August 9, 2023
Advocacy may be considered as distinct of a discipline as surgery is, given the rules, regulations, and legislation governing the practice of healthcare. As members of the surgical profession, we have unique qualifications and experiences that we can bring to policymaking. Therefore, strengthening the development of surgeon-advocates is integral to the surgical training paradigm.
Surgical trainees often function as patient advocates, a role that includes a skillset that easily can translate to political advocacy. Trainees also are the āboots on the groundā in the hospital and have lived experiences that are relevant to effective advocacy. Despite the feeling many trainees have that we cannot effect change because we lack power or authority, our experiences frequently are welcomed by policymakers, and our voice is urgently needed in the advocacy dialogue.
This article details the strategies and approaches that members of the Āé¶¹“«Ć½Resident and Associate Society (RAS)āand surgeons in general who may be new to advocacyāmay consider to further their development as surgeon-advocates.
The evolution of national regulations for residents and healthcare professionals has been accelerated, in part, by two individuals: Libby Zion and Lorna Breen, MD, who are important in historical and contemporary contexts, respectively.
Zion was a young woman who died due to a medication interaction which, at the time, was attributed to overworked resident-physician prescribers. The trial spanned nearly 10 years, but the final result was a 1989 policy in the state of New York limiting resident work to 80 hours per week and no more than 24 hours at one continuous time.1 This policy would later be adopted by the Accreditation Council for Graduate Medical Education in July 2003 and now is required for all residency programs across the US.1
Dr. Breen was an emergency medicine physician in New York City who died by suicide in April 2020, during the initial surge of the COVID-19 pandemic.2 Her death brought the issues of physician burnout and suicide into the mainstream media.
Physicians long have had a higher rate of suicide, roughly two times that of the general population.2 The death of Dr. Breen, and the surrounding spotlight on healthcare professionals during COVID-19, prompted the federal government to take notice and enact change. The Lorna Breen Health Care Provider Protection Act was signed into law in March 2022.2
The US Surgeon General describes physician burnout as āan occupational syndrome characterized by a high degree of emotional exhaustion and depersonalization (i.e., cynicism), and a low sense of personal accomplishment at work.ā3
The Breen Act requires that the US Department of Health and Human Services sets aside grants to promote mental health and resiliency among healthcare providers.2 These policies aim to reduce physician burnout and prevent patient harm or surgeon self-harm due to the stress, both physical and mental, that can accompany the work of our profession.
Early career surgeons are critical for advocating for legislation that impacts the future of surgical training and access to care. We not only have direct involvement with patients and personal experience with systems-based issues but also can provide a first-person account of surgical training.
New policies and regulations frequently are proposed that have the potential to impact the entire surgical community, specifically, the future of the workforce. As the demand for surgical care rises, ensuring availability of quality surgeons to meet this demand is essential.
However, there has not been a compensatory expansion in the number of residency positions, due largely to the caps imposed by the Balanced Budget Act of 1997, resulting in a serious supply and demand imbalance.4
By providing support to curb future surgical workforce shortages and advocating for additional funding for residency positions, early career surgeons can help ensure that the next generation is adequately prepared to meet the needs of patients.5
Surgeons also play a central role in advocating for policies that protect against Medicare and Medicaid payment cuts and ensure fair reimbursement for surgical services. Coding and reimbursement policies are constantly changing. It is not only essential for surgeons to stay informed about these changes, but also to understand the legislative landscape in order to advocate for policies that allow us to provide high-quality care to patients.
Most of the policies that affect the daily life of a trainee exist at the institutional level. These policies can vary from rotation and call schedules to resident wellness programs and the ability of trainees to prioritize their own health.
There are many life changes that occur during this time that can include alterations in the traineeās own health as well as changes in the family structure. It is important that trainees have the freedom to schedule appointments for health maintenance, which is often difficult given the existing daily workflow of most surgical departments.
Primary and dental care are vital for all trainees, but other health-related maintenance may include optometry, obstetrics, gynecology, parental, and pediatric care. Additional specialist visits may be needed for acute health needs.
At the institutional level, having a policy in place that safeguards traineesā access to essential appointments is essential. Trainees may hesitate to request time off due to feelings of guilt or wanting to avoid the perception that they are pushing the burden of their job onto someone else.
