Tips to prepare for a rotation in outpatient medicine
By Munsey S. Wheby, FACP
Our nation's failure to deal with the challenge of the medically uninsured is a sad state of affairs. Year in, year out, people inside and outside government say that trying to remedy the situation is too expensive, complex, partisan or risky. The only thing we all agree on, it seems, is how easy it has been for the nation to put off addressing the problem.
Perhaps we've waited long enough. Maybe it's time someone got the political wheels turning.
In May, the College hosted Leadership Day in the nation's capital. ACP Governors, Regents, officers, members and staff converged on Washington in record numbers to devote two very active days to political advocacy. More than 200 physicians and medical students representing 41 states—nearly double the participation of previous years—learned about the political process from ACP's Washington staff and consultants, then visited their congressional representatives.
Their goal? To acquaint lawmakers with our health care concerns. This year, ACP's top priority was garnering support for legislation that would provide health insurance coverage for more than 41 million uninsured working Americans and their families.
Leadership Day brought insight and inspiration. Noted journalist Haynes Johnson addressed College members, reviewing the rise and fall of the Clinton health plan and the lessons learned from that experience, which he and David Broder so brilliantly chronicled in their Pulitzer Prize-winning book, "The System." As Mr. Johnson reminded us, achieving health care coverage for all Americans has long been an elusive goal. Every president since Theodore Roosevelt has tried and failed.
But this doesn't mean we shouldn't try now, Mr. Johnson advised. His counsel about pursuing advocacy efforts? "Be involved, be committed and energize your patients—they're Congress' constituents."
He also praised ACP Key Contact of the Year Dawn E. Clancy, FACP, for her commitment to her patients and to political advocacy. (For more on Dr. Clancy's efforts, see "One internist takes her advocacy efforts on the road.")
Leadership Day attendees also heard from Sen. Jeff Bingaman (D-N.M.) about his health care bill, which is based on ACP's seven-year plan to achieve coverage for all uninsured Americans by 2010. For months, ACP's Washington staff have worked with Sen. Bingaman's staff to craft this bill. If it—or a modified version—is enacted into law, ACP will have fundamentally contributed to resolving the nation's most serious sociomedical problem.
Why should we advocate?
For those of us who participated, the College's annual Leadership Day was an exhilarating, worthwhile educational experience. It provided a window onto the political process, a chance to meet legislators and powerbrokers, and an opportunity to influence policymaking and the legislative process.
But considering the full scope of ACP's membership and activities, is Leadership Day worth the considerable time and resources the College invests in it? And should the College even venture into the halls of power to consort with politicians?
Nothing would please me more than to provide clear-cut, evidence-based, outcomes-measured answers to these questions. But I can't. There are no such data.
So why do we do it? First, ACP is the largest medical specialty organization in the United States. The public, lawmakers and our 115,000 members expect us to advocate for physicians and our patients to improve health care and the practice of medicine. The College can be a remarkably effective participant in public debate and health care policymaking.
Second, as physicians, we have a fundamental professional obligation to actively work for better health care for patients and a better health care system for our nation. The Medical Professionalism Project's professionalism charter, drafted in 2002 and endorsed by more than 70 national and international medical organizations, articulates principles and commitments that call us to embrace social action and political advocacy for our patients' sake.
(The charter, which was drafted by the College's foundation, the American Board of Internal Medicine Foundation and the European Federation of Internal Medicine, is online.)
We are clearly responsible to society and expected to act, whether the principle we cite is patient welfare or social justice. We all want the same goal, whether our commitment is to improve quality of care, expand access or ensure the just distribution of limited resources. Even our dedication to professional competency and scientific knowledge requires us to shape a health care system in which we can practice at our best.
Third, during every Leadership Day, senators and representatives have strongly advised us that Congress needs to see and hear from physicians if we want change in the national political agenda on health care. According to Congress, we—the nation's doctors—can best acquaint legislators with the real-life health care concerns of their constituents.
Shortly after this year's Leadership Day, for example, Reps. Marcy Kaptur (D-Ohio) and Steve LaTourette (R-Ohio) introduced legislation into the House to give millions of Americans access to care. (The legislation is based on ACP's seven-year plan to give all Americans access to care by the end of the decade. See "New House bill based on ACP proposals to expand access to care" for more information.) Rep. LaTourette's staff later told us that internists from the College's Ohio Chapter made a very effective case for expanding access.
With health care so thoroughly dependent on government actions, it's unrealistic to think of medicine apart from politics, always above the fray.
Similarly, we are the experts who can attest to what does, doesn't or might work in the nation's health care "system." We are the seasoned professionals who can speak for efficacy, quality and optimal delivery of care. Although patients are increasingly able to speak eloquently for themselves, they still trust us to bring their stories and problems to public and political attention, in hopes of effecting change.
As physicians, we have an integral role in the process of political change. With health care so thoroughly dependent on government actions, it's unrealistic to think of medicine apart from politics, always above the fray.
We cannot achieve our goals and those of our patients by steering clear of the political arena. Instead, we must become part of this process, make our voices heard, clearly articulate our views, and represent the concerns of our patients fairly and convincingly.
Of course, we must carefully manage our advocacy to avoid compromising our professionalism. Our paramount concern must be improving health care for our patients. As I review the College's advocacy agenda, especially our effort to achieve affordable health insurance coverage for all Americans, I believe we are doing just that.
Do we need a PAC?
If our advocacy efforts are indeed on the rise, would a political action committee (PAC) improve our chances of favorably influencing political outcomes?
This question came up on Leadership Day. In response, Martin Gold, adviser to Senate Majority Leader Bill Frist (R-Tenn.) and a longtime observer of Congress, suggested that we should be "in the game" of contributing funds to politicians' campaigns if we hope to compete for attention.
Several years ago, just after ACP and ASIM merged in 1998, the College's Regents and Governors debated this question because ASIM had a PAC. Speaking from his experience with ASIM's PAC, Alan R. Nelson, MACP, observed that a PAC "is not essential for successful advocacy, but it is helpful, particularly in gaining face-to-face meetings with members of Congress." Our Washington lobbyists and other astute observers of the political scene still concur with Dr. Nelson.
I've been mulling over this question ever since Leadership Day. I had lunch with members of one of our most politically active chapters and their Congressman. He is a physician very sympathetic to the College's advocacy efforts, particularly the Bingaman bill. Our lunchtime conversation made it clear that financial support is the key to his re-election. Would it be in our patients' best interests for an ACP PAC to help re-elect him and other members of Congress who are aligned with our efforts?
Some in the College would see such a scenario as improper and an erosion of professionalism. No one can deny that money influences the American political process, and PACs are the way to exert that influence. But many organizations with powerful PACs plead for entirely self-serving causes rather than advocating for any public good. The list of the most powerful Washington lobbies whose PACs donate the most money makes an organization devoted to professionalism hesitate to be among them.
As we learned from the thoughtful discussions in the Boards of Governors and Regents following the ACP-ASIM merger, good people throughout the College will have strongly differing opinions about whether or not we should have a PAC.
I welcome your opinions about the direction the College should take regarding this thorny issue. Give this question some thought over the summer and share your views with me at firstname.lastname@example.org.
This fall, the Board of Governors will consider one or more PAC resolutions. The Governors previously recommended that the College establish a PAC. If they do so again, the Regents will consider whether to make it College policy.
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