Stay Woke, Family Medicine

Greetings from Philadelphia. As I write this, your delegation to the AAFP Congress of Delegates is basking in the glow of the election of our own Ada Stewart as President-Elect of the American Academy of Family Physicians. Congratulations, Ada!

It has been an exciting and productive Congress of Delegates. In addition to electing officers, the Congress—as the policy-making body of the Academy—debated a number of issues important to our patients and our profession. These deliberations left me feeling optimistic about the future of family medicine, and hopeful for an era of civil discourse on the role of science and medicine in the quest for a healthier society.

Most of all, I have been impressed by the idealism and enthusiasm of the younger physicians I encountered at the Congress. As an “older” physician, midway through my 4th decade of practice, the passion of students, residents, and new physicians inspires me and leaves me with the comforting assurance that the future of family medicine is in good hands.

Of course, there was a modicum of controversy at the Congress of Delegates. There are some within our specialty who are uncomfortable with the Academy taking positions on controversial social issues. In recent years the Academy has supported same-sex marriage, and last year it rescinded its opposition (based on the AMA Code of Medical Ethics) to medical aid in dying. The AAFP has also joined with the American Academy of Pediatrics, the American Osteopathic Association, the American Congress of Obstetricians and Gynecologists, and the American College of Physicians to oppose several actions by the Trump administration regarding the Affordable Care Act, and its treatment of asylum seekers. It has also joined in amicus briefs before the Supreme Court regarding recent state-based anti-abortion laws.

In every large organization, there are diverse and strongly held beliefs, and the AAFP is not immune to this condition. In response to the Academy’s perceived expansion of political action, two state delegations introduced a “No Policy” resolution. They asked the Academy to “put member unity ahead of taking sides” and called on the Congress to refrain from taking positions that might conflict with some members’ “personal opinions, customs, beliefs, values, or religion.”

In essence, they were saying we shouldn’t be “stepping out of our lane.” That is also the phrase used in a controversial Wall Street Journal editorial published two weeks before the Congress.

The Journal editorial was written by Stanley Goldfarb, the former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine. In his opinion piece, “Take Two Aspirin and Call Me by My Pronouns,” Dr. Goldfarb lamented the existence of “woke” (his term) medical schools where “curricula are increasingly focused on social justice rather than treating illness.” To support his observation, he noted that a colleague had criticized him for not including the topic of climate change in the school curriculum. He also cited the recent advocacy by medical societies on gun violence and the social determinants of health.

Goldfarb doesn’t mince words. He implies that this “new” emphasis on health disparities and cultural diversity is a distraction from “rigorous training in medical science.” He pines for a mythical golden age (prior to the progressive reforms of the ‘60s and ‘70s) when medical students were taught only how to diagnose and cure diseases.

The great sin of modern medical education, Goldfarb alleges, is its goal of producing “legions of primary care physicians who engage in what is termed ‘population health.’” This, he proclaims, “should worry all Americans.” He calls for a medical school curriculum free of social concerns that are “only tangentially related to treating illness,” and implies that medical schools should train more oncologists, cardiologists, and other medical specialists.

This hits close to home. What Goldfarb is so incensed about is the very foundation of the family medicine movement.

However, Goldfarb’s golden age of “technically proficient” medical training focused on specialty care never really existed. And if it did exist in some form, it was not so golden. He needs to go back to the 1960s and read the documents that inspired the birth of family medicine: The Millis Report, the Folsom Report, and the Willard Report. He would discover an age of widespread physician shortages with rampant depersonalization and dangerous fragmentation of care.

The solution to this morass was not more specialty care or a medical education system that viewed the treatment of disease as a commodity. It was something else entirely. What America needed in the 1960s—and what it still needs today—is the very thing Dr. Goldfarb seems to abhor: A legion of primary care physicians practicing population health.

Rather than being a “new” phenomenon as Dr. Goldfarb imagines, the roots of population health, and the recognition that social determinants matter, go back even further than the birth of family medicine in the 1960s counterculture. The roots go back to the birth of the modern age—back to a September evening in 1854 London, when Dr. John Snow boldly “stepped out of his lane” and removed the handle from the Broad Street pump, in one action ending a cholera epidemic and giving birth to the field of public health.

The population health movement carries on through Dr. Joseph Goldberger who demonstrated that pellagra, afflicting tens of thousands of South Carolinians in the first half of the 20th Century, was not a disease caused by bad genes or poor hygiene. It was a disease caused by poverty and treatable only at the population level.

The movement continues to this day with the AAFP’s stated belief that “policymaking should be population-based and evidence-based, and should support current and future research on social determinants of health. (By the way, the “No Policy” resolution at the Congress of Delegates died in the reference committee.)

Rudolf Virchow once said, “Medicine is a social science, and politics is nothing more than medicine on a larger scale.” This is the fountainhead of family medicine. We cannot stay silent in the face of health disparities and the systemic failure of our nation’s healthcare policy. We must soundly reject Dr. Goldfarb’s assessment and recommendation.

We will not stay silent. Until ambulances stop delivering gunshot victims to our hospitals, physicians will speak out on gun violence. Until your zip code is no longer a better predictor of health than your genetic code, physicians will speak out on the social determinants of health. As long as reactionary politicians keep issuing gag orders when we talk about gun violence and reproductive rights, physicians will speak out.

Family physicians have been speaking out on social issues for 50 years, and the next generation of family physicians seems to be even louder and bolder than those who paved the way so long ago. So, heads up Dr. Goldfarb. There is a legion of family physicians out there working hard to improve the health of our patients, our families, and our communities— and they have always been woke.

This article was published in South Carolin Family Physician.