1. Cherry Cockrell, MD Mercy Family Medicine June 2017
Advocacy
I have had a long interest in advocating for causes that matter to me. The desire to advocate is part of what led me to family medicine and one of my career goals is to be an effective advocate for my patients, my profession and my community. I’m trying to learn how to do this as a resident, and towards that goal, completed an elective in Advocacy and Leadership. My current advocacy pursuits include advocating for the continued insurance coverage of under-served populations and advocating for/promoting resident and physician wellness.
As part of my elective, I had the opportunity to participate in FM Advocacy Day in Jefferson City, at the state level, and in Washington DC at the national level last month.
Today I will share with you some of the things I learned.
Cherry Cockrell, MD
Mercy Family Medicine
June 2017

2. What Does It Mean?
Advocacy: the act or process of supporting a cause or proposal, the act or process of advocating something
Advocate: one who pleads the cause of another, one who defends or maintains a cause or proposal
Let’s start with the basics.
The Merriam-Webster definition of the word “advocacy” is: the act or process of supporting a cause or proposal, the act or process of advocating something.
Comes from 14th century word “advocate” which means:
One who pleads the cause of another, one who defends or maintains a cause or proposal
One who supports or promotes the interests of a cause or a group
Hopefully, this is sounding familiar to everyone….

3. Family Physicians = Advocates
Why Does It Matter to US?
Family Physicians = Advocates
We advocate for:
healthy lifestyles to our patients
medication compliance to our patients
our patients needs to their specialists and their insurance companies
our vulnerable populations to their caregivers
Because, we do this every day.
Even if you don’t think of yourself as someone who “takes on causes,” you are ALREADY an advocate.
As part of our daily work we perform many tasks of advocacy, including…
Promoting not just healthy diet and exercise, as well as public health measures like vaccines and screening tests.
Advocate for patients to do their part by being compliant and coming to office visits.
Advocate for the needs of our patients: coordinating specialist care, doing prior auths and peer-to-peer (yes, advocacy can be very mundane).
Advocate for pediatric patients to their parents, disabled patients to their caregivers, and elderly patients to their families. As physicians, we are charged with protecting and promoting the interests of these patients—THAT IS ADVOCACY, by literal definition. It is part of our job duty.

4. Advocacy: the broader sense
Advocating for patient populations
Community programs, school clinics, free clinics
Legislation affecting public health
Advocating for family medicine physicians
Within our professional organizations
Legislation affecting:
insurance and reimbursement
physician licensure
health care delivery models
the physician training process
While we do many, daily small acts of advocacy, we can be even more effective for our patients by advocating on a broader scale—what does that look like?
There’s 2 primary groups that can be affected broadly by our advocacy
Advocating for patient populations on a community-wide level, including starting community public health initiatives and establishing accessible clinics but also trying to influence legislation that affects public health.
Also advocating for ourselves and our colleagues, either within our professional organizations, such as promoting CE, wellness, etc and influencing legislation that affects our work.

5. Advocacy at the Legislative Level
Advocating at the legislative level is a powerful way to effect change and promote the interests of our patients at a high level
Health care legislation has impacted:
Basic insurance coverage: The ACA, the repeal of the ACA, the AHCA
Medicare, in its entirety
Pharmaceutical coverage: Medicare part D
CHIP: health care coverage for children
Mental Health Care Coverage
Decriminalizing drug overdoses
Mandatory seat belt and helmet laws
Criminalized intentional HIV exposure
Funded residency training positions
Affected physician reimbursement: Medicare price-setting
Which brings me to: advocating at the legislative level. This is the biggest bang for buck as an advocate. On a daily basis, we help 1 patient at a time, when we advocate at the legislative level, we have the opportunity to affect the health of whole patient populations, up to thousands (or millions of people). That is not hyperbole. Apx 16 millions Americans gained health insurance with the ACA, something that physicians supported.
Not convinced?
Here are a few of the things that health care legislation has impacted.

6. SO….YOU WANT TO BE AN ADVOCATE!!
…Now What?
TALK TO YOUR LEGISLATORS
Think LOCAL: start with your local representatives.
Everyone has a district representative and senator at the state level
They all have local offices in their districts
Send letters and s
Make phone calls
Visit in person
Hopefully I’ve convinced you that this is important, does have bearing and is part of our job. Hopefully, even the most reticent among you now wants to step up and advocate at the legislative level.
BUT….you don’t know how. That’s fair. The US legislative structure is multi-faceted, surprisingly opaque and daunting. School House Rocks makes it seem so straight forward but in real life, many of us have no idea where to start when it comes to advocating for and promoting causes that matter to us.
Advocating, like many aspects of health care, comes down to people.
It’s time to start approaching your legislators.
Start locally, with your state representative and/or senator. Visit their offices, talk to their staffers, if possible, meet them! You are their constituent and have a right to make them aware of what matters to you. Representing you and your interests is part of their job. DO NOT BE SHY ABOUT ASKING FOR THEIR TIME.

