How does a doctor best act as an advocate for their patients?

Name: Rory Plant
Year of Study: Final year of Medical Studoes
Medical School: University College Dublin

Opening Statement.

Esteemed doctors of this court. As an advocate with a modest knowledge of law and medicine, I have undertaken a task to elucidate the principles of how a doctor can best act as an advocate for their patients. I will attempt to outline ten broad principles throughout this address.

Imagine, for a moment, that you decided not to pursue a career in medicine. Instead you decided to become a lawyer – more specifically a barrister. Your professional contribution is to determine what legal claims your client is making and fashion them into a coherent structured argument that makes sense in a court of law. You are using your expert knowledge of the legal system to advance your clients interests without necessarily attaching yourself to their moral cause. This detachment is in the client’s best interest and societies at large; it ensures everyone the right to a fair trial and due process. That, in general, is a good legal advocate.

Now I’d like you to remember you are a doctor. Your professional contribution is to listen to your patient’s symptoms, elicit their clinical signs and determine their medical needs. You must then fashion this knowledge into a coherent management plan that your patient is satisfied with, your peers are satisfied with, one the patient’s families are satisfied with, and one that you yourself are satisfied with.

Unlike a legal advocate, the role of a medical advocate is much more complex: You must act as the oppositions barrister by cross-examining your patient; you must act as their advocate by listening to their concerns, demands and gain their trust to be their doctor; you must be the detached judge by determining an appropriate course of action; and you must prepare to be judged by a jury of your colleagues on an ethical and moral basis. If medicine was a court room, you’d find it difficult where to place yourself.

In light of this dilemma, I’d like to examine how a doctor best acts as an advocate for their patients. Patient advocacy by its very nature is deeply rooted in a moral idealism and concept of medical professionalism.  The Guide to Professional Conduct and Ethics for Registered Medical Practitioners 2016 enshrines the importance of patient advocacy:

4.5 You should act as an advocate for your patients in two ways. You should speak on behalf of individual patients, to help make sure they receive appropriate healthcare. In addition, you should support all patients by promoting the fair distribution of limited resources and fair access to care.1

This is vague. It tells us is that your actions should be appropriate and you need to take into account the fair distribution of resources. This is a minimum expectation of doctor’s advocacy role, but it can be accused of saying nothing more than use your common sense. I do not blame the Guidelines for being unforthcoming as to what is the best way to advocate for a patient, as it is appropriate to treat individual patients individually. It is impossible to provide definitive and exhaustive guidelines as to what this means.

I will argue that there are ten broad principles we can follow to best act as an advocate for our patients. These shall be elucidated through a brief examination of the three important areas in clinical life: optimising patient experience; optimising organisational abilities and; optimising physician well-being.

Optimising Patient Experience:

The central tenet of good patient advocacy is get to know your patient. Although this is such an obvious aspect of patient advocacy it cannot be overstated. As the Guidelines of medical ethics 2016 state:

4.2 Patient-centred care means doctors treating patients as individuals, take into account their personal preferences, goals and lifestyles, acting with compassion and respecting patients’ dignity.

This is of course difficult with limited resources of time, energy and attention. Fortunately, history taking, examination and communication skills are the cornerstone of clinical practice, and these skills can help us generate relatively holistic views of a patient’s needs as well as their ideas, concerns and expectations. It becomes decidedly/exceedingly more difficult if the patient is unconscious or is unable to communicate effectively – hence why diligent documentation of doctor patient encounters and family input play such an important role throughout your practice.

Engaging with empathy is a critically important factor in optimising the patient experience. Empathy is increasingly deemed a fundamental component of effective patient care.2 Empathy, I believe, is a word that is often misrepresented in medical literature. It is often used synonymously with the term sympathy. I would argue that empathy is something that is experienced between both patient and practitioner or in other words a shared understanding of an issue and a shared emotional investment in solving that issue. This isn’t an identical understanding or emotional investment by both parties (that would be absurd for numerous reasons), but the experience is enough to establish a necessary trust that facilitates optimum patient experience in the health care system.

Unfortunately, a scenario may present itself where we are not particularly well equipped to deal with certain patients. It may be because of our area of clinical expertise, or because of a strained dynamic between doctor and patient. It is human nature that we will experience personality clashes and doctors and patients will not always see eye- to-eye. Nevertheless, it is our duty to provide the best care possible to those under our care and it may be appropriate at times to ‘agree to disagree’ and facilitate a handover of care to someone who is better equipped and/or more likely to establish a rapport with the patient. This should not be equated to as a refusal to treat. We must treat if necessary, but a good patient advocate will realise if a patient may benefit by being handed over to someone else’s care.

