Emergency Medicine Advocacy Handbook

Ch. 20. Building the Winning Message

Christopher Kuhner, MD

Chapter 20. Building the Winning Message

Recorded by Monisha Dilip, MD | Yale University School of Medicine

Effective advocacy is contingent upon being able to communicate well. Framing a clear straightforward message is important in being able to get your point across.

What does a winning message include? Sometimes it’s human-interest stories, sometimes it’s data. Come with both.

Why It Matters to EM and ME

Emergency physicians are the champions for our patients – both inside and outside the ED. But to be effective, we must be able to form clear messages that are simple and persuasive. This will serve us well when it comes to the interests of our patients, our peers, and our own careers.

How We Got to This Point

Advocacy is at the core of emergency medicine as a specialty as early EM physicians had to advocate for the creation of the specialty. It was not until the right message reached the right people at the right time that years of effort paid off and the American Board of Medical Specialties established emergency medicine as the 23rd specialty.¹ Persistent, effective messaging has been baked into the fabric of EM ever since, from clear and focused patient presentations to advocacy efforts that led to the creation of EMTALA.^2,3 In fact, it is so important it was written into of our professional obligations. According to the ACEP Code of Ethics for Emergency Physicians, emergency physicians have an ethical duty to promote population health through advocacy and to participate in “efforts to educate others about the potential of well-designed laws, programs, and policies to improve the overall health and safety of the public.”⁴

Current State of the Issue

It is our duty to stand up for our patients, our specialty, and ourselves. But persuasive communication is no mean feat in the 21st century, when the average attention span is less than 1 minute.⁵ Let’s think of the winning message as the perfect combination of who, what, when, where, and why.

Who

A key element of effective messaging is getting in front of the right audience. Make sure you know who represents you – and what committees they serve on. It is also important to ensure they have jurisdiction over the issue, meaning if it is a state-level issue, do not ask your congressional representative at the federal level to help solve the problem. While working with the member is often an early advocate's goal, the legislative staff members are powerful advocates (think of them as the office’s program coordinators) and can be the thought leader in the office on a particular subject. Lawmakers want to hear from their constituents and from subject-matter experts, but their time is limited. You will almost always start by speaking with the staff who want to hear from you. You can find them easily:

• Federal offices (both Senate and House): https://www.congress.gov/
• State legislative sites: https://www.congress.gov/state-legislature-websites

While it’s important to speak to the right people, it is also important to understand that the same message delivered by different people can have a different effect. As a physician, your voice carries weight. A survey of legislative assistants reported that 90% of physician lobbyists were either very effective or somewhat effective — and, in the words of one legislative assistant, “should recognize the power they have to influence Congress.”⁶ Moreover, within the current health care system, emergency physicians provide a disproportionate share of the care for the underinsured and can speak to their challenges far more than other specialties.⁷

Partnering with supportive organizations such as EMRA, ACEP, AMA, or a local grassroots network can add the legitimacy of a trusted source and weight of popular opinion to your issue. The more front and center an issue, the more likely legislators are to respond and act. Additionally, these professional organizations may have already laid the groundwork to present your issue. Their government affairs staff may have established relationships with legislators and can help refine and tailor your arguments.⁸ They can offer contacts to like-minded interest groups and lobbyists. Inviting stakeholder groups to participate in your effort can earn valuable allies, bolster support, and facilitate passage of a bill. Just as modern medical paradigms incorporate a health care team with a physician as team leader, various members of a lobbying team bring diverse knowledge and skills to the table, resulting in more effective advocacy.⁹

What

What does a winning message include? Sometimes it’s human-interest stories, sometimes it’s data. Come with both. A renowned example of this occurred during the debate about patient dumping, before EMTALA became law. After plentiful data had been submitted and discussed, Dr. Arthur Kellermann dumped hundreds of patient wristbands onto a table to visually illustrate the human toll of patient dumping — creating a pivotal point in the debate.^2,3 Emergency physicians may be governed by data, but politics is often governed by the human story and personal impact. Do not hesitate to get personal and share the challenges you see on your shift on an issue; it is the stories they will retell in a speech, not the data.

When

Effective messaging is rarely a one-and-done endeavor. Marketers adhere to the “Rule of 7,” which holds that an audience needs to be exposed to a message seven times before they’ll take action.¹⁰ Digital media – from websites to automated messaging to social channels – makes it at once infinitely easier to reach people and infinitely more difficult to make your message stand out in the noise. But macro messaging is not enough. Make it personal. Establish direct contact with your elected officials. Reach out to staff who are responsible for the daily office activities. Utilize local, state, and federal websites to get names and contact information. Then keep in touch when legislators hold town halls, seek constituent feedback, and when policy concerns arise.

