Introduction
Health policy is defined by the World Health Organization as the decisions, plans, and actions undertaken to achieve specific healthcare goals within a society (“Health Systems Governance,” n.d.). This encompasses a range of domestic and global policies that impact health, including those related to public health, healthcare access and services, and health insurance. The field of health policy research thus seeks to understand and improve how systems respond and adapt to health-related policies, and how health policies can shape health and healthcare systems and the broader determinants of health (“What Is Health Policy and Systems Research?,” n.d.). Despite their direct impact on health and the healthcare system, health-related policies that affect healthcare access, quality, and cost may be formulated by policymakers without direct experience in healthcare, and with variable input from health professionals who actively provide healthcare. To address the gap between those formulating health policy and those impacted by health policy, there is growing recognition of the physician’s duty to “advocate for social, economic, and political change” (“Declaration of Professional Responsibility: Medicine’s Social Contract with Humanity” 2002).
Medical students report strong interest in advocacy, particularly around healthcare and healthcare system-related issues (Chimonas et al. 2021), and voter turnout among US physicians has grown during the past two decades—indicating not only an interest but an inclination to act to influence health policy (Ahmed, Chouairi, and Li 2022). A number of major professional medical organizations provide advocacy training programs and resources and the Accreditation Council for Graduate Medical Education (ACGME) lists “advocating for quality patient care and optimal patient care systems” as a core objective for residents across all subspecialties (Accreditation Council for Graduate Medical Education 2023). However, opportunities for direct policy experience and training in related health policy research are less common.
Health policy research is foundational to advance advocacy within the house of medicine and requires dedicated attention and support. As such, health policy-based studies, which examine how policies are developed and implemented and how a policy (or lack of policy) may impact patients’ or communities’ health status, benefit from protected time for investigators, grant funding, and peer review. This mirrors the approach used in basic science, translational, and clinical research in medicine.
Physicians face unique barriers to pursuing careers focused on health policy advocacy and related research, including lack of mentorship, difficulty securing dedicated time and resources, and alignment with institutional priorities. In this brief report, we seek to describe our experiences aligning our advocacy goals and health policy scholarship, offer reflections on barriers common to early career health policy scholars, and propose individual, institutional, and national-level solutions to these challenges. This is based on our experiences in the Academic Pediatric Association (APA) Health Policy Scholars Program (“Health Policy Scholars Program,” n.d.) as scholars (EM, MM, LW) and program directors (EB, LL).
The APA’s Health Policy Scholars Program is a three-year professional development program designed to equip child health professionals with a systematic and scholarly approach to health policy and advocacy. The program has three primary components: 1) scholarly project related to a child health issue; 2) didactic education about health policy and health advocacy; and 3) experiential component for conducting legislative advocacy. Scholars are chosen through an application process, and the program is supported in part by fees paid by the scholars’ institutions for program participation. Mentorship for the scholars is provided by national faculty advisors who are experts in specific areas of research interest and by local institutional mentors in public policy and advocacy. Mentors work with scholars to formulate a career development plan, navigate institutional environments, and prepare for academic promotion, thus priming them for a successful academic career in health policy.
Barriers and Facilitators of Health Policy Scholarship and Related Advocacy for Physicians
Mentorship
Effective mentoring is critical to the success of early-career physician advocates as they develop policy initiatives, hone their skills in policy research, and achieve career advancement. As advocacy increasingly gains traction alongside clinical expertise, research, and teaching as a formal career path within academic medicine (Bode, Hoffman, Chapman, et al. 2022), so does the demand for experienced mentors. However, related to this evolving paradigm, a barrier within the field of health policy research and related advocacy scholarship is the relative paucity of senior mentors compared to other areas of academic scholarship (Table 1). This supply-demand mismatch can significantly hamper the professional development and well-being of mentees, which can contribute to advocates changing to another career path, such as clinical research, where mentorship is more readily available.
In addition to serving as role models and sources of psychosocial support and career guidance, advocacy and policy research mentors may connect mentees to unique opportunities. This includes engaging in practice- or system-level activities, disseminating knowledge to the public and policymakers, coordinating academic-community partnerships, developing advocacy lectures or curricula, and participating in national workgroups and committees that identify health policy or advocacy needs (Nerlinger, Shah, Beck, et al. 2018). For example, a junior faculty member’s initiative to increase Medicaid coverage of medical-legal partnerships for eviction prevention may be enhanced by the perspective of seasoned mentors’ contacts on the city council’s housing committee and the Metropolitan Housing Authority board of directors. As additional examples, the authors of this paper, through efforts of their sponsors, have had the opportunity to speak to state Medicaid directors, assist in the design of child health policy centers, draft and deliver legislative testimony about child health policies, conduct health policy research and publish health policy statements for professional organizations like the American Academy of Pediatrics (AAP), and secure protected time for mental health advocacy and policy work. These activities can then be incorporated into a scholar’s curriculum vitae (CV) and advocacy portfolio (Nerlinger, Shah, Beck, et al. 2018) to demonstrate value in the academic setting and support career advancement. This can result in increased access to protected time and resources needed to pursue additional health policy research and related advocacy.
