Abstract
Background: Health care professionals are in a unique position to enact health-related social change. Medicine is subject to regulation at the organizational, local, state, and national levels. Federal laws apply to physicians throughout the US; as such, federal policy affects physician practice intentions similarly. However, there is little research on state-level engagement in the political process and none on the participation by family medicine physicians.
Methods: This article examines the nature of physician civic engagement at the state level. Data were gathered and analyzed as part of the 2023 Council of Academic Family Medicine’s (CAFM) Educational Research Alliance (CERA) survey of Family Medicine educators and practicing physicians. We used nonparametric statistics (Kruskal-Wallis tests) to analyze ordinal variables. Categorical variables were analyzed using χ2 tests. We used multivariable ordinal logistic regression to assess the joint effects of participant characteristics on study outcomes and to adjust for potential confounding.
Results: The policy question section of the survey received 709 responses, a response rate of 21%. Our results show a lack of civic engagement, including less than a third voting in state elections and only 4% making financial contributions to political campaigns. Seventeen percent of respondents reported considering relocating due to state health policies. For all questions, we observed variations by geographical region and gender.
Conclusions: Our findings provide a timely analysis of family medicine physician participation in the political process, the effect of specific health policies, and how these policies are comparatively received among family medicine physicians in the United States.
- Advocacy
- Chi-Square Test
- Family Medicine
- Health Policy
- Logistic Regression
- Non-Parametric Statistics
- Physicians
- Social Change
Introduction
The American Medical Association recommends physicians “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”1 One way to fulfill this obligation is through civic engagement with health policy (advocacy). Regardless of practitioners’ political affiliations or personal beliefs, health care professionals have a social contract with society and a professional platform to enact health-related social change, which puts them in a unique position to address policies that prescribe health care delivery as active participation from physicians directly correlates with better proposed and implemented policy measures.2 Physicians are trained to educate and counsel individual patients to make good choices for wellness, but a potentially more significant impact can be made by physicians who advocate and intervene at the policy level.3 In recent years, there have been significant legislative activities at both state and federal levels that directly impact how practitioners care for their patients, including, but not limited to, general education policies, LGBTQ+ topics, abortion access, medical malpractice funding, and gun safety policies such as “gun gag” laws that restrict physician ability to initiate gun safety talks with their patients which are periodically introduced in state legislatures.4 However, there is little research on state-level policy changes, physician practice intentions, and engagement with state-level policy.
We conceived our research question before May 17, 2023, when the Journal of the American Medical Association (JAMA) published a perspective piece describing the “fight or flight” dilemma physicians face with new restrictive state policies.5 The article highlights the dearth of studies on physicians' responses to these legislative actions. Collectively, the authors have been hearing stories of physicians leaving communities due to state-level policy changes. The effect of state-level population health policies and civic engagement on physician practice intentions is a critical question, as there is no research on the connection between health policies, civic engagement, and physician career decisions. We elected to examine family medicine (FM) physicians as our study population because the Declaration of Alma-Ata recognizes the primary health care system as central to achieving health for all.6 It also envisions action on social determinants, individual and community input on health policy and planning, and cost-effective use of resources. Primary care as a subsystem is a broad-spectrum specialty that serves both urban and rural populations. Persons with access to family medicine have better health outcomes with lower costs to the health care system and downstream patient costs.7,8 Where an FM physician intends to practice and when a physician leaves a community have enormous impacts on a community regarding access and economic consequences.9 This article examines the nature of FM physician civic engagement at the state level, contributing information on how physicians engage in political and advocacy initiatives and which policies rank most important in their practice location decisions, as relocating can be a measure of engagement.
