Members of the advocacy culture find meaning primarily in the establishment of equitable and egalitarian policies and procedures for the distribution and use of health care resources within the system. Members of this culture firmly hold assumptions about how to organize for maximum effectiveness. They emphasize negotiation and compromise, the establishment of solid power bases, the forging of alliances, and the provision of convincing evidence for their point of view. Any organizational strategy that is to be accepted by this culture must address the anxiety associated with social disruption and must consider politically based strategies. As in the case of the alternative culture, the advocacy culture has served usually as a counterpoint to the managerial culture, and to a somewhat lesser extent to the professional culture.
Members of the advocacy culture tend to value both confrontation and compromise. They encourage fair bargaining among constituencies with vested interests that are inherently in opposition. These conflicting constituencies may be management and staff, or, at a broader level, the healthcare institution and potential health care consumers. Advocates tend to hold assumptions about the ultimate role of power and the frequent need for outside mediation in a viable health care system. People from this culture have the authority to touch the whole of the health care system through social policy development.
Historically, prevention has been of primary concern to advocates. Beginning with the attempts to clean up city streets and continuing through the recent efforts to clean up our global environment, the attention of most advocates has been focused on prevention rather than amelioration. Prevention is intended to reduce anxiety for both advocates and citizens. Anxiety is also reduced through this culture’s emphasis on access. Political rhetoric tends to dominate the advocacy culture and this rhetoric sometimes substitutes for tangible improvement in the health care system. When misdirected, this rhetoric also can lead to a proliferation of health care legislation and policies.
Advocates value electability, which specifically reduces the advocate’s own anxiety. A climate of expedience is created when the advocacy culture is taken to an extreme and when this emphasis on electability moves to the forefront. Eventually members of the advocacy culture may begin to do anything and say anything to get elected or appointed.
People who take this culture and its values to an extreme can forget why they got into the health care arena in the first place. The electorate, whether this be the voting public, members of a union, or representatives of a community association, collude through their skepticism and cynicism. Trust is lost and with it an ability to easily take actions that are meaningful. The media treat advocacy as a political game, ignoring the importance of the outcomes. Politics becomes personality.
The Alternative Culture: Members of the alternative culture tend to view health care as a process for sustaining and enhancing life rather than deferring death. This perspective is represented in the old Chinese tradition of paying a physician for every day of health and not paying the physician when one gets ill. Unlike members of the professional culture, those who are most aligned with the alternative culture tend to think of disease in direct contrast with the well-lived life. The alternative perspective concerns not the fact that death is inevitable—but that dis-ease inevitably comes with a life that is out of balance.