7. What Do I Say to a Senator?
It’s common to feel intimidated by legislators due to their positions and perceived power
When it comes to healthcare, YOU are the expert in the room
Make clear, concise points
Don’t use medical jargon
Treat all their questions seriously
Tell them about your patients
Ties a face to the cause
Gives meaning to your request
It’s REALLY common to feel intimidated by people in these powerful positions. They are seen as authority figures and due to their position are given credit for being experts on a lot of things that are far outside their area of expertise. Most legislators are attorneys or business people, and even if they work on health care legislation, they aren’t experts in the field. There are a handful of physician legislators, so most of the time, when it comes to healthcare, the physician in the room is the expert.
They may know literally nothing about the medical or health care related cause for which you are there.
So, start basic, be clear, don’t assume they know what you are talking about and build up if they make it clear that they do.
Don’t use medical jargon—it’s a bad idea to run the risk of making the person whose support you are seeking feel stupid.
Also, don’t think they don’t want to hear from you—smart legislators value expert opinion as it helps them make informed debates and stronger bills.
And the most important thing to do when talking to a legislator about health care legislation: help them get to know your patients.
Telling patient stories gives faces, names and emotional ties to things.

8. Tell a story Make it emotional
Cause some distress for the listener by creating a conflict for the patient
This captures their attention
Connect them to the person in the story: common ground
Tell a story that’s representative, not extreme
Talk about the person at the end of the pipeline
Pair a logical argument with the story
Make your request or “ask”
Ground emotion in policy
1-5 min increments
Individual stories provide legislator with ammunition
The advice I heard at this conference over and over was: tell a story.
Talking to a legislator about the PDMP is boring, nobody gets worked up about a database. But when you talk to them about your patient that overdosed because 2 different doctors were prescribing opioids and benzodiazepines and now her kids are being raised by their aunt—that pulls at heart strings.
Find a way to connect them to the person in the story—they are dad, your patient is a dad. They are an entrepreneur, your patient is an entrepreneur struggling to afford health care insurance for his kids.
Talk about the person at the end of the pipeline: who gets hit by the downstream effects—maybe the entrepreneurs kids whose dad can’t coach their baseball team if he has diabetic neuropathy because he can’t see a doctor and get care due to being uninsured due to a prior condition.
Pair a logical argument with the story: maybe they don’t care about your patients neuropathy or his kids feelings. But they do care about what that guy’s health will cost them when he has an MI and is in the hospital for a prolonged period then loses his job due to missed work then can’t pay his mortgage and has to go on welfare. Logical argument: helping this guy on the front end will cost them less on the back end. Great argument for universal coverage.
Now they are primed for your request: their heart’s in it because of your story, they are convinced by your impeccable logic, they are buttered up. Anchor your story back to the policy to close the loop.
Also: try to be able to do this in 5 minutes or less. REHEARSE YOUR STORY. Speaking with a Senator is not the time for improv.
Bear in mind that the legislator might actually already support your bill or your cause. In which case they don’t need convincing, they need ammunition to convince their fellow legislators. They can take your patient stories and repeat them!

9. Pixar formula Once upon a time, there was… And every day….
Until 1 day….
But bc of that…. (repeat)
Until finally….
And then happily every after
I learned this from a lobbyist: use the pixar formula. Pixar people are master story-tellers
Once upon a time, there was….(an uninsured woman whose grand-daughter had cancer)
And every day...(she helped care for her grand-daughter and home-schooled her while she got treatment)
Until 1 day….(the woman had chest pain and was really scared she was having an MI)
Because of that….(she was motivated to get on the exchange and sign up for health insurance) --repeat this step as needed
Until finally….(she saw a new PCP and had an EKG and ECHO that were normal)
And then they all lived happily ever after! (and her grand-daughter went into remission)

10. Trouble-Shooting The Elevator speech: “walk me to the elevator”
“I agree, but….”
This is very common
It’s a non-committal but affirmative response
The “but” is NOT your problem to sovle
“I disagree”
Here, you have the opportunity to ask why
Do they really disagree with the root of your cause?
Do they take issue with your proposed policy?
Or do they disagree due to politics?
Listen carefully, don’t dismiss, don’t negotiate
So some common scenarios you might encounter when talking to a legislator:
Why don’t we talk while I walk to the elevator? This is when having rehearsed a 3 minute presentation is key!
The “I agree, but….”
This allows a legislator to agree with you but not commit to your request. The reasons they feel they can’t accommodate your request are NOT your problem, you are not obligated to find a solution to their dilemma. If they want to support your cause, they will find one.
The “I disagree.”
This is less common. Legislators don’t want to outright disagree with their constituents.
If they outright tell you they disagree or can’t support your request, use this as an opportunity to find out why. What’s at the heart of their refusal?
Are you trying to secure funding for pregnancy termination and they are pro-life? That would be a value-based disagreement.
Or do they disagree with your policy proposal? Such as the PDMP debacle in MO? (everyone agrees decreased controlled substance prescribing is a good idea but are at odds over how to go about accomplishing it)
Or is their refusal political in nature? You want to increase the tobacco sales tax but the tobacco PAC funds their campaign.
If they will talk to you about why they are in disagreement with you, find a way to be grateful for their honesty. Listen to them, don’t dismiss their points and don’t try to negotiate. They have said no. Offer to be available to them should they ever want to discuss it further. They will appreciate this response more.

