I read the CMAJ Salon article by Arya1 with interest and some degree of self-assessment. The author not only provides a fascinating array of physician-based advocacy, but also touches upon the delicate balance between advocacy and empowerment.
Looking at my own practice and those of some of my colleagues, I can appreciate three reasonably distinct styles of physician-based advocacy: advocacy for health-related issues, for non-health–related issues and nonspecific advocacy.
Arya1 cites obvious samples of advocacy to “promote the health of individuals, communities or populations.” This includes direct and indirect health initiatives. Clearly, this unique contribution of physicians is the natural extension of training and expertise as medical practitioners. Not surprisingly, such advocacy remains generally uncontested and powerful.
Physician advocacy for non-health–related issues may be just as powerful, but may not be a natural extension of training and expertise. Furthermore, it may be far more contentious, depending upon the geopolitical milieu in which the advocacy occurs. In the context of divergent opinions regarding such advocacy, one could reasonably question the appropriateness of physician advocacy for non-health–related issues. However, nonspecific advocacy appears to be on the rise and is more troubling. I sometimes see physicians uncritically reiterating what their patients say, often without corroborating evidence, and at times, inconsistent with the expected course of events. A common example is the physician who advocates on behalf of a patient who is pursuing long-term disability benefits in the context of remote soft tissue injuries that have long-since healed. Although the physician has the best intentions, such advocacy may not be what is physically or psychologically best for the patient. This difficult issue was addressed some time ago by the American Medical Association.
As difficult as it may be, we must, with understanding and compassion, objectively assess impairment and not confuse our role as the patient’s advocate with our responsibility for objectivity.2
More and more, I see physicians equating advocacy for health-related issues with nonspecific advocacy. However, we must ensure that when we advocate on behalf of our patients, our actions are consistent with available clinical evidence and are truly based upon the principle of “promoting health interests,” rather than simply fulfilling expectations.