Teaching the Art of Advocacy

Vice president of Nebraska Cancer Specialists and a clinical professor of medicine at Creighton University School of Medicine, both in Omaha, Nebraska. Dr. Soori is also chair of the Council on Graduate Medical Education.

For some time now, the United States health-care system has been undergoing a significant transformation, marked by changes to our delivery and payment systems, accountable care organizations, and the ways we use electronic medical records. The practice of hematology is becoming increasingly regulated, and these regulations are being created by people who are not hematologists.

This is why hematologists need to be engaged in health policy issues: No one knows the demands and intricacies of practicing hematology better than hematologists. If we don’t come to the table with input, we will operate under regulations that ignore our needs.

Unfortunately, our current graduate medical education (GME) and training programs do not necessarily include education in health policy matters and health systems awareness. Before that becomes a reality in our GME programs, we all must be proactive in ensuring that our needs are met.

Headed to the Hill

Engagement in health policy among practicing physicians, both in academia and in the private sector, is critical to advancing the day-to-day issues of the practice of hematology, hematology education, hematology research, and its funding. While these issues are important to every hematologist, it is not in our DNA to do this kind of work.

In the Council on Graduate Medical Education (COGME), an organization of which I am chair, encouraging knowledge of health systems and including it in our training curricula is an issue we actively promote. The COGME is an advisory council authorized by the Public Health Service Act established in 1998, comprising a carefully selected group of stakeholders across the spectrum of undergraduate and graduate medical education. These include members of the private and public teaching hospitals, medical schools, accrediting agencies, health insurance sector, and business and labor. Several subjects fall under our scope, but our main concerns are the supply and distribution of physicians and GME programs in the United States and current and future shortages across the spectrum of care: primary care, surgical, and subspecialties such as hematology.

The council’s primary responsibilities are to assess the nation’s physician workforce needs on a long-term basis and make recommendations to government officials about appropriate federal and private sector efforts. The COGME is also charged with developing, publishing, and implementing performance measures for federally funded public health education programs in the United States, as well as evaluating the funding appropriations for GME.

We make our recommendations to three entities: the secretary of the Department of Health and Human Services (HHS); the House Energy and Commerce Committee; and the Senate Health, Education, Labor, and Pensions (HELP) Committee. We accomplish this by delivering annual reports to Congress and the HHS secretary, as well as by producing position papers or letters of plea to these parties if we feel a certain item needs more quick and direct attention.

Advocacy at Every Level

Advocacy, however, is not limited to larger organizations such as ours. Outside of the COGME, our members communicate with elected representatives at the local level through town hall meetings or through personal relationships. I have served with other members of the ASH Committee on Practice in the annual and ongoing advocacy efforts on behalf of the hematologists, participating in annual Capitol Hill visits consecutively for the past seven years.

This is something I believe needs to happen across the hematology community, but not everyone has the luxury to go to Capitol Hill to advocate every year. Hematologists, both in the private and academic sectors, have multiple avenues through which they can enact change, whether that’s through these types of larger lobbying efforts or simply contacting an elected official when a relevant issue is up for debate on the House or Senate floor. Our fellow hematologists, residents, and students need to know how to engage their elected officials to advance and advocate on behalf of our hematology patients – that is simply how democracy works. But, to be successful at our goals, we also need to understand how to communicate our messages.

For the amateur advocate, or for those who are interested in becoming involved with these efforts, I share a few key points that I have learned over the years. As with everything, practicing these skills is critical.

Framing the Issue

Elected officials have a very wide scope of responsibilities to their constituencies. They serve many people with many competing interests. Senators and Representatives are not keenly aware of the needs of the hematologic community, and GME programs in particular. When we try to advance an idea to an elected official, we need to be cognizant of how he or she relates to this subject. Present the issue from the perspective of their constituencies – that is how they relate. Talking about only the drug shortage, or how we as hematologists cannot practice medicine without those drugs, is not effective. We must articulate the message with our patients (and their voters) in mind.

How do we do that? We tell stories. How will the issue at hand impact an elected representative’s constituents back home? On top of that, we point out that if he or she can articulate this agenda across Congress, and if he or she can bring about a substantial motion within Congress, he or she will be celebrated. That is a point that resonates well with our elected officials.

Do Your Homework

When we engage in advocacy, we need to know what we’re asking for. Before we walk into a Representative’s or Senator’s office, we should already know what his or her colleagues have done on this subject, how many are supporting it, and if there are any concerns with the requested actions that others have raised.

As expected, the number one issue is likely to be cost. Elected officials want to know if the action requires a big increase in federal funding, or if it will translate to higher insurance payments for patients. We perform a cost analysis to prepare ourselves for these types of questions. Then, as with the first point, we need to put these costs into perspective. For instance, if there is a potential increase in premiums, we are able to tell them that, if this legislation is enacted, the impact on the premiums will be minor. If possible, we should show potential downstream savings, and then support those statements with data about cost implications.

To fully understand legislation, elected officials need to know how they will positively affect our patients and their constituents, as well as any groups of people who potentially could be adversely affected by it. Being sensitive to those potential issues and bringing it to the forefront can help us make a more cogent case to advance our idea.

