Surgical care does not take place in a vacuum. Social, economic, legislative, and regulatory issues all affect our ability to provide optimal care to each patient, to promote the best interests of all our patients, and to thrive as a profession. Working through these issues requires us to act as advocates for the science and profession of surgery. An advocate is defined as “a person who works for a cause or a group.”1 As surgeons, we work for our patients. Surgeons exist for the purpose of caring for patients; patients don’t exist to give surgeons opportunities to wield scalpels. By definition, that makes all of us advocates for our patients.
On an organizational level, the American College of Surgeons (ACS) Division of Advocacy and Health Policy provides surgeons with numerous advocacy-related resources, including the annual ACS Leadership & Advocacy Summit, the Health Policy Research Institute, and online educational tools.2 The passage of H.R. 2, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act, in April is a recent example of the impact of political advocacy efforts. The permanent repeal of the sustainable growth rate (SGR) through H.R. 2 had been at the top of the ACS’ health policy agenda for several years. The College’s advocacy efforts, together with other medical societies, were crucial to the SGR’s demise.
Numerous individual surgeons have had prominent roles in health care policy and patient advocacy, including the following: C. Everett Koop, MD, FACS, shaped the landscape of patient advocacy by serving as the U.S. Surgeon General under President Ronald Reagan; Atul Gawande, MD, MPH, FACS, awakened public consciousness through books and articles on a variety of health care topics; and countless other surgeon advocates have represented their constituents in the U.S. and state congresses. In the 114th U.S. Congress, six members of the House of Representatives—Dan Benishek, MD, FACS (MI-R); Charles Boustany, MD, FACS (LA-R); Larry Bucshon (IN-R); Michael Burgess, MD (TX-R); Tom Price, MD, FACS (GA-R); and David “Phil” Roe, MD (TN-R)—and two senators, John Barrasso (WY-R), and Rand Paul (KY-R), are surgeons.
A tale of two surgeons
Two surgeons who have helped to shape the practice of health care on a national level through their advocacy efforts are Kristen Zarfos, MD, FACS, and Todd Wider, MD. Their passion for patient care, their refusal to accept subpar treatment for their patients, and their unrelenting drive to promote patient well-being is exemplary. The complete interviews with Drs. Zarfos and Wider will be available on the RAS-ACS Advocacy and Issues Community website later this month; however, the salient comments from these interviews are summarized in this article. (Note: You will need your ACS user ID and password to access the interviews.)
Kristen Zarfos, MD, FACS
Dr. Zarfos first became interested in advocacy work when insurance companies stopped covering overnight stays for mastectomies—a policy the media once referred to as drive-through mastectomies. “I was concerned that…patients could not be treated as individuals in the context of what procedure they were having and their comorbidities and their family setting,” said Dr. Zarfos, a general surgeon specializing in breast and thyroid surgery, Hospital of Central Connecticut, New Britain.
She started by asking her patients for their opinions and by gathering objective data. “In an informal way I was surveying all of my patients,” Dr. Zarfos said, and they “replied with passion. The credit [also] goes to the patients who were willing to come forward and speak to the press.” She said working with the media afforded her the opportunity to contact individuals who were willing to come forward and reveal details about their personal experiences.
Dr. Zarfos also found allies in local legislators and policymakers. “I was told by a friend that [Rep. Rosa DeLauro (CT-D)] was someone who had had ovarian cancer—she was a survivor and interested in women’s health issues,” Dr. Zarfos said. “If you want to work with a legislator, you have to do your homework,” she advised. “You have to be completely factual and you have to learn to speak publicly [and to] not get too emotional.”
Eventually Dr. Zarfos’ efforts paid off. In 1997, Representative DeLauro sponsored H.R. 135, the Breast Cancer Patient Protection Act of 1997, which stated that health insurance plans must cover at least a minimum hospital stay for mastectomies and lymph node dissections performed for breast cancer.3 H.R. 135 was referred to a subcommittee, but it was not signed into law. However, several large national health insurance companies did agree to change requirements for outpatient mastectomies, and currently 21 states have legislation to prevent patients from being forced out of the hospital before they are ready for discharge. Today, outpatient mastectomies are common, but they are not mandatory.
Todd Wider, MD
Dr. Wider, a plastic surgeon at St. Luke’s Roosevelt Hospital in New York, NY, became active in advocacy when he realized breast reconstruction was considered cosmetic surgery and therefore not covered by a patient’s insurance. “First of all, it’s not a cosmetic operation, and in this case, we can’t even close the wound primarily, so I have to bring tissue in,” Dr. Wider once told a medical director at an insurance company. “He suggested I perform a skin graft. I answered, ‘That might have been okay in 1935, but not in 1998.’ I told him that it was medieval, and I wouldn’t do that. He answered that the insurance company would not pay for a transverse rectus abdominal muscle [TRAM] flap […], but I was not going to lie down and accept this.”
While Dr. Wider was accustomed to having discussions with insurance companies about reimbursement, this case involving Janet Franquet, a young nurse with aggressive inflammatory breast cancer, was particularly memorable. When the patient’s insurance company refused to cover breast reconstruction with a TRAM flap after a radical mastectomy, arguing that it was a purely cosmetic operation, Dr. Wider was outraged and performed the reconstructive procedure for free. This experience served as a catalyst for his interest in patient advocacy and social justice in general.
