Timothy J. Pietro, MD, doesn't care much for the term "patient advocate." It sounds too adversarial for his tastes, too indicative of an implicit "us" and "them" whose interactions, without said advocate, would surely be injurious to said patient. It sounds too much like somebody itching to throw a punch, in other words. And that's not how healthcare should work, the Riverside urologist argues. The term "often leads to a mindset to ready ourselves for a fight," he says, "when the real fight for all of us is not among us, but rather a fight to achieve the same goal--a healthy mind and body." And besides, he says, there's no reason to label the obvious. "I think good physicians, by the very nature of their sworn duty, are to always be patient advocates," he comments. "I believe we were acting in that capacity long before that contemporary and overused term became so popular."

Dr. Pietro isn't the only Southern California physician who chafes a bit under the term "patient advocate." Doctors, of course, treasure their role as--well, whatever the best term for it is. It's the reason many doctors became doctors in the first place, in fact: to take care of patients, at every step in the increasingly confusing healthcare consumer experience. And, like Dr. Pietro, doctors hasten to note that physicians were, indeed, advocating on their patients' behalf long before that particular phrase came to be used for it. That's just what doctors do.

But physicians also recognize that the ground is moving under their feet, and that means the landscape is going to wind up looking very different in the future from the way it looks now. The relationship between patients and the healthcare system is changing radically, as the people who pay the freight keep changing the rules and as the technology behind the profession keeps upending the operational apple cart. And one of the key side effects is change--or the possibility of it in the near future--in the physician-patient relationship.

That's a good thing, patient advocacy-wise, says Tarzana dermatologist Dan Gross, MD. "I have no problem being a patient advocate," he says, "and that means informing patients what their options are if something happens between them and their insurance companies or government agencies that's truly not in their best interest." But, he says, he really wants patients to be empowered to advocate for themselves. "I think that's better for everybody," he says. "When I contact an insurance company, it's not going to be motivated to act positively on my request because it's going to have to pay out additional money. But patients do pay premiums, and without premiums, there is no insurance company. So I like for patients to be their own advocates. I'm happy to assist them and guide them."

For some doctors, though, it's all too much. And none of them speaks as eloquently on the topic as Howard R. Krauss, MD, a West Los Angeles ophthalmologist and the president of the Los Angeles County Medical Association. It's time, he argues, to clear out the clutter and move healthcare forward by returning to what made the system work so well in the first place: the absolute primacy of the physician-patient relationship. Indeed, one of his goals as LACMA leader is "raising physician and patient consciousness and uniting physicians and patients in the common vision of recovering and protecting the primacy of the physician-patient relationship across all modes of medical practice." He adds: "If we set aside the differences we have among physicians and focus on taking control back from for-profit health plans and returning it to the individual physician, in concert with his or her patient, we can accomplish a lot. But we get bogged down in petty fights with each other." As a result, he says, "we run the risk of delivering diluted messages to the regulators, legislators and media and thus neutralizing our own best intentions."

Donald J. Kurth, MD, MBA, MPA, an associate professor at Loma Linda University, chief of addiction medicine at the LLU Behavioral Medicine Center and mayor of Rancho Cucamonga, sees the same unfortunate phenomenon affecting physicians' ability to advocate for their patients. "Physicians have failed in that role," he says. "We have the moral high ground by virtue of what we do every day, but somehow we have allowed ourselves to be relegated to the status of gatekeepers for the insurance industry. I'm not saying we haven't tried to stem the tide of bad public policies. But the fact remains that healthcare policy has been largely turned over to Washington and Wall Street, neither of which knows the first thing about healthcare or the needs of our patients." Before physicians can effectively advocate for their patients, in other words, they need to first advocate for themselves and regain the authority they need to then make their patients' voices heard as well.

Of course, "patient advocacy" means different things to different doctors. Dr. Kurth is one who, like Dr. Krauss, sees an activist edge to the phrase. "Patients often need advocates to get their needs met," he says, "and physicians, nurses and others often speak on their behalf. Indeed, our nation's bankrupt healthcare policies have somehow left our patients out of the equation." And in the wacky healthcare system we live with today, if a patient does not have an advocate within the system, he or she is unlikely to receive adequate care, he argues.

For other doctors, "advocacy" has a more traditional meaning. Richard H. Guth, MD, MPH, FACEP, an emergency medicine specialist at Riverside Community Hospital, for example, notes that "the medical care system in the United States is complex, largely based on free-market principles that are inappropriate when an individual's life and limb are at stake and that require a level of understanding of medicine itself that is beyond most patients." A patient advocate, then, is "someone who possesses specialized knowledge of some aspect of that system who assists the patient in obtaining cost-effective medical care and who is willing to, on occasion, challenge the system, the hospital, the health plan and the utilization reviewer."

Not only is that an important role for physicians to fill, Dr. Guth adds, it's an essential one. "Unfortunately, most consumers simply lack the knowledge to be their own advocates," he says, "and when they attempt to perform that role they simply complicate the delivery of care by asking the wrong questions and by establishing an antagonistic relationship with their providers." The ideal, he says, is still "a patient who trusts his or her physician and a physician who takes seriously his or her ethical obligation to look out for the best interests of the patient."

Riverside Medical Clinic's Steven E. Larson MD, MPH, FACP, agrees. A physician who isn't a patient advocate is committing malpractice, for one thing, he notes. But what the doctor does may not be what the patient initially requested. "People are very savvy today about health matters, but lack any sense of scalability of their symptoms," he says. "Ordering an MRI is not my first thought when someone comes in with knee pain, but that may be the patient's concept of what is needed." As their advocates, physicians must determine the appropriate diagnostic and therapeutic maneuvers to return them to health, Dr. Larson adds, and "the essence of the relationship is trust that the physician will do what is in the patient's best interest. The trust must be earned and maintained, but that is what professionalism is all about."

