Training Pediatricians to Become Child Advocates

The primary goal of pediatrics is to improve the health and well-being of children. Pediatricians work toward this goal by enhancing medical knowledge and technology through basic science, biomedical and clinical research; as well as by providing high-quality clinical care. Our pediatric training programs educate young physicians to be competent and confident clinicians and many specialty fellowships provide excellent research training. However, pediatric training programs often overlook the need to train young pediatricians to become community leaders and effective advocates for children despite articles published over a 20-year period stressing the importance of child advocacy.1–5 Child advocacy has become more difficult as managed care and competition have threatened the financial status of many public and private providers as well as health insurance plans. As responsibility for making child health policy shifts from the national to state and local levels, we need more pediatricians to become effective advocates. Experience in several states such as Hawaii, Minnesota, and Colorado has demonstrated that pediatricians can influence the passage of state legislation that greatly benefits children. For this to occur, pediatric residencies should develop leadership training programs that stress community service and child advocacy. Leadership and child advocacy skills can be learned in the same way as clinical decision making skills are acquired, through problem-based learning and experience.It has been my personal experience that many medical students and pediatric residents are eager to learn how they can become more involved in child health policy decision-making and child advocacy. Unfortunately, I do not know of curricular materials or training guidelines for teaching these important advocacy skills. The goal of this commentary is to provide a framework for teaching these skills based on the author's experience working with community-based organizations and legislators in Colorado. This commentary describes a three-stage process for becoming an effective advocate for children. These stages are: 1) developing credibility in the community through community service and networking; 2) understanding the legislative process by becoming involved in attempting to pass legislation; and 3) working proactively as a recognized expert in a child health policy by appropriate policymakers.Initially the young pediatrician must develop credibility in the community as someone who cares about children and their families and gets things done. This is best accomplished by working with an established organization to design, fund, and implement a community service project. The successful implementation of the project often leads to one or more invitations to join the board of a community organization. Although time-consuming, participation on the board of a respected and effective community organization provides an opportunity to establish a base for future advocacy efforts. It also helps establish personal relationships and networking with nonmedical community leaders. These relationships generally become very strong and productive over time. This initial period of community service and networking, which provides the foundation for future advocacy efforts, usually takes at least 3 years. However, it is important to understand the importance of building on the initial success of this community service project. An ongoing commitment to community service and an expanding network of personal relationships is essential to being a successful child advocate.The second stage in becoming an advocate is a legislative internship during which time one learns how the legislative process works by serving as a medical expert for a bill related to a child health issue. This usually involves working with a legislator and a lobbyist of either a provider institution or a community-based organization. In addition to acquiring an understanding of how the legislative process really works, networking is extended to include legislators and their staff, legislative council and bill drafters, as well as other lobbyists. This stage often takes several years because many bills do not pass on the first attempt and it also takes several legislative sessions to establish appropriate personal relationships. The time spent at breakfast and lunch as well as the end of day debriefings and strategy sessions will be more important than a 2-minute testimony at a committee hearing. This legislative experience or internship period may be extended over a long period of time when a pediatrician has extensive clinical responsibilities and tight restrictions on scheduling. Alternatively, having an established relationship with an influential legislator can shorten this second stage.The third stage of child advocacy begins when you are recognized as an expert in child health policy by the appropriate policymakers. By this time one should have the tools and personal contacts to identify important child health issues, develop a legislative agenda, have community organizations endorse part or all of your agenda, find legislative sponsors, assist in bill-drafting, build a coalition to support your legislation, testify before legislative committees, and work with the sponsors and lobbyists to pass the legislation and have it signed into law.In transitioning through these three stages it may be worthwhile to consider certain principles of effective advocacy (Table 1) that will be reviewed in detail below.Effective child advocacy should be based on a common vision that is easily communicated and understood. Increasing awareness of the mission in the community motivates individuals to take action. It is usually preferable to have a goal that is limited in scope, achievable, and measurable. For example, during the past 10 years the Colorado Chapter of the American Academy of Pediatrics (AAP) has set four main child advocacy goals: 1) to make comprehensive health insurance available and affordable for all Colorado children; 2) to promote efforts to immunize 90% of Colorado children on the recommended time schedule; 3) to promote efforts to reduce childhood injuries, especially those related to automobile accidents and gun violence; and 4) to support efforts to maximize every child's developmental potential through efforts to promote better parenting skills and provide quality early childhood education.Selecting an appropriate strategy for change is always a difficult task. Remember that the perfect can too often be the enemy of the good and that fundamental, comprehensive change is always very difficult to achieve. Correct timing is usually essential to achieving comprehensive change because many organizations are threatened by this type of change. Working incrementally to improve or change a system is much less dependent on timing issues. Therefore, the small wins incremental approach is preferable.6 First, it legitimizes the advocate within the community as a leader who can get things done. Second, the process empowers community organizations to become involved in child health issues. By creating a series of small wins, community organizations build and consolidate a power base that can be a springboard to accomplish more comprehensive change in the future.The