Dr. Wider’s next course of action was to reach out to various lawmakers, including Sen. Alfonse D’Amato (R-NY), who gave press conferences and speeches to raise public awareness regarding proper insurance coverage for breast reconstruction before presenting this issue to the U.S. Senate. A bill was eventually passed in both houses and President Bill Clinton signed the Women’s Health and Cancer Rights Act in 1998. The law mandates that health plans offering mastectomy coverage also have to cover reconstructive options as well as complications that may arise from the operation.4,5 “It was a very rewarding experience to advocate for your patient and have a real impact[….] I was bitten by the social advocacy bug because I thought I could actually have an impact on the society we live in, and that led to my film career,” said Dr. Wider, who is also a nationally acclaimed filmmaker of documentaries on social justice issues. He advises surgeons interested in advocacy to follow their moral compass. “My advice is to never lose sight of one’s own integrity. Practice with integrity. You always know in your heart what the right thing to do is—always.”
Five steps to success in advocacy
Drs. Zarfos and Wider are nationally recognized health care policy advocates, but not every surgeon needs to achieve this degree of success to effect change. In a time of increasing political and financial pressure, decreasing physician autonomy, and profound changes to the health care system, an active interest in our health care system is more important than ever.
The two surgeon advocates featured in this article had relatively few resources when starting out. Today, surgeons can receive support from the ACS, which offers educational materials, including webinars and brochures, talking points to refer to when e-mailing or calling legislators, legislative updates at the regional and federal level, and more. In addition, the ACS hosts the annual Leadership & Advocacy Summit in Washington, DC, which offers in-depth advocacy training and in-person opportunities to meet with legislators on Capitol Hill.
Surgeons interested in advocacy should also review the advocacy section of the ACS website and, in particular, information pertaining to the ACS Professional Association Political Action Committee, which is accessible to all ACS members.2,6 These resources offer concise information on current health policy topics and highlight opportunities to get directly involved in local and national advocacy efforts. Subspecialty organizations and local chapters have recognized the importance of political advocacy and offer numerous resources geared toward grassroots advocacy efforts.
The following are suggested guidelines for surgeon advocates:
- Get objective data, and be prepared. Advocating for our patients is personal and can be emotionally charged. However, in political advocacy, numbers and verifiable data count. Every successful advocacy effort starts by knowing the facts. Be up-to-date on health policy issues and prepare objective data, which may come from a variety of sources including patient surveys, medical literature, national databases, as well as from such entities as the ACS Health Policy Research Institute and the Kaiser Family Foundation. More information on these groups can be found on their respective websites.
- Connect with local advocacy groups and grassroots organizations. In many states there are local advocacy groups and grassroots organizations. Be sure to tap into the ACS chapters and other surgical societies for resources and opportunities for collaboration. Think outside the box—allies don’t have to be exclusively medical organizations.
- Harness the power of the media. Members of the media can be important allies, as their ability to reach people allows surgeon advocates to reach a wide audience and disseminate important health care-related information. Letters to the editor and guest editorials on a variety of key health care policy topics may be published in local newspapers. Be sure to reach out to journalists who may have access to legislators and who may be able to connect you with like-minded advocates.
- Contact local legislators after doing your homework. Preparation is key before approaching politicians about an issue. Look for legislators who may have a personal connection to a particular issue or who may have a special reason to work with you. Obtain objective, verifiable information, discuss issues in a professional manner, and be bipartisan. Support can come from unexpected places and from both sides of the aisle. Don’t discount the knowledge and influence of your legislator’s staff. They have your elected official’s ear and can move your issue to the top of the priority list.
- Never lose sight of your integrity. The most important piece of advice both Dr. Zarfos and Dr. Wider had to offer is that health care policy advocacy is a worthwhile and noble cause. We became physicians to help patients in need, and this moral compass is the best guide for successful and honest political advocacy.
Professional success is commonly viewed in terms of academic or clinical achievement, but the health care policy-related triumphs led by surgeon advocates deserve more attention.
The experiences of the surgeon advocates described in this article may motivate some surgeons to become more active in health care policy and provide a template for any surgeon interested in taking up an issue affecting patient care. In this time of increasing nonmedical influences on daily medical practice, active involvement in health care policy initiatives may ensures that we, as surgeons, can shape our practice environment and continue to provide the best possible care to our patients.
- Merriam Webster Dictionary. Available at: www.merriam-webster.com/dictionary/advocate. Accessed June 18, 2015.
- American College of Surgeons. Advocacy. Available at: www.facs.org/advocacy. Accessed June 18, 2015.
- Library of Congress. H.R.135–Breast Cancer Patient Protection Act of 1997. Available at: www.congress.gov/bill/105th-congress/house-bill/135. Accessed June 18, 2015.
- U.S. Department of Labor. Employee Benefits Security Administration. Your rights after a mastectomy. Available at: www.dol.gov/ebsa/publications/whcra.html. Accessed June 18, 2015.
- Centers for Medicare & Medicaid Services. The Center for Consumer Information and Insurance Oversight. Women’s Health and Cancer Rights Act (WHCRA).Factsheet. Available at: www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet.html. Accessed June 18, 2015.
- American College of Surgeons Political Action Committee. ACSPA-SurgeonsPAC. 2015. Available at: http://surgeonspac.org. Accessed June 18, 2015.