Although a conventional dyad of a senior mentor and a junior mentee works well for some scholars, contemporary mentoring now increasingly incorporates many different formats, including peer or group mentoring (Table 2), and occurs face-to-face or via teleconferencing. The give-and-take dynamic of peer mentoring naturally lends itself to the networking, community-building, and collaboration that facilitates traditional scholarly productivity. With as many challenges as the COVID-19 pandemic brought, it also created opportunity through increased virtual meeting capacity, allowing scholars to develop a “web” of mentors. This enhanced mentorship model may be particularly helpful to mentees who may benefit from connections to professional mentors outside their division, institution, specialty, or academia altogether, including community partners and non-profit organizations. Indeed, co-production and community engagement are key to maximizing the impact of academic advocacy and health policy scholarship. By implementing these strategies, early-career health policy scholars can foster a culture of mentorship and ensure a continuous supply of skilled mentors for the future.
Professional Development
One barrier to completing advocacy projects within academic medicine is the lack of formalized, structured support (Table 1). Many academic healthcare institutions include advocacy as part of their mission, and most academic pediatric chairs perceive advocacy is increasing in importance among faculty in their departments (Chung et al. 2022). However, it is less common to have a distinct pathway for recognition of advocacy as unique from other types of academic work including education, research, and service. As such, finding support including mentorship, funding, and protected time to devote to advocacy efforts may be more challenging than for the more traditional areas of academic medicine. In addition, the products or outputs from advocacy work may not have the same academic currency, as they are not always captured as well by traditional methods of measurement for promotion. However, the health issue of focus and policy improvement in this area must also continue to be priorities for the individual physician, as changes in the outcome, as well as the academic products, may come slowly over time.
To further examine the time, effort, and resources that may be devoted to an advocacy project, consider the example of a physician advocating for improved access to mental healthcare services for children in the state in which they practice. This could be achieved by advocating with legislators and other community partners for additional mental healthcare parity laws, providing stakeholder input during the regulatory and implementation process of existing mental healthcare parity laws, asking the state department of insurance to audit compliance of insurance plans, holding meetings with insurance plans directly to request adequate mental healthcare networks, writing a white paper or conducting a needs assessment of what mental healthcare services are lacking for children in the area, and/or many other action-oriented steps towards achieving the goal of improving mental healthcare access for children in the state (So, McCord, and Kaminski 2019). Each of these approaches are known to promote accessibility, affordability, acceptability, availability, and/or utilization of mental healthcare services for children and are important forms of health advocacy, which take time, effort, and resources to achieve. In fact, it could take a physician several years to achieve the goal of increasing access to mental healthcare services for children in their state.
These projects would likely be more successful if the academic physician has protected time to devote to the project, a trusted mentor with health advocacy experience, and a way to measure the outcomes (Table 2) that is meaningful in the academic environment and essential to policy change (Bode, Anwar, Best, et al. 2024). While outside the scope of this paper, outcomes data can guide the physician advocate in efforts to transform the conventional health policy-making process into a data-driven process by informing the formulation of new policies and evaluation of existing policies. Similar models exist for physician scientists, for whom receipt of mentored career development awards (which provide protected research time and guided skill-building) are linked to enhanced productivity and an increased likelihood that they will successfully transition to independent research careers (Nikaj and Lund 2019).
Research and Academic Support
One way to overcome these barriers is to approach health advocacy projects through a research lens (Table 1). Health policy research can include policy analyses, health equity research, cost-effectiveness analyses, needs assessments, and implementation studies. Infrastructure already exists at many academic medical centers to support faculty in research endeavors (Bode, Hoffman, Chapman, et al. 2022).
By using a health advocacy topic to ask a research question, the savvy academic can advance their advocacy aims while also gathering data that can be disseminated in an academic product. By framing a project as research in nature, the academic physician has increased access to mentorship, grants, and protected time, as well as the resources of research assistants and biostatisticians at some institutions. Resulting scholarship, including publications, population-level interventions, and policy change, could then be included in the CV and/or the advocacy portfolio (Nerlinger, Shah, Beck, et al. 2018). Using the example above, a physician could gather data on the adequacy of pediatric mental healthcare networks in their state and then disseminate that information through scholarly means, such as an abstract, poster, or journal publication.
Funding for health policy research and related advocacy could come from institutional or external, including community-based organizational, sources. This could include internal or external funding for curriculum development and educational programming, community organizations could support community-based projects, and professional medical organizations (e.g., AAP) could provide funding for medical trainee projects.
Alignment with Institutional Priorities
Some of the appealing aspects of health policy research are that, depending on the scientific findings, it can position physician advocates with specific areas of passion and expertise to serve as powerful voices for children and effect policy change. These advocacy opportunities can be led by individuals, institutions, or state and national organizations. Unfortunately, passion is insufficient for effective health advocacy, especially at the institutional level.
However, growing numbers of physicians are not independent practitioners but rather employed in large healthcare organizations, which may have objectives or agendas that benefit from a coordinated approach, and may actively oppose specific advocacy topics (e.g., firearm violence prevention), especially if they have concerns about the potential impact on their academic system or business (Table 1). Thus, it is important to have discussions with the government relations staff at healthcare institutions prior to embarking on an advocacy-focused research project.