Strike While the Iron is Hot!

Timing is everything: When a relevant act is due to be presented and debated on the House or Senate floor, contact your Senator or Representative.

Like all of us, I believe, our elected officials become attuned to the issue at hand as they confront it. So, when the time is right, we need to take the initiative and contact them. All it takes is one telephone call or one email, even using one of the template letters that ASH provides (available at www.hematology.org/advocacy). Taking two minutes of your time has very important efficacy.

Many people may think that those calls and emails go overlooked; in fact, though, congressional offices keep tabs on how many telephone calls, emails, or letters come in on any given topic to gauge how important that subject is to their constituency. For example, if they only receive three emails regarding a certain topic, they assume that it is not important to constituents; if they received 3,000 emails, though, they would feel obligated to advocate, either for or against. Therefore, timeliness of the response is essential.

The Future of GME Without Advocacy

Knowledge in health policy and health systems awareness is simply not part of our training, so it falls on practicing hematologists to pick up this torch. In my opinion, that is a shortcoming of our current undergraduate and graduate medical training programs.

I am very passionate about the need for innovation in graduate medical education, both in its architecture and its funding. The current GME programs are modeled on the Flexner-ian system, which was created a century ago. Training programs have evolved, but the underlying system is arcane for training the 21st-century physician. The modern-day physician needs to be properly trained and well-aligned with society’s expectations, in providing high-quality, cost-effective care that is also compassionate and personalized. To do that in a highly technologically advanced (and quickly advancing) medical care environment, we need to rationally reexamine whether our current system adequately prepares our physicians.

Funding for public GME programs, all of which comes from the federal budget, has been frozen since 1997. Let’s be honest, asking for an increase in federal funding is not going to get us very far. Our task as hematologist-educators, then, is to rationalize any increases in GME funding. It is our responsibility to improve the efficiency of graduate medical education.
In its current form, our GME is too costly, too long, and too inefficient. Much like we need to do our homework before meeting with our Congressional members, if we make any requests for funding, we have to prove our willingness to modernize the architecture of our training programs and improve their cost-effectiveness.

These issues are not on our elected officials’ radar, and they may not even be familiar to many hematologists, illustrating the importance of raising awareness. Some topics affecting the practice of medicine, such as unaffordable drug pricing, has entered the mainstream, but there are issues affecting the practice of hematology that are specific to and understood best by hematologists. Unfortunately, there is only a small percentage of us who are actively engaging in advocacy.

That responsibility, though, should be shared among all of us. That doesn’t necessarily mean that everybody has to take two days to participate in Congressional lobbying on The Hill; just the click of a mouse is enough to spread the message to an elected representative. If there is one thing I stress to my hematology colleagues, it’s that advocacy absolutely falls under your purview.

We have effected a great amount of change with only a small minority of us engaging in these activities. If the majority – or simply a slightly larger minority – of us participated in advocacy, imagine what we could accomplish.

Disclaimer: Dr. Soori’s role at COGME is advisory to the Congress through the public deliberations of the Council. The opinions expressed here are personal and not representative of the Council’s.


Become an Advocate in Support of Hematology

ASH needs the help of all its members to bring issues important to the future of hematology to the attention of the U.S. Congress and other U.S. governmental agencies. The ASH Advocacy Leadership Institute was created in 2011 to provide additional opportunities for ASH members to learn more about advocacy, health policy, the legislative process, and to become more engaged in the Society’s activities.

This two-day leadership workshop is an opportunity for members to gain a better understanding of the Society and its activities and to learn about legislation and health policy affecting hematology research and practice. The first day of the Institute focuses on learning about the legislative process and health policy; it will include training in the policy-making process, advocacy, and media relations. Sessions will feature guest speakers from Congress, the Administration, and the National Institutes of Health, as well as other health agency officials. On the second day, participants will visit their respective congressional delegation on Capitol Hill to apply what was learned on the first day.

Candidates for the ASH Advocacy Leadership Institute must be U.S. citizens and current ASH members and should be interested in health policy, advocacy, and becoming more involved in ASH activities.

The fifth annual Advocacy Leadership Institute will take place on October 28-29, 2015, in Washington, DC. The nomination period for the 2015 ASH Advocacy Leadership Institute is now closed, but please visit the ASH website (www.hematology.org/Advocacy/ALI) in late spring 2016 for dates and information on the nomination process for the 2016 Advocacy Leadership Institute.

In the meantime, ASH members are encourages to visit the ASH Advocacy Center at www.hematology.org/takeaction to take action on the Society’s advocacy campaigns and to join the ASH Grassroots Network. Members of the ASH Grassroots Network receive action alerts and information about issues in which they indicate interest. At times, Grassroots Network members are also invited to represent hematology in activities such as visits to Capitol Hill, with NIH leadership, and with other regulatory agencies.

If you have any questions about the ASH Advocacy Leadership Institute or the ASH Grassroots Network, please contact ASH Legislative Advocacy Manager, Tracy Roades, at [email protected].

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