Principles 1-3

1.Get to know your patient.
2.Cultivate an empathic encounter.
3.Find a better advocate if necessary.

Optimising Organisational capacities.

In order to successfully advance and create tangible benefits in the life of your patients, you need to be able to externalise your ideas into actions. The different actions one can take are manifold. It should be noted that the Guidelines state you should support all patients by promoting the fair distribution of limited resources and fair access to care. The ability to successfully achieve this competency suggests you need good organisational skills – i.e. planning, delegating, and managing different tasks effectively and fairly.

In order to develop appropriate plans, a lot of prerequisite knowledge is required. Without knowing what options are available, how it is possible to address what is appropriate management and further ask what is appropriate or cost-effective?

Knowledge can be attained by engaging in continuing medical education and pursuing your own research interests. Without being up to date on the best practices, the patient will not benefit from the best evidence based practice, nor can the benefit from potential new treatments or management strategies. The dissemination of knowledge through actively educating others or publishing articles is further key in advocating for your patients. It is often not immediately apparent but the benefits will hopefully be felt by their patients through the promotion of discussion and new innovative ideas. The discussion can further stimulate the potential for future empathic encounters with patients and doctors in the future.

Although learning about your area of interest from an academic point of view is important, it’s important to stay aware of different emerging facilities in your physical locality. Patient groups (both physical and online) have been invaluable in improving the quality of lives in individuals, but even other activities such as local bridge clubs, local gyms etc. can be important in encouraging healthy activities and improved quality of life. Would you be able to suggest 4 facilities/activities in your area for each age group?

Principles 4-6:

1. Be organised.
2. Continue your education.
3. Acquire knowledge of local facilities.

Optimising Physician Well-Being:

So far we have addressed the patient and the patient advocate. Now I would like to somewhat conversely address the advocate as a patient i.e. the physician as a future patient. The very fact that physicians are human means that we are all destined to be patients too at some stage in our lives. As a general rule of thumb, we’d all rather be patients later rather than sooner, but it is worth reminding yourself of this truth before you meet with any patient. Optimising physician well-being is therefore critically important in ensuring that the patient advocate can perform his/her duties and limiting the number of patients that require the advocacy service!

It is an interesting aspect of doctor psychology that many doctors are particularly adept at identifying when individuals are working too hard or overly burdening themselves, yet we cannot recognise when we are guilty of over exerting ourselves. I don’t think any doctor is a stranger to the idea of burn-out. It has been a growing concern for years. Numerous resources have suggested how we can combat this. The basic messages are that doctors should not expected to be patient advocates 24 hours a day, 7 days a week. Good sleep, good nutrition and good exercise are all pieces of advice that we should give our patients and heed ourselves. Some have argued that Mindfulness could be involved in stress reduction,3 although there is a suspicion that the research may be subject to self-selection bias. Nevertheless, doctors should also look for activities outside of medicine to recharge and enjoy their own lives.

This is of course easier said than done and there are many factors that create barriers to this perfectly regimented ways to tackle stress. Nevertheless finding an activity or routine that allows you to recharge is worthwhile for yourself and for patients in the long run.

Principles 7-9.

1. Remember you too will be a patient one day.
2. Try and live by some of the advice you give your patients.
3. Find activities to recharge – you don’t have to be an advocate all the time.

Closing Statement:

Being a patient advocate is a different challenge from being a legal advocate. Whereas lawyers may often struggle to remain detached from their clients, medical professionals have to balance being both detached and emotionally engaged. They must further juggle the role of patient advocate; medical judge and face a jury of their peers constantly.  The moral and ethical implications of this challenge are intimidating at the best of times.

At the same time such a challenge is a very rewarding part of medicine. It is very inspiring as a medical student to see many doctors from all disciplines thrive in spite of this herculean task. Fortunately medicine is a far more collaborative profession and part of its appeal is that you can get a great sense of fulfilment from meeting new patients, and solving their problems in a multidisciplinary setting.

The points I have presented might appear self-evident. By having them enlisted here, I hope that it will allow you to reflect on the importance of patient advocacy and to realise that patient advocacy is one of the best aspects of a doctor’s career. In closing, I ask you to reflect on choosing to pursue a career in medicine – or put another way – why didn’t you become a lawyer?

Principle 10:
1. Advocate for your own profession.