What does it mean to be a surgeon? If you ask the general public or surgeons themselves, the answer likely will center on the surgeon as a clinician. However, although patients rely on surgeons for their medical and technical expertise, the role of a surgeon also includes teaching, mentorship, and advocacy. Unfortunately, advocacy often is the forgotten part of a surgeon’s identity, despite being the first responsibility listed in the code of conduct of the American College of Surgeons (ACS): “Serve as effective advocates of our patients’ needs.”1
As patient advocates, surgeons have an essential role in educating the public about how social and economic factors affect the outcomes and accessibility of operations or other nonoperative therapies.2 Surgeon involvement in advocacy, specifically as it relates to health care policymaking, is essential to patient-centered care and is a crucial responsibility to our patients beyond the operating room (OR). Ultimately, the crux of surgical advocacy lies in the following truth: If we, as surgeons, hesitate to speak up for ourselves and our patients, 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.
Health care policy, as defined by the World Health Organization, “refers to decisions, plans and actions that are undertaken to achieve specific health care goals within a society.”3 These goals include better education, access to affordable care, reductions in nonfinancial barriers and social determinants of health, and creation of efficient health care delivery systems. Health policy is driven by governments, insurance companies, providers, and patients. The evolution of health care requires the participation of all of these entities to create a fair, balanced system and to achieve the best outcomes with the most efficiency. Without involvement of all parties, particularly physicians, the dialogue and decision-making around health care policy lacks a critical voice.
In this article, members of the Associate Fellow Committee of the Resident and Associate Society (RAS) of the ACS describe why and how young surgeons should participate in advocacy and health policy.
The need for young surgeon involvement
The ACS has more than 80,000 members, 13,000 of whom are early-career, including Resident Members, Associate Fellows (surgeons in their first years of practice), and Young Fellows who are younger than 45 years of age. These data reflect only a small proportion of the total number of surgeons in the U.S. and Canada. On a daily basis, early-career surgeons and surgical trainees are affected by issues shaped by the following topic areas: physician reimbursement, electronic health records (EHR), health information technology (IT), funding public health bodies, and strengthening surgical specialties from trauma to cancer care. Arguably, policy decisions affect young surgeons more than more established members of the ACS because the policies being created and enacted today will likely affect early-career surgeons for decades.
At present, 17 physicians are serving in the 117th Congress, but not one is a general surgeon.4 It is critical that surgeons engage with elected officials, who need expert input to determine beneficial policies. Furthermore, Americans trust physicians more than politicians to make recommendations regarding health policy, according to a 2009 Gallup poll.5
Residents, fellows, and early-career surgeons need not serve in local, state, or federal offices to effect change in health care policy. In 2020, the ACS Division of Advocacy and Health Policy (DAHP) team supported multiple bills and provisions to benefit patients and surgeons. Advocacy efforts included preventing Medicare payment cuts, ensuring provider relief during the coronavirus 2019 (COVID-19) pandemic, limiting the scope of practice for physician extenders, and modernizing data systems and patient access to care through telehealth.6
Despite the clear necessity of surgeon involvement in health care policy and advocacy, few early-career surgeons fully realize their potential to engage in this activity.
Barriers to surgeon involvement
Despite the clear necessity of surgeon involvement in health care policy and advocacy, few early-career surgeons fully realize their potential to engage in this activity. Only 44 percent of the RAS governing board and 73 percent of the Young Fellows Association (YFA) governing board contributed to the ACS Professional Association’s Political Action Committee (ACSPA-SurgeonsPAC) last year. One reason for this low participation may be a lack of time. Starting a practice comes with many challenges, both personally and professionally.
One may think that advocacy requires additional energy, which could be too taxing for early-career surgeons. Another reason for low participation in health care policy work may be the fear of retaliation from the hospital and community if a physician vocally supports or opposes local or national policies. In addition, some young surgons believe policy work at academic centers will result in lost opportunities for compensation or promotion.7 Contributing to political causes also may be a lower financial priority for young surgeons burdened with student loan debt. Lastly, but perhaps most importantly, not knowing how to get involved is a critical barrier to participation in advocacy-related activities.
Personal experiences, mentorship, and formal training are vital aspects in career decisions, including involvement in advocacy and policy.8 A standardized curriculum focused on health care policy and advocacy for residents has yet to be developed, which can make entry into advocacy more daunting. In a review of the literature, only 10 percent of the advocacy programs integrated into resident education were available to surgical specialties.9 It is important that we as a society promote this type of education for medical students and residents. Some argue that medical school selection committees should specifically look for students with an interest in health care policy and social responsibility.10
The skills needed to become involved in advocacy and health care policy can be taught, and lack of experience should not prevent surgeons from getting involved. Seeking out education and mentorship through local, state, and national organizations, including hospital systems, can be useful in fostering advocacy skills and networks.