Methods
Data were gathered and analyzed as part of the 2023 Council of Academic Family Medicine’s (CAFM) Educational Research Alliance (CERA) survey of Family Medicine educators and practicing physicians. CAFM is a combined initiative of 4 major academic family medicine organizations: The Society of Teachers of Family Medicine, the NAPCRG, the Association of Departments of Family Medicine, and the Association of Family Medicine Residency Directors. CAFM members were invited to propose survey questions for inclusion in the CERA survey. Approved projects were assigned a CERA Research Mentor to help refine 10 questions. Each response option counted as 1 question. The project team worked with research mentors, the survey director, and the CERA steering committee to evaluate questions for consistency with the overall subproject aim, readability, and existing evidence of reliability and validity. Pretesting was conducted with family medicine educators who were not included in the sampling frame, and questions were evaluated for flow and readability.10
Study Population
The CERA survey was conducted between November 20, 2023, and December 22, 2023. The survey was distributed to 3,879 individuals, including 198 non-MD/DO persons. (See Appendix for the Survey Questions) Of these, 155 were returned as undeliverable e-mail addresses, and 49 who had previously opted out of receiving surveys from Survey Monkey were also excluded. The survey was delivered to a final sample of 3,675 members of the CAFM organizations. The survey contained qualifying questions for participation. We removed 275 people who failed to meet qualifications, leaving a population size of 3,400. From the 833 responses to the survey, we removed 16 nonphysician responses and 108 who did not answer any of the policy questions. This resulted in a sample size of 709.
Indicators
We examined demographics and associations between regions and respondent gender. We define health policy as “health goals at the international, national, or local level and the specific decisions, plans, and actions to be undertaken to achieve these goals.”11 We define health advocacy as “Activities related to ensuring access to care, navigating the system, mobilizing resources, addressing health inequities, influencing health policy, and creating system change.”12 For question 7, “How likely are you to relocate to a different state if one of the policies you selected in question 4 changed?” We deliberately left this question open to interpretation as to whether the policy was good or bad. We were more interested in the effect of policies in general and if they influence a provider to leave their current state.
Survey question 10 explored the one activity respondents engaged in that they felt had the biggest effect on changing policy. We categorized the responses as political or advocacy activities. Political activities included voting in a state election, publishing a political opinion, and financially contributing to a political campaign. All else was collapsed into advocacy activities.
Data Analysis
For questions requiring respondents to rank their top 3 choices out of several options, we reordered the ranking scheme so that 3 was the highest priority and 1 was the lowest priority. We gave the areas where the respondents did not select a rank score of 0. This allows us to use typical summary measures (eg, mean, median).
We calculated the number of respondents that ranked the area (1, 2, or 3). We summarized survey responses using frequencies and percentages in categories. We used nonparametric statistics (Kruskal-Wallis tests) to analyze ordinal variables.13 Categorical variables were analyzed using χ2 tests. We used multivariable ordinal logistic regression to assess the joint effects of participant characteristics on study outcomes and to adjust for potential confounding. Percentage differences between groups and odds ratios summarized effect sizes. Findings are reported as statistically significant at 0.05 or below, and two-sided P-values were reported.
We divided the responses into 4 US Census Bureau regions: Northeast, Midwest, South, and West.14 We arbitrarily selected the Midwest region as the comparator for regional comparisons.
Ethics
The American Academy of Family Physicians Institutional Review Board approved the study in November 2023.
Results
We analyzed whether health policy impacts the desirability of practice location and family medicine physician civic engagement. A total of 709 responses to the policy questions were received, with a response rate of 21%. The demographics of respondents are in Table 1: Respondent Demographics.
CERA Respondent Demographics
To assess baseline knowledge, we asked respondents how familiar they were with health policies being considered in their state legislature. Most respondents (84%) were slightly to moderately familiar. Before investigating associations with civic engagement, we asked respondents to rank 3 state-level policies they consider most important out of 6 options, with 1 being the most important. Almost one-half (n = 208, 48%) ranked abortion as a significant policy and gun policies were ranked least important overall (n = 32, 14.7%). While more people identified education as the most important topic, people felt stronger about abortion. Almost one-third of respondents (n = 208, 29.3%) selected abortion as their number 1 priority. Among those that ranked abortion at all, 48% ranked it as number 1. Gun policies were ranked the least important state-level policy. See Table 2 for state-level policy importance.
Importance of State-Level Policies
We observed significant regional variation in policy importance for abortion (P = .019), education (P = .026), and LGBTQ+ (P = .004) rankings. In post hoc analyses, respondents in the West ranked abortion policies more highly, and respondents in the South ranked LGBTQ+ policies significantly lower. We also observed significant variation in policy importance by gender for abortion, education, LGBTQ+, and malpractice rankings. Women ranked abortion (P < .001) and LGBTQ+ (P = .002) more highly than men, whereas men rated education (P = .008) and malpractice (P < .001) policies more highly than women. Abortion and LGBTQ+ rankings remained significantly different with adjustments for both gender and region.
