Advocate System Versus System That Does Not Need Advocates

A recent conversation with my friend Peter Fielding, a doctor who lives at our retirement community about patient/client advocates led to some interesting conclusions for both the medical and legal worlds.

When Peter and I discussed the fact that some medical patient and family caregivers councils have set as a goal having a patient advocate for each patient, he said, in effect: “No, you want the system to be so good that nobody needs an advocate.”  His point was that if you give everyone an advocate you take away the incentive to improve the system.  You just fix each problem as it occurs.

We in the legal system, are in a very different place.  We have build a system that assumes that everyone has an advocate, but then made it so that only a small minority can afford one.  That’s the worst of all worlds.

So, we are trying to do four things:  change the system so that as few people as possible need advocates, find the resources to pay for those who need them even in the transformed system, build ways that less highly trained, and therefore less expensive people, can perform some of the advocacy, and, critically, design good systems that decide who really does need an advocate, and what kind of advocate, even in a reformed system.

Back to the medical system, therefore, the questions become:  How can one design a system that behaves so that as few people as possible need an advocate, how can one identify the tasks and situations in which patients still need advocates, how can we provide advocates, with what skills in those situations, and how can those advocates be trained and connected to the system so that they provide the feedback and information that allows the system to even further reduce the need for patient advocates.

In a way, the analog to the last point would be, in the legal system, having part of the role of lawyers be to support the reduction of the need for lawyers.  It’s sort of like the role of dentists in promoting fluoride.

In a way, it is what the legal self-help services movement, and the Self-Represented Litigation Network do.


Peter adds:

This is a thought starter piece. If we were to pursue the topic we would need to define Advocate and why / for what purposes they may be needed: Technical issues; emotional support ; checking function about treatment details and timing; hotel functions in hospitals; violations of individual autonomy; poor doctor /patient relationship issues and so on. This list of the  “ Surveillance Domains” could be quite long.

Clearly we would need a “Systems approach” to mitigate the need ( or some of the need) for Advocacy: probably the most important being the setting of standards which would form the basis of education:  self-correcting / self-flagging  methods of data recording ; blame free cultural development ;  putting patient needs first ; policy and procedures for Quality Improvement ,  error correction ,and in more critical issues methods and experience in conducting Root Cause Analysis.

Assuming that there will continue to be a need for Patient Advocacy should such a person come to the event/situation on the arm of the patient or should it be the institution which provides independent patient navigators and advocates in support of the usual declared aspiration of “ providing the highest standards of care “.

In practice most hospitals , PCP groups, and other health care organizations have a hard time just keeping up with clinical and bureaucratic demands which are currently placed on their shoulders.

So how can we get enough “ blue sky” to think about ,implement, and then manage such a big task ? A challenge indeed.

Peter Fielding




About richardzorza

I am deeply involved in access to justice and the patient voice movement.
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6 Responses to Advocate System Versus System That Does Not Need Advocates

  1. Claudia Johnson says:

    In law, we need a ladder of services and licences (with required tests and educational requirements) that break down the different specialty services in law–akin to X Ray technician vs. Radiologist, Physician Assistant vs. Internal Medicine, ultra sound technician vs. ob/gyn. I have not thought enough about this to know if in medicine the sub specialties that don’t require 4 years of medical school and 3+years of post med school interniships are sorted by the type of equipment/and chemicals being used. Maybe the licencing/educational requiremetns would yield some light onto how different states set those requirements.

  2. Claudia Johnson says:

    I think the word “advocacy” needs definition–as they mean different things in the 2 different contexts. Advocay in the medical situation might be what we call a “support role/person” in medial settings–like helping the patient get to the procedure and get home safely, helping the patient ask all the questions before a procedure, helping the patient explain the medical billing practices, and privacy practices, etc. The medical services–are peformed by professionals licenced in different tiers–nurses, nurses who can prescribe (psych meds and non psych meds), people who can do some medical tasks and not others.

    In law, the word advocacy is broadly defined–and it could mean actual lawyering tasks–which include legal writing, appelatte writing, oral advocacy, preparation for a trial or admin hearing, researching the law and coming up with theories for a case and strategy, evidence, code review, case law review, and the like. It can also mean advocacy in the support role way–helping the person file for protection and collect the evidence to share with the DA or DV court, helping the person find legal services, going with someone to a trial as a support person, helping draft materials for review by an attorney etc.

    In the legal context, we only have two licencing modes: lawyer and non lawyer–so we don’t have the layers of professionals that can do different level of professional services that exist in health care, like registered nurse with right to do prescription, dental hygeniest, X ray technician to take the pictures/images with specific equiptment, radiologist to interpret the X ray, physician assistant, internist, oncologist, therapist, etc etc. We are developing some new professional non attorney categories–in WA and in NY, but we still don’t have the depth of non attorney caterogies that break down skills, tasks, by education and training level. So we need to start developining a category of non lawyer advocacy roles–that can suppor people as they move through the legal process and across forums (not just courts but also before courts) –that go beyond scribner and trial support person–but get to other tasks that can be safely be performed by a non attorney given certain training and conditions.

  3. George Chandler says:

    I think you’re right on. We built a system that not only requires and advocate, but one that only serves the advocate.

  4. Isabel Field-national child advocate says:

    Data correcting,flagging needs upkeep, yes, as does data ‘acceptance’, or data recieving.
    I am thinking third parties such as data from government sector, and even from Non for profit organisations.
    Law, is, in the main very simple. The fees are not justifed. The legal industry could cut their bluff and pompsity, and seperate into lower waged , medium waged and higher waged groups.
    Personally, I reckon anyone that can add and subtract, and is a reasonable person, and upright, can manage easily. I have had more success using plain old commonsense, than perhaps all else.

    Some media using groups do howl when they see their ‘luxury’ life at risk. #lol

  5. David Udell says:

    In medicine, patients advocate against system. In law, litigants advocate against each other. The difference requires additional analysis, I think.

    • Isabel Field-national child advocate says:

      I see an enormous amount of persons advocating against the legal system, in addition to advocating against another, both in the Courtroom during hearings, as well as outside the Court. I have seen many self represented doing that, as well as Lawyers, and also numerous Judiciary.
      It could be that I am more likely to have seen, or heard this because of the types of issues I am interested in, as well as it occurring because I was listening ( opportunistic by others)

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