experience of the Colorado Chapter of the AAP provides a case study in the legislative strategy of small wins. Table 2 displays the legislative accomplishments of the Colorado Chapter of the AAP in collaboration with the Colorado Children's Campaign, a statewide child advocacy organization during the last 7 years. In 1990 the Colorado legislature passed the Colorado Child Health Plan bill. This program provides ambulatory health care services to children who live in working families with incomes <185% of the federal poverty level and who are not eligible for Medicaid. The plan does not include inpatient medical services, mental health services, or dental services. Initially the plan was limited to children 6 years and younger who lived in the non-Denver metro counties with the highest unmet need for primary care. In 1993, the legislature expanded the Colorado Child Health Plan to include children up to the age of 13 and streamlined eligibility and enrollment by allowing the use of other state and federal means tested programs to document family income. In 1995 the state legislature passed the Child Preventive Health Benefit Bill. It mandated that all health plans licensed in Colorado include basic pediatric preventive care based on the AAP schedule as defined in the state small group basic and standard benefits package. The division of insurance, with input from the health department and members of the state AAP chapter meets each year to review proposals for preventive services that should be added to this basic and standard plan. Once these preventive services are included in the basic and standard plan, the legislation requires all health plans in Colorado to include these preventive care services. For example, a nursing home visit 48 hours after discharge from a nursery, when ordered by a physician, was added to the basic and standard plan, and became a required benefit for all licensed health plans. In 1995 the legislature also passed the Child Automobile Safety Restraint Law. This law requires children to be in an appropriate auto restraint system regardless of whether they sit in the front or back seat. Failure of an adult to ensure that children are appropriately restrained results in a fine. In 1996 the Colorado chapters of the AAP and the American College of Obstetrics and Gynecology facilitated an agreement between the largest managed care plans in Colorado and the Division of Insurance. This voluntary agreement stated that no previous or concurrent authorization would be needed to allow mother and infant to remain in the hospital for 48 hours after delivery. Furthermore, the mother and infant would be treated as a dyad, so that if the infant had to stay in the hospital, the mother would be allowed to stay with the infant for that first 48 hours. The plans agreed to implement an education program both within their organizations and for the members in their plans. In 1997 the Colorado legislature passed a bill that would allow school districts to be reimbursed by Medicaid for health-related services that were included in a student's individual educational plan as well as Medicaid administrative case management services. The additional Medicaid revenue that school districts receive must be used to enhance health-related services for children within the school district. In 1997 the Colorado Child Health Plan was also expanded throughout the entire state for low-income children under the age of 19. This plan will transition into the Children's Basic Health Plan, which will offer comprehensive benefits (including inpatient care and mental health services) and qualify for federal funds through Title 21 federal legislation.Pediatricians need to become involved in a range of community organizations. Volunteer community service is the first step in establishing networks that will be needed to build a strong child advocacy coalition. This is a process that requires time and patience because it is based on establishing personal relationships with people that strengthen over years of working together. It is important to build two types of coalitions; first, among community service and business organizations, and second, among providers. In Colorado, our active community service and business coalition included the Colorado Children's Campaign, (our statewide child advocacy group), the Colorado Chapter of the March of Dimes, the Junior League, the Colorado Association of Commerce and Industry, the Denver Chamber of Commerce, and the Colorado Forum (a group of business leaders). The provider coalition included other professional societies such as the Academy of Family Physicians, the Colorado Medical Society and the Denver Medical Society, as well as major providers of care to low-income families such as the University of Colorado Health Sciences Center, the Colorado Community Health Network, Denver Health Center and the Children's Hospital. The effectiveness of these coalitions increased with time as the pattern of small wins became established. Coalition members became more active supporters of legislation when they developed more confidence in their ability to influence the legislative process.Recognizing who will oppose the child health legislation that you support is as important as building a strong supportive coalition. Neutralizing opposition is critical because public disagreement during committee testimony, especially involving respected organizations, tends to paralyze the legislative process and jeopardize a bill's passage. Most legislators dislike controversy and are usually reluctant to pass a controversial bill that has a substantial appropriation. After identifying organizations that are likely to speak out actively against your proposed legislation, try to convince them it is in their interest not to take a position but remain neutral. There are four approaches that can be useful in neutralizing potential legislative adversaries (Table 3). First, explain why your position is in their self-interest. Many times, the proposed legislation is poorly understood or misinterpreted. Taking the time to explain the potential implications of the proposed legislation and the reasons why it will benefit that organization and its members is time well-spent. If this does not work, explain why your position is the right thing to do. This is the “children are our future argument,” that stresses the importance of giving children the best chance to succeed. It is also worthwhile to explain the relationship between good child health and learning and education. Review the high financial and social costs of high school dropout rates, substance abuse, and the juvenile justice system. When your adversary isn't convinced by this type of argument, explain the potential public relations problems that their organization will have by taking a public position against children. A well-placed phone call from a newspaper reporter or television commentator to the head of the adversarial organization can often drive this point home. When compromise is not possible, identify ways to get around the obstacle. When a 500-lb gorilla is in your way, find the right 800-lb gorilla to clear your path. Find a powerful member of the adversarial organization to be an advocate for your position. When administrators of institutions will not budge, find an advocate on the board