Jacobs, Douglas B.; Greene, Meredith MD; Bindman, Andrew B. MD
Mr. Jacobs is a third-year medical student, University of California, San Francisco (UCSF) School of Medicine, San Francisco, California.
Dr. Greene is a fellow in medicine–geriatrics, UCSF, San Francisco, California.
Dr. Bindman is professor of medicine, health policy, epidemiology, and biostatistics, UCSF, San Francisco, California.
Acknowledgments: The authors wish to thank Professors Steve Morin and Jim Kahn at the University of California, San Francisco (UCSF), for their contributions in designing the survey; Dr. Talmadge King Jr. and Ms. Bonnie Johnson for facilitating the completion of the survey questionnaire among faculty members in UCSF’s Department of Medicine; and Mr. Richard Wang for his assistance in creating the Web-based survey tool.
Other disclosures: None.
Ethical approval: Because the information was gathered for administrative purposes as part of a strategic planning process, the protocol was considered exempt from review by the institutional review board.
Correspondence should be addressed to Dr. Bindman, PRL-Institute for Health Policy Studies, 3333 California St., Suite 265, San Francisco, CA 94118; e-mail: firstname.lastname@example.org.
Debate exists as to whether physicians should participate in public policy activities as a part of their academic role. The issue has garnered increased attention in recent years following the decision by the Accreditation Council for Graduate Medical Education (ACGME) to include “advocacy for quality patient care” as one of the evaluation criteria of residency programs.1 Several medical leaders and professional organizations have strongly encouraged physician public policy involvement, especially to counteract pervasive health care systems issues.2 Others, however, have rebuked such a commitment to advocacy, arguing that civic virtues should lie outside of the professional realm.3
In a study by Gruen et al,4 physicians in the community rated public-policy-related activities as very important, and two of three physicians reported that they had worked with community-based organizations, engaged in political activities, or participated in collective advocacy in the prior three years.4 While practicing physicians in the community are participating in public policy activities, there is relatively little known about the degree to which academic physicians are similarly engaged. If academic faculty members are to serve as role models to help young physicians learn how to advocate for policies to support patient care, they will need experience in participating in public policy activities.
We conducted a survey of medical school faculty members to better understand whether and how they were involved with public policy activities.
Between February and April of 2011, as a part of a strategic planning process we conducted a cross-sectional survey of all active Department of Medicine faculty members at the University of California, San Francisco (UCSF), to investigate whether and how faculty were engaged in public policy activities. UCSF is a public university that trains medical students, residents, and clinical fellows in three main hospital settings: a teaching hospital, a community-based public hospital, and a Veterans Administration hospital. The Department of Medicine is the largest academic department in the UCSF School of Medicine, and among all such departments nationally, it is among the very top recipients of National Institutes of Health funding.
We e-mailed a Web-based questionnaire with both closed- and open-ended response options to all Department of Medicine academic faculty members. Because the information was gathered for administrative purposes as part of a strategic planning process, the protocol was considered exempt from review by the institutional review board. Survey questions focused on faculty members’ participation in three types of public policy activities: (1) policy-related research, (2) expert advice to government officials, and (3) public policy advocacy in collaboration with organizations such as professional societies or community-based organizations. These three activities were among the main ones identified by Gruen et al4 in their assessment of community-based physician participation in public policy.
In the questionnaire, each public policy activity was defined for faculty members. Policy-related research was defined as “quantitative or qualitative studies conducted for the purpose of formulating, implementing, or evaluating a public policy.” Expert advice was defined as “interaction with government officials or their representatives for the purpose of informing, formulating, or influencing policy decisions.” Advocacy in collaboration with organizations was defined as “work with organizations outside of government to support their efforts to inform or influence government decisions.”
To assess their involvement in public policy research, faculty members were asked, “Have you published any policy research articles in the past five years?” To assess involvement in the provision of expert advice in public policy, faculty were asked, “During the past five years, have you provided expert advice to government officials or their representatives?” Faculty members were also asked about the level (national, state, local, other) and branch (executive, legislative, judicial) of government for which they provided expert advice. To assess involvement in community-based advocacy, faculty members were asked, “During the past five years did you contribute to public policy advocacy through organizations outside of government?” For each aspect of public policy, faculty members were asked whether they received extramural funding for their involvement.
Faculty members were not required to identify themselves but were asked about their demographics (age, gender, and race) as well as their academic rank (professor, associate professor, assistant professor, clinical instructor) and academic role (clinical investigator, clinical educator, or adjunct). Faculty members in adjunct roles include either nonphysicians of any rank or physicians at the assistant professor level fulfilling roles as either teachers or researchers. Faculty members who included an e-mail address with their response could be linked to a specific division within the department.
We compared the demographic and academic characteristics of respondents with comparable information separately available for the department’s entire faculty. We calculated the percentage of respondents who participated in each of the three public policy activities and examined whether participation in each and any of the three types of public policy activities varied in association with demographic or faculty appointment characteristics. All predictors, including age, were captured and analyzed as categorical variables using chi-square tests. Because there were limited numbers of faculty members from minority groups, the race data were collapsed to white versus nonwhite for analysis. We also conducted a multivariate logistic regression using gender, race, academic role, and academic rank to predict whether a respondent was participating in any of the three policy activities. Age was dropped from this analysis because it was collinear with academic rank (correlation = 0.79). Analyses were conducted using Stata version 12 (StataCorp, College Station, Texas).