Government affairs specialists, by sharing both healthcare advocacy priorities and topics that might not be supported by the institution, can help to clarify the scope of a research question in that context. Additionally, senior leadership within an individual’s department and in the healthcare system can provide valuable mentorship when discussing potential advocacy-focused research projects. Taking time to build a working relationship with these individuals should be a priority, as their support can be essential in institutional buy-in (Clark 2012). This is especially important if a project is seeking approval by the home institutional review board (IRB) or if that IRB is the only potential approval source for the project itself. Additionally, while an institution might be broadly sympathetic to an advocacy research project, there may be outside entities that are not, and this could affect a project’s scope.
To change institutional healthcare policies, healthcare providers may look to optimize opportunities to change internal and external policies and systems through networking, particularly with peer mentors. For example, staff in a neonatal intensive care unit may gather patient stories, medical evidence, and budget information to advocate for expansion of a donor milk program for high-risk newborns. In addition, healthcare providers can work with community partners and other local health professionals, familiarizing themselves with and adapting their strategies based on the institutional and community political environment. For example, community pediatricians, parents, and school staff can work together to develop evidence-based COVID policies that create a healthier school environment. Finally, healthcare professionals can also align their research and advocacy pursuits to grow their reputation and relationships as valuable content experts and resources for health policymakers. For example, Dr. Robert Sanders, a pediatrician and car safety expert, played a key role in the passage of the first mandatory child safety seat law in 1978. Since that time, the U.S. has observed more than a doubling of car seat usage and a reduction of childhood traffic fatalities by 70 percent (Elliott 2022). In circumstances where an advocacy or health policy research project may not receive institutional support, it can be helpful to have ongoing discussions with the previously mentioned individuals to delineate areas and limits of potential support.
While an advocacy or health policy research topic may not be something that can be pursued as initially envisioned, there may be other approaches to that same topic that are supported or less controversial. For example, the institution might not support an application for grant funding that would allow an individual to study health outcomes for undocumented children. However, if the focus of the grant was to examine health outcomes for unhoused children, some of whom might be undocumented, it might be deemed more acceptable. Revising the research questions would not be disingenuous and the work would not be any less meaningful. Flexibility is a vital part of health policy research and being willing to pivot can enable ongoing research.
In instances where a home institution may not fully support a research project, physicians can consider additional partners, such as local or professional organizations (e.g., AAP grants) or other institutions (e.g., a hospital in a neighboring state that can serve as the home IRB and allow them to conduct research, albeit maybe not at the original site). Engaging colleagues, mentors, and a community network can broaden the reach of a project and help it find a path forward (Table 2). By partnering with influential contacts, physicians may be able to build support for a health policy initiative that might otherwise be challenging to develop on their own (Clark 2012).
For some states and locales, institutional policies that detail what research can and cannot be done are not set in stone. There may be a time in the future when a previously challenging project suddenly becomes feasible. Paying attention to the current climate, looking for signs of change such as shifting institutional priorities or societal conditions, and embracing a new window of opportunity are essential for developing a health policy project and successful policy change.
Conclusions
Although there is growing institutional recognition of advocacy as the “fourth leg of the academic stool,” (Chung et al. 2022) traditional support for health policy scholarship, including experienced mentorship, dedicated time and resources, and institutional prioritization, may be inadequate. Awareness of these barriers allows physician advocates to anticipate hurdles and equips them with attainable solutions. Removal of these barriers will allow physicians to bridge the gap between those making health policy and those impacted by it, leading to better policy and thus better health outcomes.
Individuals can seek out career development resources in a systematic manner to maximize their effectiveness, including participation in a dedicated professional development program such as the APA’s Health Policy Scholars Program. Institutions can act intentionally to support health policy scholarship and associated physician advocacy as they similarly support research, education, and clinical career pathways. National organizations also can create opportunities and provide resources to promote professional growth.
While it is helpful to be systematic and purposeful in one’s approach to advocacy and health policy-focused research, physicians should keep in mind that health policy design, implementation, and analysis rarely unfold linearly or go through all the steps laid out in the initial plan. For individuals conducting health policy work, it is important to be flexible, build a network, and be open to gains that may look very different than what they expected.
Potential Conflicts of Interest
The authors declare no competing interests.
Acknowledgements
The authors would like to thank their colleagues and mentors in the Academic Pediatric Association Health Policy Scholars 2021-2024 cohort for their support developing the ideas for this manuscript.
Author contributions
EM, MM, and LW conceptualized the manuscript and shared writing of the first draft. All authors critically reviewed the manuscript and approved submission.
Funding/Support
The authors received no financial support for the research, authorship, and/or publication of this article.
Abbreviations
Academic Pediatric Association (APA)
Accreditation Council for Graduate Medical Education (ACGME)
American Academy of Pediatrics (AAP)
Curriculum vitae (CV)
Health Policy Scholars Program (HPSP)
Institutional review board (IRB)