Deciding which advocacy issues are ‘in our lane’

The “This Is Our Lane” social media movement began in November 2018, when the National Rifle Association (NRA) attacked ACP and Annals of Internal Medicine for publishing updated recommendations to reduce injuries and deaths from firearms. The viral response from ACP, Annals, and tens of thousands of physicians, creating the #ThisIsOurLane hashtag, affirmed that advocating for policies to reduce gun violence is very much within physicians' lane.

The movement continues. In August, ACP joined with six other leading physician and public health membership organizations in a renewed call to action, published by Annals, recommending that background checks be expanded to all gun sales, loopholes be closed that allow some domestic violence offenders to purchase and own guns, and red flag laws be enacted to allow the temporary removal of firearms from those found by a judge to be at imminent risk of using them to harm themselves and others, among other steps.

That physicians have a right and responsibility to speak out on reducing injuries and deaths from firearms is self-evident to me, because it's their patients who suffer. Yet the question of what belongs “in our lane” when it comes to physician advocacy can't be casually dismissed. From time to time, I hear from ACP members who believe that issues like climate change, women's access to reproductive care (including their right to make decisions on whether to continue a pregnancy), immigration policy, and environmental and socioeconomic conditions affecting health are outside of what appropriately belongs in ACP's advocacy lane.

How does ACP decide what is in that lane?

First, we ask, “Is patients' health affected, and in what way?” Issues that affect the health of patients, individually and as part of a broader population, appropriately fall within ACP's Board of Regents-approved goal, “To advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members.”

Advocating for policies to reduce the harm from use of tobacco products, for instance, now seems obvious. Yet for a good part of the 1960s, doctors sat on the sidelines as tobacco companies and scientists on their payrolls tried to discredit research showing a link between cigarettes and cancer and heart disease. Similarly, the fossil fuel industry today is funding a small number of scientists to discredit the overwhelming consensus among their peers that climate change adversely affects human health (as reported by The Guardian in a Feb. 21, 2015, article, “Work of Prominent Climate Change Denier Was Funded by Energy Industry”).

The treatment of immigrants seeking entrance at U.S. borders clearly affects their individual health. Children separated from parents may experience trauma that carries over for their entire lives. Immigrants in the United States, whether present lawfully or not, will experience harm to their health if they avoid medical care for fear of being deported, putting the broader population at risk if, for example, they carry an infectious disease that goes untreated.

The health of LGBTQI patients is harmed when they are discriminated against, stigmatized, or subjected to harmful and nonscientific interventions, like “conversion” therapy.

Women's health is affected if they are denied access to contraception, required to carry a pregnancy to term, or subjected to invasive tests, procedures, and nonscientific government dictates to their physicians about what they must be told before they can make a decision relating to their pregnancy.

Second, we ask, “Even if patients' health is affected, do physicians have the expertise to recommend policies to reduce harm to patients?”

This is trickier. Saying that climate change adversely affects human health is one thing, but knowing what to do about it is another. ACP, for example, is not an expert on oil and gas production or alternative energy sources, or on whether carbon taxes are the best way to reduce carbon emissions. Yet ACP has the ability to review the published literature by those in environmental, climate, and economic sciences who have the required expertise and draw conclusions to guide its advocacy.

Similarly, while ACP is not an expert on how best to control U.S. borders, we do have expertise on the potential impact of immigration policies on the health of immigrants who are denied access to care or detained in hazardous facilities without adequate nutrition, health care, and support for personal hygiene. We have the expertise to say that denying permanent legal status (green cards) to immigrants admitted to the U.S. legally because government bureaucrats decide they are likely to use Medicaid or have a preexisting condition without health insurance coverage—as the administration aims to do in its new “public charge” rule—will cause many to forgo needed medical care.

Yet a degree of humility and caution should be exercised in determining when a professional association of physicians has the ability to recommend specific public policies outside of their usual training. Even when there is an impact on health, physicians and their professional societies may not always know the best way to address it.

Third, we ask, “Does the membership agree that an issue should fall within ACP's advocacy lane?” ACP's Board of Governors often is the first place where this is debated and decided. For instance, ACP's advocacy on climate change and women's access to reproductive health care was in response to resolutions adopted by the Board of Governors. In addition, all ACP policy recommendations are subject to debate and review by its policy committees, councils, Regents, and Governors, before the Board of Regents acts to approve them.

At the same time, ACP must be respectful of those who disagree that a particular issue belongs in its advocacy agenda, or on the policies that ACP proposes to address it.

Fourth, we ask, “Where does the issue fall within the organization's priorities?” One can argue that because just about everything affects health in some way or another, there's a risk of taking on so many issues that ACP's effectiveness on any of them is diminished. No organization, including ACP, can devote unlimited resources to advocacy. Also, a balance is needed between issues that affect the health of the public and issues that affect the well-being of internal medicine physicians, such as ACP's advocacy to reduce administrative burdens and improve payments for internists' services.

Determining what advocacy issues belong “in our lane” should never be a quick and easy decision. Rather, it should be based on deliberatively reviewing the impact on health, assessing ACP's expertise to address an issue (or ability to offer solutions by considering recommendations from those with the required expertise), obtaining consensus among members, deciding where an issue fits in with our overall priorities and resource limitations, and ensuring balance between advocacy for the profession and advocacy for the public.