Two hundred twenty of 553 faculty (40%) responded to the survey. There were no significant differences in demographics, academic rank, or academic role of respondents compared with data available on overall faculty demographics (see Table 1).
One hundred twenty-four of 220 (56%) of the respondents, comprising 22% of the department’s 553 total active faculty members, participated in at least one of the three types of policy-related activities. Fifty-one (23%) respondents conducted policy-related research, 67 (30%) provided expert advice to government officials, and 93 (42%) reported collaborating with organizations to advocate for public policy. Fifty-eight (46%) of faculty members engaged in public policy reported involvement in at least two of the three public policy activities listed, and 29 (23%) reported involvement in all three activities.
Of the three public policy activities, policy research was the one most frequently funded. Twenty-four (47%) faculty members involved in research reported receiving extramural funding for their public policy work as compared with 12 of 67 (18%) respondents who provided expert advice to government officials and 10 of 93 (11%) faculty respondents who advocated through organizations outside of government.
Of the 67 faculty members who provided expert advice to government officials, 52 (79%) provided advice on the national level, 33 (50%) provided advice on the state level, 22 (33%) provided advice on the local level, and 12 (18%) provided advice on “other” levels, typically international governmental organizations, such as the World Health Organization. Forty-one of 67 (72%) respondents who provided expert advice to government officials reported giving expert advice to the executive branch, which was typically under the jurisdiction of the Department of Health and Human Services and its different divisions. Twenty-eight of 67 (49%) respondents who provided expert advice to government officials reported giving advice to policy makers in the legislative branch, typically via testimony, committee appointments, or meetings with representatives.
Involvement in policy research varied significantly with faculty role, with the highest rate of participation among clinical investigators. Higher faculty rank was significantly associated with faculty members reporting that they were involved in one or more of the three policy activities (P = .04) (see Table 2). In the multivariate logistic model predicting participation in any of the three policy activities, there was no significant difference by male gender (odds ratio [OR] = 1.3; confidence interval [CI] 0.6–2.5), white race (OR 1.4; CI 0.6–2.9), or faculty role as a clinical investigator as compared with a clinical educator (OR1.1; CI 0.5–2.4) or an adjunct professor (OR 1.0; CI 0.4–3.0), but assistant professors were significantly less likely than full professors (OR = 0.3; CI 0.1–0.9) to report participation in any public policy activity.
Among the 124 faculty members who reported that they were participating in one or more of the three policy activities, 52 provided optional information on their specialty division. These 52 respondents were distributed among 12 of the department’s 17 specialty divisions; the Division of General Internal Medicine had the largest number of faculty members (13) involved in public policy.
Among faculty in the Department of Medicine at UCSF, more than half of respondents reported that they were engaged in public-policy-related activities. These activities were widespread among faculty who varied in demographic characteristics, academic roles, and specialty interests, suggesting that substantial numbers of academic internal medicine faculty regarded involvement in public policy as an important part of their professional role. The involvement of faculty in these roles was associated with higher academic rank, suggesting that faculty members may assign greater importance to these roles over time.
Approximately one-third of faculty members reported that they received extramural funding support for their work in public policy. Those whose involvement in public policy was through research investigation were the most likely to receive extramural funding. However, almost half of those who received extramural funding for their work in public policy received it for either working directly with policy makers or community-based organizations.
Our survey is among the first that we are aware of to assess the type and scale of involvement that faculty members at an academic health center have in public policy. This is important information for teaching programs as they attempt to meet the ACGME’s expectation that residency programs teach their trainees about patient advocacy. We conducted our survey because information on faculty members’ involvement in public policy was not otherwise visible through administrative files or from the materials that the department requires faculty to report as a part of the promotions process. We discovered that many faculty members are making significant contributions in the area of public policy even if this function is not an explicit part of their defined job role as a clinical investigator or clinical educator.
There are several limitations that should be considered when drawing inferences from the results. First, the experiences of UCSF faculty members may not be reflective of faculty members at other academic health centers. UCSF is a public institution, and its faculty member involvement in public policy activities may reflect the organization’s public mission. However, many private institutions are beginning to similarly embrace the improvement of health systems in their mission statements.5 Others could use our questionnaire to determine the degree of faculty member participation in public policy activities within other departments and at other institutions. Second, we did not test faculty members’ knowledge of academic policies that limit or protect their right to engage in public-policy-related activities. Academic faculty members who engage in public-policy-related work would be wise to understand the policies and expectations of their employer before engaging in public-policy-related work, especially if that work could be perceived as creating a conflict of interest with the university. Third, the survey findings may be biased because of nonresponse. However, even if we were to assume that none of the nonrespondents participated in any public policy activity, we would still have found that more than one in five of the total faculty members in UCSF’s Department of Medicine are engaged in public policy. Finally, we focused on three specific public policy activities, and in doing so we may have undercounted some of the other ways faculty members are engaged in policy work related to patient advocacy.
If the findings among the faculty members in the Department of Medicine at UCSF are generalizable to those in other departments and academic health centers around the country, then this would suggest that there may be an unrecognized resource to help meet the ACGME’s call to incorporate patient advocacy as a core element of residency training. Academic departments may be in a position to leverage this capacity by facilitating opportunities for faculty members to have a greater shared awareness of what they are each doing in the area of public policy, by supporting the establishment of mentoring relationships between more and less experienced faculty in the area of public policy, and by incorporating standards of excellence for work in public policy into the promotions process. By harnessing academic physicians’ interest in public policy activities, academic medical centers could ultimately increase faculty member satisfaction, inform policy makers, improve health systems, and advocate for better patient care.