Fortunately, the ACS DAHP offers many resources for surgeon-advocates at both the local and national levels. The DAHP works with several committees centered on health policy and strongly encourages young surgeon involvement, including the Health Policy and Advocacy Group (HPAG), the Health Policy Advisory Council (HPAC), the Legislative Committee, and the General Surgery Coding and Reimbursement Committee (GSCRC). All ACS members, including residents, may apply to serve on these bodies in liaison positions. Table 1 lists these entities and their purposes.
TABLE 1. GETTING INVOLVED THROUGH THE ACS
Key ACS committees
Under the leadership of the ACS HPAG, several committees play integral roles in coordinating surgeon involvement. These committees include the Legislative Committee, GSCRC, HPAC, and the ACSPA-SurgeonsPAC Board of Directors.
HPAG sets the DAHP’s advocacy agenda and priorities and aims to ensure that all advocacy-related subcommittees are working in coordination with that policy agenda. The Legislative Committee plays an important role in analyzing legislation and providing data-informed policy position recommendations to HPAG at the federal and state levels.
One of the many valuable HPAC activities is advocacy for a fair and equitable reimbursement system. The GSCRC has a crucial role in this arena as well, in that it addresses coding, billing, and reimbursement issues. Specifically, the GSCRC focuses on activities of the American Medical Association/Specialty Society Relative Value Scale Update Committee and the Current Procedural Terminology Editorial Panel, which determine surgeon reimbursement rates.
The ACSPA-SurgeonsPAC has a crucial role in making surgeon advocacy more accessible to all surgeons, regardless of experience with political engagement. The SurgeonsPAC, a 501c(6)-affiliated corporation governed by an appointed Board of Directors, engages with various policymakers in Washington, DC, to ensure surgical advocacy remains a top priority and supports policies and candidates that have our patients’ best interests in mind. The funding comes directly from voluntary contributions by members of the ACSPA to SurgeonsPAC, and 100 percent of these “hard dollars” are used to support candidates for Congress, political campaign committees, and other PACs. An individual may contribute up to $5,000 annually to SurgeonsPAC, although any amount is encouraged.
State and local chapters of the ACS advance the College’s health policy agenda through lobbying activities, grassroots efforts, and political affairs. The ACS DAHP ultimately advances the ACS health policy agenda via lobby activities and interaction with federal and government entities, including Congress, the Centers for Medicare & Medicaid Services, and other agencies within the Department of Health and Human Services.
Surgeons also may become HPAC members, who are experts in health care policy and serve as liaisons between ACS DAHP and ACS Fellows. HPAC is focused on communicating, educating, and providing the necessary resources to build a strong network of surgeon-advocates consistently willing to take action on important health policy matters and encourage their colleagues to do the same.
Resources to stayed informed and engaged
SurgeonsVoice is the ACSPA’s nationwide, interactive advocacy program that provides surgeons with tools to strengthen their impact in Congress and around the country. An Advocacy Center section on the website lists ongoing legislative priorities and describes how surgeons can contact elected officials to support specific reforms. The website also has an easy-to-use online form that one can complete to help schedule meetings with legislators via Advocacy at Home. Additional tools and resources such as an Advocacy Handbook, congressional calendar, Grassroots Guide, Inside Elections, and Legislation Lookup can be found on the website as well. Each year, ACSPA recognizes an Advocate of the Year for their engagement and use of SurgeonsVoice. This person is invited to play a leadership role within the College and to participate in other advocacy-related activities to continue to establish and maintain relationships with legislators in order to advance ACS health policy priorities.
Participating in the annual Leadership & Advocacy Summit in Washington, DC, is another useful opportunity to get involved. This summit offers comprehensive and specialized sessions pertaining to effective surgeon leadership as well as advocacy training. The guest lecturers and breakout sessions help a young surgeon become familiar with the pertinent legislative issues facing surgeons at that time and also help surgeon-advocates establish connections. The advocacy program highlights the legislative priorities of the College and assists attendees in developing advocacy skills, learning about legislative and health policies, and participating in meetings with members of Congress and their staff. At the end of the summit, the ACS arranges coordinated visits between ACS surgeons, congressional leaders, and their staff. The summit even offers RAS-ACS Scholarship Awards for RAS members to attend the conference for free.