One national survey of urology trainees found that having routine access to medical and dental care was reported as one of the most impactful policies to reduce professional burnout.6 An institutional culture that values and prioritizes trainee healthcare can alleviate concerns about work burden. This issue will only increase with the predicted surgeon deficit of more than 30,000 by 2034.5
In the wake of COVID-19 and the spotlight that the pandemic placed on physician burnout, the Āé¶¹“«Ć½created the Surgeon Well-Being Workgroup and developed a page on the Āé¶¹“«Ć½website featuring curated resources.7
The goal of the workgroup is to improve overall surgeon well-being. The RAS Advocacy and Issues Committee also has committed to developing new strategies that support resident well-being and maintain a productive training and learning environment.
The workgroup recognizes that the way each training program navigates resident wellness may be individualized; however, governing bodies like the Āé¶¹“«Ć½can adopt and promote a framework to focus local interventions.
Another contributor to trainee and surgeon burnout is the financial burden of educational loan debt. The Āé¶¹“«Ć½has prioritized advocacy for several pieces of legislation that can directly affect residents and early career surgeons by reducing the burden of loan debt. The Resident Education Deferred Interest Act allows borrowers to defer payment of loans without accruing interest until the completion of their training program, with the goal of substantially reducing the burden of repayment during training.5
The Specialty Physicians Advancing Rural Care Act creates a loan repayment program for specialty physicians practicing in federally designated rural areas by providing up to $250,000 for up to 6 years of service.5 The goal of this legislation is to help address rural access to care issues and encourage new graduates who want to practice in these areas be able to afford the costs of rural practice and still pay back their loans. Both bills have been introduced in Congress and are awaiting legislative action.
Achieving change at an institutional level typically requires collaborative action between residency and departmental leadership. Another approach for driving change at this level could include the work of a trainee representative on the administrative boards. Whether the trainee representative interacts with the graduate medical education office, the hospital, or the entire network of institutions, this role can be an effective way to directly bring issues to leadership.5
Getting involved in an Āé¶¹“«Ć½chapter is the gateway to state-level advocacy, which can connect surgeons involved in advocacy throughout the state, introduce members to state-level policymakers, and provide surgeons with opportunities for career advancement. The Āé¶¹“«Ć½continuously tracks state legislation of interest to surgeons and provides guidance and assistance with state-level advocacy meetings and campaigns.8
The Āé¶¹“«Ć½also connects state chapters that have achieved advocacy successes to other chapters with similar goals. In addition, the College supports chapter-level advocacy projects through a chapter grant program.8 Recently, RAS members have been involved in providing testimony for state-level legislation like STOP THE BLEEDĀ® bills, which is a California Āé¶¹“«Ć½Chapter initiative.
State advocacy is an opportunity for trainees and young surgeons to learn how advocacy works, gain valuable advocacy skills, and take an active role in leadership.
An uncomplicated way to be involved in advocacy work at the national level is to use SurgeonsVoice.9 This website is a central repository of current political issues that are impactful to the surgical community. Any member of the Āé¶¹“«Ć½can access this advocacy site that features prepared letters surgeons can use to contact their members of Congress. The process simplifies surgeon support of bills that benefit the profession and our patients.9
Another way to be involved in advocacy is the Āé¶¹“«Ć½Leadership & Advocacy Summit hosted each year in Washington, DC. This two-part conference begins with a robust leadership program, then transitions to an advocacy meeting that includes discussions with experienced lobbyists, visits from lawmakers and legislative champions of Āé¶¹“«Ć½priorities, training sessions on how to be an effective advocate, and more. The summit concludes with a day of meetings on Capitol Hill with members of Congress.
This conference is a singular opportunity for networking, including the SurgeonsPAC reception, hands-on advocacy training, and the chance to learn from informed and inspiring speakers.
Trainees and young surgeons are vital to surgical advocacy because they have a unique understanding of surgical patients and the issues that impact their surgical care. We encourage all RAS members to learn more about the many ways that the Āé¶¹“«Ć½and RAS support the development of surgeon-advocates. As a young surgeon, you have an important perspective that helps address even the most complex problems facing surgery today and the surgeons of tomorrow.
Dr. Rachael Essig is a fifth-year general surgery resident at MedStar HealthāWashington Hospital Center in Washington, DC. She also is Vice-Chair of the RAS Advocacy and Issues Committee.