It’s not enough.” These words kept echoing through my head as I walked out of the operating room. I stood in the empty hallway, listening to the buzz of fluorescence overhead, gazing down at my blood-covered shoes. Another young life lost to senseless violence. Trying to save lives in the operating room, seeing patients in the emergency department, taking care of critically ill patients in the intensive care unit—it is important work, but is it enough?
We all remember the day we recited the Hippocratic Oath. But I’ve wondered, do I remember the extent of this solemn promise? It’s not just to dedicate ourselves to the art and science of medicine for the betterment of our patients, but to apply “all measures which are required to benefit the sick.” Certainly, those measures aren’t limited to the walls of the hospital. Any physician can recall frustrating attempts to provide the best medical care yet being met with devastating patient complications or restrictions that a proverbial “other” has set for the way physicians practice medicine and, during these moments, I’m left knowing we can do more for our patients—that medical and surgical care alone are not enough.
So, what is enough? It wasn’t until I became active in the American College of Surgeons (ACS) Resident and Associate Society Advocacy and Issues Committee and in the Committee on Trauma (COT) that I had my first epiphany of sorts during residency: the prodigious importance of advocacy. While pursuits in clinical and research excellence are the two great tenets of a surgeon, I believe the third—the forgotten sibling—is advocacy. When advocacy is employed, the feeling of “it’s not enough” suddenly starts to wane.
The surgeon’s voice must be heard
Surgeons need to be engaged in politics. That’s right—politics. The “p” word makes some surgeons shudder, and even more so when the discussion is about money. But it wasn’t until I realized that if surgeons don’t speak up on behalf of our patients and ourselves, someone else, who may not have our best interests at heart, will decide how we practice medicine and how we take care of our patients. And yes, that means having conversations that involve politics and money. The reality is, the saying “no margin, no mission” rings true in the business of medicine. If a hospital doesn’t make enough money to keep its doors open, our higher purpose (of patient care) becomes irrelevant or, in other words, not enough.
At the risk of sounding hyperbolic, we are facing a crisis in health care. Countless forces are vying for surgery’s slice of the health care funding pie—funding that allows us to uphold our sacred oath and mission to our patients. Legislation pops up seasonally that presents true existential threats to the practice of surgery. A recent example was a proposed rule that would have cut Medicare payment to surgeons and increased reimbursement for evaluation and management services that primary care professionals provide.
In this instance, surgeons won the fight—at least for a couple of years—because of robust ACS advocacy. Thousands of ACS members voiced their concerns to legislators, and surgeons’ advocacy efforts won in Congress. These are the tools we have to fight these seasonal “storms” that blow in year after year: letters, phone calls, financial contributions, demonstrations, and advocacy.
Surgeon advocacy matters
Consider, too, the success stories in public health—from tobacco laws to seatbelt and automobile safety to newer victories such as reauthorization of the Children’s Health Insurance Program, limitation of prior authorization requirements, drug pricing transparency, and increased resources to address the opioid epidemic. These efforts were all made possible because of physician and surgeon advocacy.
And seemingly small public health programs can snowball into greater conversations, leading to policy change and that can have a lasting impact. Consider the COT’s STOP THE BLEED® program. What started as an educational program has grown into a tool for advocacy, facilitating productive conversations about firearm injury prevention. STOP THE BLEED®, like other programs born of surgeon advocacy, has the potential to become something akin to bystander cardiopulmonary resuscitation, with millions of laypeople prepared to save lives. But this won’t happen without political will or government funding.
Another example with great potential, which at present is theoretical but could become reality through active surgeon advocacy, is the establishment of a national trauma system with a dedicated research institute. The development of a national trauma system only will occur through a persistent heavy lift to win legislative backers and reallocation of limited U.S. Department of Health & Human Services (HHS) funds toward this end.
Apathy is the greatest hindrance to effecting change
The relationship between surgeon responsibility and advocacy, between our effectiveness as clinical providers, our effectiveness as advocates, and the grave necessity of physician advocacy is obvious, in my opinion. But as my impassioned soapbox remarks at hospital meetings and committee gatherings have often been met with glazed eyes, it has become apparent that not all surgeons share this sentiment. This is readily apparent in other metrics of surgeon involvement in advocacy—whether letters to government officials, donations to surgeon advocacy groups, or attendance at surgeon advocacy activities.
So, perhaps our greater mission is the recruitment of our peers. It is essential that all surgeons, at all phases of a surgical career, grasp the profound gravity and untoward consequences should we fail to sustain and build upon the momentum exemplified by the College’s efforts in the Medicare pay cut battle this past fall and winter.
What is holding you back from becoming more involved in advocacy? Surely you’ve had an “it’s not enough” experience at work, a sense that surgeons need not only to provide quality patient care to achieve optimal outcomes, but also to advocate for policies and legislation that will benefit patient care. Should our advocacy efforts shrink to a certain threshold, we will see a precipitous drop-off on the impact we command on Capitol Hill—an impact which ultimately affects our patients and our work environment.
In 2019, I attended my first ACS Leadership & Advocacy Summit. The weekend events, which took place in Washington, DC, included sessions on the current political climate and obstacles facing our patients and other surgeons and ended with meetings with our representatives and senators to articulate the relevant “asks” of the College on behalf of our constituents and patients. At the end of the weekend, I sat in a room thronged with surgeons. The energy in the room was palpable. There was an intense feeling of comradery in the shared feeling that “it’s not enough”; that we must do more for ourselves and our patients. Sitting in that room, surrounded by surgeons dedicating their lives not just to patient care but to patient and physician advocacy, I finally felt: this may be enough.
So, I beg of you—that’s right, you—to sit down and ask yourself, “Is what I’m doing enough?” Only you can answer this question, only you can know your talents, gifts, passions. But I challenge you to consider the fact that a part of your sacred oath to your patients is a promise of advocacy. These acts of advocacy can be small and seemingly insignificant. Make a commitment every day, or every week, to read an article, make a new contact, talk to a colleague or representative, and/or find local organizations that are engaged in advocacy. Until we look to exemplars like the COT Advocacy & Engagement Workgroup that serve as models for the whole of the ACS and until we see 100 percent participation in the ACS Professional Association Political Action Committee (ACSPA-SurgeonsPAC) and participation in ACS-facilitated constituents’ letters to members of Congress, these efforts may not be enough.
Now more than ever, advocacy matters. And even advocacy is not enough without all of us working together.
The thoughts and opinions expressed in this commentary are solely those of Drs. Jeng and Coleman and do not necessarily reflect those of the American College of Surgeons.