In my urban primary care clinic, creativity and advocacy are some of our most basic tools. Recently, one of our residents brought up a homeless patient’s social barriers to colorectal cancer screening: no companion to escort her home from a colonoscopy, no address to send a mail-in test, no reliable commode location to collect a stool sample. This resident created a new workflow to have mail-in screening tests shipped to our clinic, held for such patients to pick up with in-clinic specimen collection, and shipped off by our clinic. This particular resident is a prime example of the new generation of physicians – incisive problem-solvers who seamlessly meld evidence-based medicine with patient advocacy. By no accident, he has joined a two-year elective Health Equity Track in our residency program (a voluntary addition to the 60 to 80-hour average workweek). The fact that resident physicians participate in similarly focused programs nationwide attests to the importance of social factors in medical care.
As we saw in recent Wall Street Journal pieces “Take Two Aspirin and Call Me in the Morning” and “Corrupting Medical Education,” some would rather remove training on Health Equity from medical schools, in favor of “a scientific approach to treatment.” Dr. Stanley Goldfarb posits that “The prospect of this ‘new,’ politicized medical education should worry all Americans.” His arguments are unconvincing, as science is the method that makes us aware of the need for changes in medical education: CDC reports reveal two consecutive years of decreasing US life expectancy driven by suicide and drug overdose. Only Chile and Portugal have a larger income-based disparity in the health status of their citizens than the US does. Racial disparity is directly involved with the doctor-patient relationship as evidenced by disparities in antibiotic, analgesic, and buprenorphine prescriptions. These tragedies spread under the purview of the most technologically advanced medical system in human history.
Efforts to shrink Health Equity curricula underestimate the capacities of our trainees. They are some of the most gifted, driven, and altruistic students in our society. The most valuable students and residents I work with can flow from deep clinical reasoning to motivational interviewing, then on to connections with community resources without hesitation. Whether or not they are the smartest person in the room, their compassion and social approach will drive them to find the right answers. While the universe of medical knowledge is ever expanding, students show that a proportional increase of rote learning is unnecessary – They regularly find more efficient means of curating information.
The Wall Street Journal article also states that medical schools “are not the place to produce” activists on issues such as gun control or climate change. Of course, medical schools exist to produce physicians. Physicians, however, are by nature experts on the health of our patients and communities. When their health is impacted by societal factors and governmental policies, who else will speak for them? No sector of “activists” are similarly prepared to take up our patients’ individual or collective cause. I look to the example of Dr. Mona Hanna-Attisha presenting initial data on lead levels in Flint, Michigan. Other brave physician advocates include Drs. Pamela McPherson and Scott Allen, who described the harms facing children in immigrant detention centers.
Irony arises when the specter of “stay in your lane” is raised in the opening sentence of an article about medical school curriculum on the website of a business-focused, lay press company. Why would this discussion be so widely distributed? Last week, who would have imagined that #MedTwitter would be mentioned as a “left-wing” entity in a Wall Street Journal editorial regarding medical school curriculum? Just as there are parties interested in discrediting news media as a source of truth, similar groups see incentives to sow mistrust of doctors. We are traditionally respected as experts with a moral code, and our collective voice is a powerful force for social change. If our expertise can be undermined, then opportunities to exploit patients will increase. I doubt that Dr. Goldfarb intends these outcomes, but I’m less certain of the Wall Street Journal’s motivation for publishing his thoughts.
I have been grateful for this reminder to reflect on the philosophy that undergirds my work, as the extent of our role in pursuing health is questioned. I serve my patients so that they can achieve health as the WHO defines: “complete physical, mental, and social well-being.” Each moment that a patient climbs upward on Maslow’s hierarchy of needs, I take joy. But if they’re not able to find a primary care doctor, afford insurance coverage or co-pays, access transportation, read a prescription, locate safe housing, drink clean water, or call an ambulance without fear of deportation – how can medical science help them? In an ideal practice setting, social workers would be available and effective for all of these needs. Since few of us work in ideal practices, we take on the work of overcoming social barriers as physician-advocates in alliance with our patients. Who else would do it?
Thanks to all of you who are mentoring the next generation of physicians. Do not let your aspirations for individual and societal health dwindle. We are healers and advocates — the two roles are inseparable.
We’re ready. Call us anytime.
Thad Salmon is an internal medicine-pediatrics physician.
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