Civic Engagement
Providers engage in various activities that fall under “political” or “advocacy” initiatives (See Table 3: Civic Engagement). We first analyzed regional activities to see what practitioners do in these realms.
Respondent Civic Engagement Activities
Women and men were engaged in policy and advocacy at similar levels. The Midwest region is the most active (highest N value) in advocacy (n = 126, 57%) and policy initiatives (n = 95, 43%). The Northeast region is the least active (lowest N value), with 68% engaged in advocacy (n = 82) and 32% engaged in political work (32%). Respondents in all regions were more engaged with advocacy (n = 437, 62%) than politics (n = 272, 38%).
Policies and Practice Relocation as a Measure of Civic Engagement
Nearly 1 in 5 (17%) respondents stated they had considered relocating to a different state due to current or proposed state health-related policies. This sentiment varied significantly by region, with Southern (45%) and Midwest (33%) respondents reporting higher sentiments than Northeastern (8%) and Western (15%) respondents (P < .001). Women respondents reported considering relocating more than men (19% vs 13%, P = .048).
We also asked respondents to rate their likelihood of relocating to a different state if one of the policies they identified as important changed. We observed significant differences in the likelihood of relocating to a different state if the most important policy they identified was to change (P < .001). No group expressed a high likelihood of relocating. Respondents identifying abortion, guns, and LGBTQ+ as their most crucial policy were all neutral (median, 3), and those who identified education, insurance, and malpractice were unlikely to consider relocating (median, 2).
Discussion
Voting as a Political Activity
Our results show more participation in advocacy than political initiatives. Voting can shape public policy which affects population health and clinical practices. For example, gun policies were ranked the least important, yet gun safety laws improve population health.15 Although participation has increased over the last decade, physicians at the federal and state level vote at about the same or lower rate as the general population.16⇓–18 Our results found similar findings, with slightly less than one-third of respondents voting in a state election. Reasons for this have been cited as lack of time, not being registered to vote, and work conflicts.16 The American College of Physicians has a policy “opposing limiting polling hours and locations and attempts at partisan gerrymandering, which can contribute to low voter turnout, particularly among members of historically marginalized populations.”19 Individual physicians have created unique pathways to encouraging health care systems to integrate voting registration into health care visits.20 While these initiatives may increase patient voting, there is a lack of information in the literature on improving physician participation. We recommend extending polling hours, having polling places colocated in or near health care systems, and researching what methods work in various contexts, including whether formal training improves engagement in the political process.21
Advocacy Training and State-Level Policies
Multiple facets, including health policy education, engender civic engagement. Similar to our findings, formal advocacy training is rare among practitioners, although advocacy teaching requirements have been increasingly implemented in graduate medical education.22,23 Our results suggest that physicians receive health policy training more commonly outside formal medical education, reinforcing existing limits on physician education and comfort with engaging in politically polarizing topics such as abortion.24,25 The ranking of abortion/education as an important state-level policy may be linked to the care family physicians provide for women and children, similar to how pediatricians have noted the value of advocacy for adolescents given their context of care.26
Relocating as Advocacy
Relocating (or not) due to state policies can be a measure of civic engagement. Numerous studies have found that physicians base their practice location considerations on medical or residency education, employment opportunities for significant others, and personal background characteristics.27⇓⇓–30 However, to our knowledge, no studies have examined potential links between specific policies and a desire to relocate. Our results show a limited effect of state-level health policies on physician migration. However, there were regional and gender differences in the consideration of relocation. In addition, an examination of the National Provider Identifier Directory has shown that younger physicians are trending toward the left politically and that political orientation can determine employment location in rural versus urban locations.31 While our results were limited to family medicine physicians with an average age of 45, many still practice obstetrics and gynecologic care, and the higher relocation sentiment in Midwestern and Southern states aligns with changes in matriculating resident physicians. Graduate Medical Education match data supports such sentiment, as during the 2022 to 2023 year, the Electronic Residency Application Service (ERAS) reported a decrease in Obstetrics and Gynecology applicants by 5% nationwide. That number decreased by 10% in States with complete abortion bans.5
Limitations
Although we have over 700 responses, the study's main limitation is the low response rate, which may not reflect the sentiments of all FM physicians. In addition, this analysis was limited to academic physicians and did not focus on specific policies. Our respondents' average age is 45, and our results only partially represent this changing demographic regarding the desire to relocate. Another limitation of our study is that leaving policies open to interpretation as “good” or “bad” may weaken associations. Regarding activities engaged in, some respondents may have interpreted the question as asking, “which do you believe had the greatest impact?” without knowing the actual impact. In contrast, we were interested in what activities respondents had participated in and considered important to impact policy.