11. RELATIONSHIPS Legislators trust the people they know (like all of us)
The squeaky wheel gets the oil
Develop relationships with legislators and their staffers
Find a way to connect: look for commonalities
Children (or pets)
Hobbies: everyone watches something on Netflix
Sports teams: Cardinals, anyone?
Relationship at the state level is VERY important
Give financial support
Follow up: aim for quarterly
ALWAYS SEND A THANK YOU
A hugely important factor in the success of your advocacy efforts is having a relationship with your legislator.
As family medicine doctors, we understand the importance of having a relationship and continuity with someone. It’s no different with a legislator than it is with a patient.
They trust the people they know and the listen to the constituents they hear from over and over on specific issues.
Develop relationships with legislators AND their staffers.
Their staffers hold the key to their schedules. It’s like when patients are nice to us and rude to our staff.
Look for commonalities: start with an introduction, tell them more about yourself than just your “cause,” then talk about your cause and do your advocating, then circle back to something you have in common. Get to know THEM, they will feel valued.
Advocating at the state level is very important. Your local legislators and their staffers are the most accessible to you and have the most in common with you in terms of geography. These people should be easiest to get to know. Eventually, when you want to move your advocacy efforts up to the national level, your friends at the state senator’s office may be able facilitate that.
If you can, give financial support—though not necessary, I’d be lying if I told you money doesn’t grease the wheel. It does.
FOLLOW UP: calling once or going by once is not enough. Follow up a few times a year: not so much that you’re creepy, but enough to develop a friendship (in as sense)
Also—this relationship stuff, works. My dad became friends with a state senator in OK through local leadership stuff and a state rep whose daughter was in cheerleading with me and wound up having legislators who would propose legislation that was pro-optometry. OK is now one of the most optometrist-friendly states.
Follow up every conversation and meeting with a thank you. It keeps you on their radar and frames you in a nice way.

12. Diversify Your Advocacy
campaigns
Phone calls from VIPs
Constituent visits
Town hall visits
“Coffee with a Congressman”
Letters to the Editor: get it in print
PAC activities and fundraising
Diverse advocacy is the most successful advocacy.
Hit it from more than one angle to really emphasize the significance of your cause and to make the legislator aware that you aren’t the only constituent that cares about it.
Do this with campaigns
If you have a “VIP” that supports your bill, have them call the legislator.
Empower other constituents to make visits. When patients complaint about recent health care legislation, I tell them where to find the name of their rep and their office info.
Try to arrange town hall visits through the legislator’s office. This is a great opportunity to open dialogue and help your legislator learn why your cause is important.
Senator Blunt does Coffee with A Congressman once a month. Any constituent in DC is welcome to attend.
Write “Letters to the Editor” in your local paper. If you can, name the legislator whose support you are seeking. Every representative and senator’s office has a “media surveillance” staffer who checks papers for articles containing their employers’ name. Those articles get clipped and saved and your name gets put in a database of constituents who have written about them. You now have name recognition in that office. That being said, be careful what you write.
Arrange PAC activities for fundraising and obtaining campaign donations—this goes back to furthering the relationship

13. Will It Work? Diverse advocacy is the most successful advocacy but…
Best predictor of success of policy change is support at multiple high levels
Support of high level legislators
Support of high-ranking party leaders
Support of high level officials
BE PERSISTENT: what you are doing matters
“Success is going from failure to failure without a loss of enthusiasm”
“Success is not final, failure is not fatal, it is the courage to continue that counts”
“Never, never, never give up!”
So a diverse advocacy strategy is the most likely to be successful but the best indicator that your policy change will be successful is a lot of high level support. Basically, you want the support of someone whose name you hear on NPR a lot. This includes high-ranking party officials (such as the head of the DNC), high level legislators, such as the speaker of the house or senate pro tempore, and high level officials, such as the attorney general, the VP, or at the state level the governor.
And finally, a few quotes from one of my personal heroes, Winston Churchill, who I look to for inspiration when doing things that scare me but which I feel to be right such as advocating and talking to senators.

14. References
“Advocate." Merriam-Webster.com. Merriam- Webster, n.d. Web. 5 June 2017.
STFM Online Classroom: Advocacy
AAFP Family Medicine Advocacy Summit
Guest speakers:
Flora Sadri-Azarbayejani, DO, Chair of AAFP Commission on Governmental Advocacy
Ellen Brull, MD, FAAFP, FamMedPAC Board of Directors
Cliff Johnson, Practice Leader, National Journal
David Lusk, CEO, Key Advocacy
Representative Ami Beri, MD (D-CA)