Sorting through current legislation that pertains to surgeons and our patient population can be daunting. The Bulletin Advocacy Brief is a biweekly newsletter that gives a brief overview of the pending legislation and regulations that affect surgeons and surgical patients. It covers ACS efforts to advocate for surgeons and their patients on Capitol Hill. It also notifies surgeons of upcoming educational health policy seminars. Reading this twice monthly, online newsletter will keep you abreast of the latest issues and how to get involved.
State and local advocacy
If the national advocacy scene still seems intimidating, involvement is possible at the state or local level. Most ACS chapters have advocacy programs and are constantly working with government officials at the state level. Health policy often starts at the state level and then is taken to the federal level, so working locally helps build policy from the ground up. State advocacy resources provide Fellows with the ability to track bills, review legislative tool kits, write to their representatives, develop legislative strategic plans, and more. Tracking state legislation and monitoring potential impact on surgical practice at the local level is critical. A comprehensive list of state legislation that the ACS staff is monitoring is available at facs.org/advocacy/state/legislation.
Health policy often starts at the state level and then is taken to the federal level, so working locally helps build policy from the ground up.
RAS members may be quite familiar with social media, as for many of us it has been a part of our lives long before we became surgeons. One example of using social media for advocacy is “following” or “friending” elected officials to engage with them about their policies in a respectful and convenient way. In 2018, the average number of social media accounts held by members of Congress was six, with Facebook, Twitter, YouTube, and Instagram as the most popular types of accounts.10 According to a Pew Research study, in an average month in 2020, more than 2,000 active official Facebook and Twitter accounts for the 116th Congress produced more than 100,000 tweets and Facebook posts.11 Using social media to connect with elected officials is an excellent way to participate in advocacy that takes very little time but can have a big impact.
It is essential that young surgeons understand and value the importance of advocacy as a critical component of a surgeon’s identity. By using the resources described in this article, it is possible to become informed, empowered, and engaged with health care policy. Early-career surgeons are poised to have a significant effect on health policy, and they likely will experience the ramifications of these policies for years to come. Ultimately, our voices speak for our patients, our peers, and our profession. It is up to us to steer the course for the future of surgery.
- American College of Surgeons. Statements on Principles. Available at: facs.org/about-acs/statements/stonprin. Accessed June 24, 2021.
- Luft LM. The essential role of physician as advocate: How and why we pass it on. Can Med Educ J. 2017;8(3):e109-e116.
- World Health Organization. Health policy. Available at: www.euro.who.int/en/health-topics/health-policy. Accessed June 24, 2021.
- Physicians of the 117th Congress. January 4, 2021. Available at: patientsactionnetwork.com/physicians-117th-congress. Accessed June 24, 2021.
- Saad L. On healthcare, Americans trust physicians over politicians. June 17, 2009. Available at: news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx. Accessed June 24, 2021.
- Suermann A, Zlatos C, Chagrin H. American College of Surgeons. End-of-year funding bill packed with ACS legislative victories. January 25, 2021. Available at: facs.org/advocacy/federal/2020-recap. Accessed June 24, 2021.
- Khatana SA, Patton EW, Sanghavi DM. Public policy and physician involvement: Removing barriers, enhancing impact. Am J Med. 2017;130(1):8-10.
- Law M, Leung P, Veinot P, Miller D, Mylopoulos M. A qualitative study of the experiences and factors that led physicians to be lifelong health advocates. Acad Med. 2016;91(10):1392-1397.
- Howell BA, Kristal RB, Whitmire LR, Gentry M, Rabin TL, Rosenbaum J. A systematic review of advocacy curricula in graduate medical education. J Gen Intern Med. 2019;34(11):2592-2601.
- Bhate TD, Loh LC. Building a generation of physician advocates: The case for including mandatory training in advocacy in Canadian medical school curricula. Acad Med. 2015;90(12):1602-1606.
- Straus JR. Social media adoption by members of Congress: Trends and congressional considerations. Congressional Research Service. October 9, 2018. Available at: crsreports.congress.gov/product/pdf/R/R45337. Accessed June 30, 2021.
- Van Kessel P, Widjaya R, Shah S, Smith A, Hughe A. Congress soars to new heights on social media. July 16, 2020. Available at: pewresearch.org/internet/2020/07/16/congress-soars-to-new-heights-on-social-media. Accessed June 24, 2021.