Respondents might have recall bias as we asked respondents to reflect on past intentions and activities. In addition, there is a difference between intent and actual behavior. Finally, the authors acknowledge that it may have been better to phrase gun policies as “gun safety” rather than “gun control,” and the topic of abortion might have triggered strong reactions and may have contributed to a low response rate. Some statistical procedures may not be valid within the analysis since all the zeros highly skew the data. It is also important to note that our results are limited to Family Medicine physicians. Policy issues, advocacy, and political activities may differ among physicians of other specialties.
Conclusion
Our findings provide an analysis of civic engagement by family medicine physicians nationwide. Future research should explore additional specialties and their engagement with state-level policies and methods to increase physician participation in policy and advocacy. Increased physician engagement could provide doctors a pivotal voice in shaping state-specific legislative health policies, providing a catered approach to treating suffering and contributing to overall well-being, an obligatory and moral responsibility for physicians.
Acknowledgments
The authors thank Frederick Chen, MD, MPH, American Medical Association, for guidance in developing the research questions.
Appendix
Appendix CERA Survey Health Policy-Specific Questions
1. How many years have you been in practice?
Less than 1 year
2 to 5 years
6 to 10 years
10+ years
Retired
2. Have state health-related policies ever influenced where you chose to practice?
Yes/No
3. In the last year, have you considered relocating to a different state due to current or proposed state health-related policies?
Yes/No
4 to 6. Rank the top 3 following policies impacting your practice that would make you consider relocating to a different state (1 being most important and 3 the least important)
Abortion policies
Education policies
Health insurance coverage policies
Gun control policies
LGBTQ+ policies
Malpractice policies
7. How likely are you to relocate to a different state if 1 of the policies you selected in question 4 changed? [relocate_policy_change] Likert Scale Questions:
1 – Extremely unlikely, 2 – Unlikely, 3 – Neutral, 4 – Likely, 5 – Extremely Likely
8. Please identify the primary source of your health policy training. (1 response only)
Medical School Curriculum
Residency Curriculum
Continuing Medical Education
Non-MD degree that prepared you for policy/advocacy work (MPH as an example)
Nonmedical work experience
Training outside of formal education
Never had training
Unsure
9. How familiar are you with health policies being considered in your state legislature? Likert Scale Questions: 1 – Not at all familiar, 2 – Slightly familiar, 3 – Somewhat familiar, 4 – Moderately familiar, 5 – Extremely familiar
10. Which of the following activities have you engaged in that you believe has had the greatest impact in influencing policy. Choose 1 response only.
a. Voted in a state election
b. Gave testimony to policy makers
c. Participated in health policy discussions within my organization
b. Participated in research evaluation of health policy (at the assessment, implementation, or outcome stages)
e. Participated in health policy-related protest demonstrations (eg, sit-ins or marches)
f. Joined a local, state, or national professional society
g. Reviewed a health policy for a decision-maker
h. Drafted a policy with health implications (school level, organization, city, state, etc.)
i. Published a political opinion (social media, editorial, blog etc.)
j. Made a financial contribution to a political campaign
Notes
This article was externally peer reviewed.
Funding: None.
Conflict of interest: The authors have no conflicts of interest to declare.
To see this article online, please go to: http://jabfm.org/content/38/3/610.full.
- Received for publication November 17, 2024.
- Revision received January 22, 2025.
- Accepted for publication January 29, 2025.
