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JEFF BRAULT: Welcome to Simply PM&R, a Mayo Clinic Talks production, the simple solution for physical medicine and rehabilitation health care professionals who want to keep up while on the go. I'm your host, Dr. Jeff Brault, Physiatrist in PM&R at Mayo Clinic.

Advocacy. Advocacy for our patients-- that's every physician's job. Today, we're joined by Dr. Michelle Gittler, Medical Director, Residency Program Director and Chair at Schwab. Thank you, for joining us Dr. Gittler.

MICHELLE GITTLER: It's my pleasure.

JEFF BRAULT: And we're broadcasting live from the AAPM&R Annual Assembly. So, Dr. Gittler, why should physicians-- why should advocacy be a core competency for us physicians?

MICHELLE GITTLER: Well, Jeff, as physicians, we're advocating for patients all the time without knowing about it. As rehabilitation physicians, we're doing a peer-to-peer to get someone into inpatient rehabilitation. We're appealing a medication denial. We're appealing the denial for an imaging study. We are working to document all the things we need to make sure that someone with paraplegia gets a wheelchair because DME has to meet certain expectations. And being paraplegic isn't a reason for a wheelchair anymore.

JEFF BRAULT: Really?

MICHELLE GITTLER: It's fascinating. So when we think about the things we do-- and we understand that being the voice for our patient is being an advocate-- we ask the larger question, how do we train people to really be advocates for our patients and for our communities?

And one of the problems with advocacy right now is the more you do it, the less money you make, because every time you're on the phone, every extra form you're filling out, you're not seeing patients. So not only are you doing this for your patients because it's the right thing to do, but in some ways, you're getting penalized for being an advocate.

And that, to me, just seems wrong. We do this every day. We're advocating for people. And when you do it for an individual, it's called agency. I'm appealing on behalf of you. But we're doing things because there's a problem. And if we do advocacy well, what we're going to do is hopefully prevent the problems. So as a physician, we can advocate on behalf of individuals all day long. And that's OK. That's great, and we need to do that.

But if we really want to make a change in our communities and in our healthcare structure, we probably need to step it up and start advocating for bigger issues like access to health care for all the people that require access to health care, which is probably everybody, right? Or a community that's accessible and has accessible housing so your patients can make it to their doctor appointments. Or training for individuals with intellectual disabilities so they can participate meaningfully in their community and be able to move out of their homes.

So what this means, though, is that you have to be comfortable getting either in front of a microphone or speaking to a senator or speaking to community groups or church groups to engage them to get them to understand that health care is being involved in what many people think is the political sphere.

A lot of people think doctors should be apolitical. But if politics is about making our communities the best communities they can be, about using our global resources, our national resources, our local resources for the population in the best ways so everyone thrives, that's health care. It's not just politics.

So what are the things that you could advocate for? And I'll just tell you, some people may be uncomfortable with some of the things I say. I'm going to choose the one that's the most uncomfortable right now-- firearm violence. As a physician, I believe that anything that is going to impact the health of the people I serve should be looked at seriously.

So my job isn't to say what the solution is. My job is just to say, this is something that impacts my patients. This is something that's resulted in many individuals having lifelong disabling conditions or individuals that are so distraught about their condition, sadly taking their own life. So I'm not saying, here's what the solution is. I'm saying, let's look at this because it's a health care problem.

We've done it with vaping-- a bipartisan, immediate response to a dozen vaping deaths. And any death is a tragedy. So why wouldn't we do the same thing to another object that's created many more deaths? And by the way, firearm violence creates more suicide than homicide in any given year. So that's just an example of how I think we need to be involved in issues that many people think are political that are really health care-based.

We could look at issues related to water quality, right, which we saw in Flint, Michigan. A pediatrician speaking out, saying, this is bad for the patients. She's not saying what the solution should be. Rather, it's a health care problem. So I think that if we can create this as a competency in health care-- and granted, in rehabilitation, we're probably better at it than anybody else is because we value it, right? We have to.