of directors of the institution. When opposition comes from a governmental agency, talk with someone higher up in the agency, and if necessary an elected official such as a city council person, or the mayor or governor.Willingness to compromise is essential to gain the respect of both legislators and lobbyists. Be pragmatic and willing to compromise; never accept the position of active opposition without attempting to compromise. Central to the process of compromise is being able to prioritize key elements of the legislation. Try to identify issues of low priority that appear to have greater value to your adversary. It is also important to understand whether it will be possible to regain the lost element either later in the legislative process or in subsequent or alternative legislation. For example, in the Colorado Child Health Plan, three bills were enacted to expand the age of eligibility for the Child Health Plan from age 6 to age 19 years. An issue that was very important to managed care plans was copayments for office visits including preventive care. To get their active support that was crucial for passing the Colorado Pediatric Preventive Services Bill, plans were allowed to charge a copayment for preventive care.You never know when a legislator who opposes a bill that you are supporting during the current session may be willing to sponsor an important bill in the future. Don't take opposition to your bill by a legislator personally. If you lose your cool and personally attack a legislator, you'll regret it. Never play one legislator off against another, especially when they are friends. Compromising a legislator and questioning their integrity is a common incendiary device for burning a bridge. Remember that you will always need legislators to sponsor bills, to vote in committee, to vote on the House and Senate floor, and finally, even after legislation passes to get votes for a yearly appropriation if needed.Child advocacy involves teamwork, and an effective professional lobbyist is usually an essential part of that team. Pediatricians alone, without the assistance of a professional lobbyist, are at a great disadvantage in working in the legislature. In hiring an effective lobbyist, be aware of the other organizations that your lobbyist may represent. It is essential to avoid conflict of interest to be sure that any additional clients have values that are consistent with advocating for children. It is important to determine that your lobbyist can do the basic work of counting votes and closing the deal with a legislator so that you can count on that legislator's support. Assess whether your lobbyist works well with your strongest supporters in the legislature, as well as the lobbyists of the other organizations in your coalitions. A good lobbyist will also assist you to prepare for testimony before a legislative committee. It is essential to be brief and highlight your main points. Whenever appropriate, distribute an easy-to-read 1-page fact sheet (usually with bold headings and bulleted points) to accompany your testimony. Always be prepared to answer questions related to projected expenditures or savings as well as experiences of other states with similar legislation. Always appear respectful of the committee members, especially the chairperson.Another important aspect is to establish good contacts with the media. It is important to establish a long-term relationship with members of the media. Be responsive to their inquiries and try to provide material for child health stories on a regular basis. Establish your reputation as an expert in child health with ready access to relevant data. Be able to provide access to patients for pictures, videotaping, and interviews. Remember that personal stories are the essential ingredient in a good news story. Incorporate the use of the media into your overall legislative strategy, and know when and how to plant media stories to maximize their impact on legislators.As a physician and a pediatrician who has relationships with a hospital, a university, or a specific health plan, it is essential that you be viewed as a child advocate first, rather than as an advocate for your provider organization. One way to minimize the appearance of being self-serving is to represent yourself as a spokesperson for the AAP and other community-based organizations, rather than a provider organization. It is important to represent the needs of children and not interests of a provider. As soon as you appear to support a provider perspective instead of a child's perspective, you become suspect and lose credibility.Perhaps one of the most difficult challenges in the legislative environment is the need to be rational, even in the most irrational situations. Surviving as a child advocate working directly with your state legislature is not easy. Attempting to juggle and balance patient care responsibilities and other academic activities with the legislative world can often lead to frustration and burnout. Table 4 is a list of survival tips. Survival requires a generous dose of patience, humor (it's especially important not to take yourself too seriously), the ability not to take personally any attacks on your legislation or position, and the ability to recognize the benefit of forgiveness (don't hold grudges). Be gracious in both failures and success. Maintain your respect for legislators, as they have an incredibly difficult job and most want to do the right thing, and finally, maintain your integrity at all cost.Successfully advocating for children is an incredibly rewarding experience. Being able to rally the troops in a successful campaign for children provides a sense of accomplishment and enhanced meaning to a pediatric career. Pediatric residents and young pediatricians should understand that the level of involvement advocating for children is likely to vary greatly throughout one's professional career. One doesn't always have to commit a large amount of time to be an effective child advocate. One should always select issues that are personally important and narrowly focus time and energy. Pediatric training programs can do a better job preparing residents for this role. Residents can acquire some basic concepts and skills that will help them to contribute to the health and welfare of children in their community without having the benefit of 10 years of networking with colleagues in the business and provider community. Pediatric residents should acquire an understanding of the child advocacy stages through a structured curriculum that includes didactic presentations, seminars using active learning methods, and, if feasible, exposure to the legislative process. Didactic material can be presented at resident conferences and small group seminars and exposure to the legislature can be integrated into required ambulatory rotations such as primary care continuity clinic seminars, behavioral pediatrics, adolescent medicine, or specialty clinics. Residents with a higher level of interest should have the opportunity to spend an elective rotation with an appropriate child advocate mentor to become involved in community service projects and more extensive legislative activities. In addition, the AAP should also expand and strengthen its current advocacy and leadership development programs, especially for young members.