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."