Notably, ACEP holds a Leadership and Advocacy Conference every spring, designed to help you learn how to craft a winning message, not only for federal issues but also at the local and state levels. The conference also allows participants to network with others interested in advocacy and go to the hill to practice delivering their message.

Where

Another key component of a winning message may surprise you: location. A randomized trial conducted by a lobbying firm found that state lawmakers who were socially lobbied –approached outside of a formal office setting – were more likely to be supportive, and a subsequent survey of registered lobbyists found social lobbying to be a common occurrence. “Political elites are influenced by the social environment; interest group direct lobbying is influential when conducted in places not easily observed by the public.”¹¹

Why

As physicians, we are taught to focus on objective data to make decisions. However, scientific evidence alone is not enough for effective messaging. You must tell people why they should care about an issue. Tragically – as seen during the COVID-19 pandemic – “for the greater good” is no longer a convincing reason for a significant segment of the population to care. Bring them more. Make it personal.

The policy world is complex, and scientific evidence is unlikely to be conclusive in making decisions. Timely qualitative, interdisciplinary, and mixed-methods research may be valuable in advocacy efforts. The potential impact of evidence can be increased by “packaging” it as part of knowledge transfer and translation. Increased contact between researchers and policymakers could improve the uptake of research in policy processes. Researchers can play a role in advocacy efforts, although health professionals and disadvantaged people, who have direct contact with or experience of hardship, can be particularly persuasive in advocacy efforts.

Different types of advocacy messages can accompany evidence, but messages should be tailored to the target of the advocacy. Several barriers hamper advocacy efforts. The most frequently cited in the academic literature are the current political and economic zeitgeist and related public opinion, which tend to blame disadvantaged people for their ill health, even though biomedical approaches to health and political short-termism also act as barriers. These barriers could be tackled through long-term actions to raise public awareness and understanding of the SDH and through training of health professionals in advocacy. Advocates need to take advantage of “windows of opportunity,” which open and close quickly, and demonstrate expertise and credibility.

Moving Forward

Effective messaging will be important at every phase of your career, whether you’re advocating for your patients or for yourself. Knowing the key decision-makers, being familiar with the legislative process, and becoming effective in communicating with the parties who influence that process will make you a success.

• The winning message is a combination of who you approach, when, where, and why.
• Be ready to repeat your message multiple times, in multiple ways.
• Join forces with your colleagues in organized medicine for a more impactful presence.
• Establish and maintain regular contact with your representatives and their staffs.

References

1. ABEM History. American Board of Emergency Medicine. Accessed at https://www.abem.org/public/about-abem/abem-history.
2. Equal Access to Care: Patient Dumping, Record of Testimony. ERIC. Accessed at https:/files.eric.ed.gov/fulltext/ ED297237.pdf.
3. University of Washington. Arthur Kellermann: I’ve saved more lives with public health work than in the emergency room. Accessed at http:/sph.washington.edu/alumni/profile.asp?content_ID=1648.
4. Policy Statement 2017: Code of Ethics for Emergency Physicians. ACEP. Accessed at https://www.acep.org/globalassets/new-pdfs/policy-statements/code-of-ethics-for-emergency-physicians.pdf.
5. Mark G. Attention Span. A Groundbreaking Way to Restore Balance, Happiness and Productivity. New York NY: Hanover Square Press; 2023.
6. Landers SH, Sehgal AR. How do physicians lobby their members of Congress? Arch Intern Med. 2000;160(21):3248-51.
7. Hsuan C, Horwitz JR, Ponce NA, Hsia RY, Needleman J. Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions. J Healthc Risk Manag. 2018;37(3):31-41.
8. Hemphill RR, Sklar DP, Christopher T, Kellermann AL, Tarrant JR. Emergency medicine and political influence. Acad Emerg Med. 2009;16(10):1019-1024.
9. Christoffel KK. Public health advocacy: Process and product. Am J Public Health. 2000;90(5):722-726.
10. Kelly K. At least seven touches: One academic library’s marketing and outreach strategy for professional programs. Pub Serv Quarterly. 2017;3:200-206.
11. Grose CR, Lopez P, Sadhwani S, Yoshinaka A. Social lobbying. J Politics. 2022;84(1).