On November 8, 2016, family physicians went to work across the United States caring for patients. Some patients wore caps emblazoned “Make America Great Again” and others had buttons declaring “I’m With Her.” As on any other day, the task was to care for each patient with respect and dignity. On November 9, the country awoke to a new president-elect. Half of voters were excited by the promise of a new administration leading the nation toward a greater future, and half were fearful of what lay ahead.
We do not pretend that all family physicians share the same political ideology. But we do believe that in a nation seemingly so at odds, family medicine can help heal the divide. The months preceding the election exposed many wounds. Unemployed and underemployed workers in the Rust Belt decried the departure of well-paying jobs. Videos streamed images of police officers killing unarmed African American men, provoking public outrage and movements to confront institutional racism. Dallas, Baton Rouge, and other communities mourned the premeditated killing of unsuspecting police officers. Immigrants found heightened cause to fear that their families would be wrenched apart by deportations. Individuals denounced the rising cost of insurance in an era of supposed affordable care. A fractious campaign culminated in an election revealing deep schisms based on geography, race, ethnicity, social class, and religion. Whereas 88% of African Americans and two-thirds of Latinos and Asians voted for Hillary Clinton, exit polls indicate that 58% of whites voted for Donald Trump.1 Support for Trump was particularly high among whites without a college degree and among residents of rural communities. Highly educated city dwellers strongly preferred Clinton.
Although pundits portrayed the election as red state bigots versus entitled blue state elitists, family physicians see a more complex portrait of the nation’s diverse communities. Family doctors practice in communities reflecting the geographic distribution of the nation’s overall population more than physicians in other specialties. 2 They work on the front lines of US health care in remote rural towns, inner cities, and sprawling suburbs, caring for patients across a spectrum of social classes, races, and political persuasions. The work of primary care involves listening to patients’ stories, which affords insight into the complex mix of kindness, prejudice, generosity, frailty, decency, pain, and courage in every person. The task of family medicine is to partner with patients, families, and communities, acknowledging all their complexities, vulnerabilities, and strengths, to improve the nation’s health and well-being.
What does it mean to be a healthy society? Rarely has this question felt so urgent, and the answer so fragile. A powerful first step family physicians can take is to reject the false dichotomy that characterizes the nation as having a problem of either economic hardship or racial injustice. We have both. The United States lags behind other industrialized nations in indicators of population health. Much of the poor overall health of Americans is rooted in the underlying social and environmental conditions that powerfully influence health and illness.3 Since the 1970s, income inequality in the United States rose to levels not seen in America for the last century.4 These vulnerabilities are reflected in public health statistics showing a 3-year advantage in life expectancy for white Americans compared with African Americans.5 In addition, death rates among middle-aged whites increased from 1999 to 2013 after many decades of steady declines, with less-educated whites experiencing the largest increase.6 The past year exposed the grievances of many working-class Americans about a globalized, technology-driven economy that has left them behind and the outcry of people nationwide that Black Lives Matter.
The journey to a healthier nation cannot progress well over a terrain fractured by divisiveness and distrust. Family physicians have a duty to heal divisions and build bridges between the diverse communities in which they live and practice.
We propose that family physicians commit to 4 actions:
1. Address Bias
Patient-centered care requires recognizing and valuing every individual as unique. The election highlighted an abundance of misassumptions, biases, and tendencies to stereotype people across the political spectrum. Unconscious bias tests show that physicians hold implicit prejudices that influence the care they provide.7 We urge all family physicians to explore the roots of their bias by examining their privilege, fostering workplace conversations to address discrimination, and challenging institutions and policies that propagate implicit bias.
2. Model Inclusivity
Family medicine practices should be welcoming, inclusive, and safe places for patients, staff and trainees. Insisting on zero-tolerance for hostile work environments is not political partisanship. Modeling inclusivity also requires cultivating clinician leaders from diverse backgrounds underrepresented in our ranks. More than half of US medical students come from the wealthiest 20% of US households, and the number of African-American male students matriculating to US medical schools has declined from 1978 to 2014.8,9 We need to do better.
3. Attend to the Social Determinants of Health
A growing body of literature supports the feasibility and effectiveness of deploying interventions in the primary care clinical setting to address social determinants.10,11,12 Primary care practices should identify pragmatic steps to link patients to community resources. Health care payers implementing population-based payment models should support family physicians adopting these interventions. Medical professional organizations have affirmed that physicians must understand and address poverty to effectively care for their patients,13,14 but we need to further emphasize community strategies to tackle the “causes of the causes” driving poor health.15
4. Advocate for Health
Family medicine can lead by emphasizing health in a world of competing political priorities. This means advocating for patients beyond the clinic with civic institutions such as faith organizations, community associations, social clubs, and advocacy groups. As the nation debates the future of the Affordable Care Act, immigration policy, the federal tax code, and environmental regulations, family physicians must ensure that the agenda for our nation’s future includes a healthier and more equitable America.
Footnotes
Conflicts of interest: authors report none.
- Received for publication November 24, 2016.
- Revision received November 24, 2016.
- Accepted for publication November 27, 2016.
- © 2017 Annals of Family Medicine, Inc.