But what about the people you talk to who don't care about their patient? The specialist who's not listening to what the patient says, and they send them to you only for you to recognize that the reason this person has difficulty walking is, in fact, because they have cervical myelopathy, and they really do need imaging, even though they're a heroin addict, right?

JEFF BRAULT: Sure.

MICHELLE GITTLER: What do you do about people you work with who won't advocate for their patients? I think some of it is because they don't know how. Some of it is because you don't get RVUs for it. We don't value it. And frankly, when something's not on the test, then it's not part of the core competencies. We don't put resources into it.

So what I would love to see is that we create this cadre of individuals. And we know, of course, the best doctors are rehabilitation physicians. We listen the best. We understand the big picture of the person in their community, in their home, and reassuming the best role of themselves that they can after whatever their disabling condition is. We need to be valued for that. And other people need to learn how to do it and how to value it. And that's why I think advocacy should be a core competency in health care.

JEFF BRAULT: So how would you teach advocacy? I mean, it's not an intuitive thing.

MICHELLE GITTLER: Well, it is intuitive when you talk about individual patients.

JEFF BRAULT: It is. It is.

MICHELLE GITTLER: So all I'm saying is, we teach people how to do difficult interviews when we want to ask questions about sexuality, which, by the way, we're terrible at, right? And we had a really hard time asking people about drug use and alcohol use. We're getting better at it. And we've created tools to help us do that.

I think it's a matter of investing in this. Some people are going to be interested. Some aren't. But at least we have to learn how to value it first and then train people up so that you could be the best at the peer-to-peer, or you could be the best at speaking with your local government, regional, or national government to make sure that we're valuing things that we can fix to promote the health of the entire community we serve.

JEFF BRAULT: I applaud that. On the flip side, I'm a busy clinician. You know, seeing patients-- how do I fit that into my day?

MICHELLE GITTLER: And that's-- Jeff, that's the struggle. How do you fit it in? Well, that's what physicians are doing now, right? The burden of health care is on physicians because we're doing more and more for less and less.

What I'm saying is if we start to value this, then every time you do that peer-to-peer or every time you're spending extra time with that patient, we've created an opportunity to recognize that, to value that, and for you to be reimbursed that way. You should be reimbursed more for the work you do getting your patient an imaging study that prevents a surgical procedure than the guy who does an unnecessary surgery.

JEFF BRAULT: I agree with you 100%. The hardest thing is talking to the patient. The easiest thing is doing a procedure to the patient.

MICHELLE GITTLER: Absolutely.

JEFF BRAULT: It sounds lofty. How do we do this?

MICHELLE GITTLER: We have to agree that we value it.

JEFF BRAULT: And who do you mean by "we?"

MICHELLE GITTLER: I think it's the health care community has to agree that agency for the patient and advocacy is a larger issue is well within the sphere or realm of health care because if we don't prevent the things we can't fix, then we're not really doing our job as doctors. Nothing will happen overnight. But we have to celebrate the physicians that speak out and speak up and rattle our cages and make us look twice at issues that we think are political so that we understand that these are health-related issues.

JEFF BRAULT: I liked your idea about gun violence. I mean, that has completely become a political-- it makes just as much sense as vaping. You're right. We were able to take care of that.

MICHELLE GITTLER: Right.

JEFF BRAULT: And I sit back here and I think, is it the money involved? Is it the groups involved that are fighting and resisting this?

MICHELLE GITTLER: I think that what it is, is we've all become so entrenched in being right, we've lost the ability to listen and create consensus about what's best.

JEFF BRAULT: We've been talking about advocacy with Dr. Michelle Gittler. Dr. Gittler, thanks for your time.

MICHELLE GITTLER: Thank you for having me.

JEFF BRAULT: This is Jeff Brault, Physiatrist in PM&R at Mayo Clinic saying thank you for your time. Until we talk again, remember the words of one of our founders, Dr. William Mayo-- rehabilitation is to be the master word in medicine. Thanks for joining us.

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