Lobbying politicians, obviously, is what patient advocacy means to many people, plain and simple. And it is the most common and most basic element of the physician's patient advocacy arsenal. But not every physician is comfortable in that role, and not every physician agrees that it's actually the best way for them to act as patient advocates. And no one ever argues that it's the only way. So how can doctors act as patient advocates without traveling to Sacramento? Turns out there are myriad ways, and Southern California physicians are practicing them with their patients every day.

"Physicians should be honest and open and informative when patients ask them questions about the cost-effectiveness of particular treatments," Dr. Guth suggests. "We need to be able to recognize the inherent conflicts of interest in both fee-for-service and capitated payment systems, and always seek to do what is best for the patient." In his case, that may require a conversation the patient needs to have, but may not particularly enjoy having. "I don't have much time for discussion," he explains, "but will often say something like, 'If you feel too sick to go home, I will call your doctor and explain your feelings and request your admission to the hospital.' I may have to add the caveat, 'Because you have an HMO plan, there are certain guidelines for hospital admission and a doctor representing your medical group may choose to come to the ER and make the final decision about whether you require it.'"

For Raincross Medical Group's Harold W. Jackson, DO, patient advocacy means promoting better health. "When advice is needed, we give it freely," he says. "When patients can't afford medications, we give free samples or help them sign up with one of the pharmaceutical companies' patient assistance programs. And when patients can't afford to pay for a visit, many of us provide free services on a temporary basis." In addition, his office keeps information available to help patients find other needed health services resources they may not know exist. "We volunteer for free clinics," he adds. "And my staff spends hours every day making appointments for patients with other physicians to expedite rapid, when needed, access to specialty services, arranging for durable medical equipment needed by patients, getting prior authorizations for needed medication and services and often just lending a sympathetic ear."

Day-to-day patient advocacy also often centers around helping patients get the medications they need. Glendale neurologist Ilena J. Blicker, MD, is frustrated because quite frequently the diseases she sees have very limited treatment options--options that are often either not covered by patients' insurance or require co-payments that are too expensive for them. "I spend a lot of time arguing with or cajoling insurance plans to cover the medications, arranging for extra samples if possible or, if the patients are able to qualify, helping them secure medications directly from the pharmaceutical companies on their patient assistance programs," she says.

Making sure patients get the testing needed to determine and treat their conditions takes a lot of time--and represents the kind of patient advocacy physicians practice every day. So does making sure they receive the length of hospitalization that is necessary, Dr. Blicker adds, "We live in an era of timelines for length of stay," she says. "There is no question that in the past there were flagrantly over-long stays, but the art of medicine is to know when something isn't quite right and that the patient needs to be observed another 24 hours, for example." Physicians also routinely let patients know about newer techniques for treatment and about disease-specific groups and foundations that can help them, she adds, and provide information about which treatments are helpful and which ones are not.

One word comes up a lot when doctors talk about the multitudes of ways they advocate for their patients outside the now-smoke-free smoke-filled rooms of the statehouse. It's the twin sister of "empowerment," and it's at the heart of the best of what doctors do for their patients in the advocacy arena. It's "education." Says Dr. Kurth: "As physicians, our role is to help educate our patients on an individual basis and to define the argument for better healthcare policy in the public forum. Most people simply do not understand what they can do to help correct the system. Our job, as physicians, is to learn how to articulate the issues and gain public support for better healthcare policies. If we do not step up to the plate nobody else can do it for us."

That--physicians doing it for themselves--is the theme that comes up most often when doctors talk about patient advocacy in all its forms. Physicians disagree on what, exactly, it means and how, exactly, physicians can best do it. But they agree wholeheartedly that defining "patient advocacy"--what it means and what it is, in practice, every day--is the responsibility of doctors and their patients. Nobody's arguing that medicine should stay the same forever and ever. But doctors must make sure that, whatever shape the healthcare system takes moving forward, how they interact with their patients is decided by them and those patients, not by an outside entity.

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Sidebar: The Consumerism Buzzword

There's another healthcare buzzword you hear as often as "patient advocacy," and that's "consumerism." Are the two mutually exclusive? Or are they the Yin and Yang of tomorrow's system? Doctors are divided. Orange pediatrician Sudeep Kukreja, MD, sees it, but doesn't see it changing his practice much. "Consumerism is on the rise," he says, "but I as a physician will always remain an advocate for my patients' health." Under any new paradigm, he emphasizes, "I will develop a symbiotic relationship with my patients as far as advocacy for health is concerned and work in partnership with them."

Oxnard ophthalmologist W. Lee Wan, MD, sees it and embraces it. Physicians are always advocates, he notes, and beyond just treating them, that often includes helping them navigate their way through the system, "most often by going to bat for them with their insurance companies, but also by helping them get needed care from a pharmacy, a hospital or another doctor. And that can mean helping them get needed authorizations or referrals, timely appointments with other doctors' offices or name-brand medications they need." That's as time-consuming as it sounds, he concedes, and it's not reimbursed. "At some point, we need to educate patients on how to be their own advocates," he says. "They need to understand their care, how their insurance works, what benefits they have and what their responsibilities are."

But, Dr. Kurth warns, "much of what passes for consumerism is often manipulation by the profiteers in the healthcare system. One glaring example is the marketing strategy of some pharmaceutical companies to target consumers and encourage them to demand this drug or that from their physicians."