Almost daily, another “public health crisis” is identified that compromises the health and healthcare of Americans and places an even greater burden on an already burdened healthcare system that struggles with chronic conditions, access, excessive costs, and disparities in care.
These public health crises are real in terms of their impact on the overall health of our communities, and physician leaders and the healthcare systems in which we operate have a responsibility to contribute to their resolution; however, that is not our sole responsibility. The gap between what ought to be done and what can be done is growing. Physician leaders must understand themselves and their work to contribute meaningfully to addressing the challenges we all face in health and healthcare during these stressful times.
Physicians are people, too, with our own struggles, facing the same challenges our patients face, including an ongoing pandemic, rising inflation, and uncertainty in the political system. Physicians must navigate these personal concerns and those of their families in addition to caring for others in a busy and stressful profession.
Dimensions of Self
All professionals, including physicians, bring elements of themselves to their work, including their values, attitudes, biases, and beliefs. These dimensions allow us to give of ourselves to our patients, families, and society. How we give this gift of self is important to consider and depends on context.
Dimensions of Self in Caring for Patients
Medical schools devote a substantial amount of the curriculum to the medical model because it focuses on developing the relationship between the physician and the patient. This is a construct that all physicians learned and took an oath to uphold.
Fundamentally, the medical model implies that our unwavering role and responsibility as physicians and professionals is to advocate fully for those patients and their families who seek us out for advice and consultation. It is important to remember that our patients are ultimately the decision-makers; our role is to provide information based on current knowledge of the risks, benefits, and alternatives for their decision.
Dimensions of Self In Advocating for Public Health Problems
Although the undergraduate medical school curriculum usually includes an introductory course in public health, most physicians have only a cursory exposure to public health and its toolbox, which includes prevention, epidemiology, education, statistics, advocacy, and policymaking. Physicians use these tools every time they apply diagnostic testing based on sensitivity, specificity, and positive and negative predictive value. When prescribing a specific medication or therapy, the evidence comes from data that may have been collected in a clinical trial at the population level and is being applied to an individual patient.
In advocacy, the public health model’s framework is about addressing the needs of populations, not patients. Public health as a profession moves the conversation from individuals to populations and population subgroups. This is important. When physicians advocate for the benefit of populations, the interests of an individual may become subordinated to the interests of the population. This is a different approach than the doctor-patient relationship, where the physician advocates directly for the patients.
There are several differences between the public health and medical models.
First, as leaders, we may develop specific areas of interest that energize and drive us to advocate for others. Some may be related to our work and interest in healthcare, and others may be topically apart from healthcare or influence healthcare indirectly.
Whereas the medical model and our service to patients have us informing their personal decision-making with objective data and expertise, the public health model and our advocacy contributions are not nearly as constrained. You can be a doctor and advocate for the things that fuel your passion.
Second, physicians often find advocacy and policy work in the public health sphere less fulfilling with a long lead time between advocacy work, intervention, and outcome. Further, the results may not be as tangible as in the care of patients because they are measured at the level of the population, and it may take time to have a broad-scale impact on the outcome.
Finally, advocacy work can be more qualitative than quantitative. This is particularly difficult for those trained in science and math to accept. However, the ability to rigorously collect and use qualitative data to advance a policy position can also be satisfying.
Case Example
A simple historical case objectively demonstrates these three levels of self-determination for physician leaders. Several decades ago, the deleterious effects of smoking became apparent and led to one of the largest-scale public health interventions of the time, a warning from the surgeon general about the dangers of smoking.
Physicians themselves had their own attitudes, beliefs, and perspectives regarding smoking, which was a commonly accepted social norm. Physicians had their right to self-determination and could decide whether they were going to smoke. However, regardless of the physician’s personal beliefs, in their professional role in counseling patients, they had a responsibility to share with their patients new information about the deleterious effects of smoking on health, including long-term cardiovascular and pulmonary disease, and to support the patient in making a decision about this personal health habit. Some patients on the physicians’ panel may choose to continue smoking after this conversation, and others may not, but their decision was made without interference from the physician’s personal biases.
A physician who felt particularly passionate about smoking, in either a pro or anti stance, could certainly engage in advocacy work outside of their clinic setting to support or oppose the new smoking regulations. The physician may face criticism for a given stance, but it is theirs to live by based on their attitudes and beliefs.
Present and Emerging Public Health Crises
While providing service, it is always important to remember who is the target beneficiary because it helps to appropriately align our advocacy efforts and avoid conflicts that will invariably arise. In ranking public health crises, smoking is not the lightning rod that it once was, but there is a range of other public health crises today that are. Table 1 is a simple line listing of several contemporary challenges that have been labeled as public health crises.
Physicians will make their independent decisions about how each of these challenges affects their personal life and practice. Physicians will have a responsibility to obtain up-to-date information so they can counsel patients and families, informing them on topics and about how to make a decision that is best for that patient and family. And, for those physicians who want to lead on topics in which they are particularly passionate, there may be advocacy opportunities to help inform more broadly the benefits or consequences of a particular public health problem based on our unique and privileged perspective as physicians.
While it is convenient to describe the attributes of a given model, these attributes are artificial in the setting of a real public health crisis, which is why I believe that we must be careful about those areas that we define as public health threats or crises.
The purpose of this framework is to identify the multiple and sometimes conflicting roles of physician leaders so that we can be better prepared for the decision-making in these crises by understanding our own values, attitudes, and beliefs and applying them in a constructive way for those we aim to support.