, medical professionals can still advocate for their patients at local, regional and international levels. In a local GP clinic, as well as medical treatment, a doctor can refer patients to appropriate services or write to local representatives as advocates concerned for their patients’ welfare. For example, they can advise patients suffering from progressive diseases on when to establish a power of attorney and how to make a will.
In the community, doctors can take on leadership roles that shapes the wellbeing of their patients at a public health level. School boards, sports teams and local government all harbour opportunities for doctors to promote positive health measures outside of the conventional healthcare system by affecting the economic, social and environmental determinants of health.
At the national level, doctors can become part of organisations that campaign for better care. Bodies such as the Irish Medical Organisation have the social capital to influence government and collectively advocate to change health policy.
Recently, the need for patient advocates in this country has become even more clear with the public uproar over Ireland’s hospital bed crisis. As we reach an unwanted milestone with 10,511 people on trollies in March 20185, a record-breaking figure, doctors are now more than ever needed to be advocates for patient welfare. Without government lobbying and campaigning from dedicated medical professionals across the country, we will be facing a similar problem in this country for the foreseeable future. In a similar fashion, the debate around the proposed removal of the 8th amendment will be shaped by experienced medical professionals advocating the stories of women at their most vulnerable moments.
Internationally, doctors can have the greatest net positive impact on patient health. The World Health Organisation is the prime example of a body that promotes awareness of the most pressing global health issues such as TB, HIV/AIDS, ischaemic heart disease and women’s health.
NGO organisations such as Médecins Sans Frontières are also global advocates and are comprised of passionate and determined doctors who strive for improved healthcare at a global scale. From Gaza to Ghouta to the Greek Islands, some Irish doctors have found their calling to treat and advocate for the poorest and most disadvantaged of patients on earth.
As a medical student, my ability to advocate in the health service is currently limited to observation and reflection. It is my hope that what I have seen thus far in my education will be valuable in effectively advocating for my patients in the future whether that be in the clinic, the wards, the board room or via the media.
Health advocacy has achieved a great amount since the beginning of the 20th century. Campaigning for awareness and government intervention into the most pressing health issues has affected billions of people world-wide via: routine vaccinations, treatment of infectious diseases, lifestyle interventions into lung and heart disease and cancer awareness. A female child born in Ireland now can expect to live 82.8 years (males: 78.4) as opposed to 59.9 years (males 57.4) in 19265 There is no denying the positive contribution that progressive health advocacy has had to our increased longevity.
While we should not de-value the achievements made by patient advocacy in the past, we must continue to shine light on the issues where much more work still to be done. These include mental health, global health inequity and inequality, as well as evolving lifestyle issues such as models of care for the elderly and childhood obesity. We must continue to speak at local, regional and international levels for those that go otherwise unheard.
1. Anon, 2018. ‘Advocate’ In 1st ed. [Online]. Available at: https://en.oxforddictionaries.com/definition/advocate
2. Children First: National Guidance for the Protection and Welfare of Children (2011). Available at: http://www.dcya.gov.ie/documents/Publications/ChildrenFirst.pdf
3. Medical Council 2009: Guide to Professional Conduct and Ethics for Registered Medical Practitioners
4. Irish Nurses and Midwives Association. (2018, March 29 ). March Trolley/Ward Watch Figures Break Several Records. [Press release]. Available at: https://www.inmo.ie/Home/Index/217/13181