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Friday May 26, 2017

Come On, Grads, Let's Start Cultivating a Healthier World

In the weeks leading up to graduation, I found myself mulling over the "big-picture" significance of the M.D. and master of public health degrees I was about to acquire. As a newly minted family physician, what is my role in improving the health of my community? My state? My nation?

When I think about the reasons I chose to pursue an M.P.H. and a career in medicine, most fit neatly under the umbrella of promoting health equity. So, now what?

The credentials are official, and I'm ready to eliminate health injustices! But I know that, realistically, it's not that simple. As Camara Jones, M.D., M.P.H., Ph.D., recently explained during the AAFP National Conference of Constituency Leaders, ensuring health equity is a process, not an outcome. Rather than looking toward some imaginary finish line, we need to focus -- and continuously refocus -- on what is holding us back from eliminating health disparities.

During my medical and public health education, I learned how social determinants can impact the health of individuals and communities much more deeply than any clinical intervention. These social factors include poverty, education and employment opportunities, ZIP code, transportation, nutritional access, and much more. As physicians, we should aim to understand the many forces that converge to influence the health of our patients. The AAFP's recently launched HealthLandscape mapping tool is a significant step in improving the way we make clinical decisions with our patients based on relevant local information.

Social factors are vital considerations in addressing health disparities, but as Jones cautions in her analogy of moving a population away from a cliff, we risk exacerbating health disparities if we ignore the role of social determinants of equity. This refers mostly to the list of "-isms," including classism, sexism, heterosexism and the perpetual elephant in the room: racism. Today, most of the damage resulting from racism occurs at the systemic level, rearing its ugly head through policies such as redlining, predatory lending and discriminatory policing. Racism is a real force that perpetuates health inequity, and Jones explains this phenomenon through an allegory that has dramatically shaped the way I view my role as a family physician.

Jones developed the Gardener's Tale allegory to illustrate the effects of racism on health. The scenario begins with a gardener who has two flower pots, each with different soil quality, and two packets with seeds of the same type of flower but in different colors -- one that will bloom red and the other pink. Because the gardener prefers red flowers, she plants those seeds in the better soil. The quality of potting soil impacts how the seeds grow and flourish, and over time, the plants with red flowers and their progeny grow taller and more vibrant than the others. The gardener looks at this and thinks that she was right to prefer red over pink. She then begins to pick away the withered pink blossoms, and if a pink seed blows into the red flowers' nutritious soil, she removes it before it can take root.

Who is the gardener in this tale? Although the government is often regarded as the gardener, I like to think in terms of a garden club. Members of the garden club include policymakers, educators, public health professionals and, of course, physicians. Family physicians, in particular, play an important role in fertilizing and nourishing communities. We are well-positioned to advocate to other key members of the garden club to ensure fertile soil is a reality for all.

Many have said it, and I feel it is important to constantly remind ourselves that health equity is not a zero-sum game. It is possible for all members of all communities to be planted and to grow in fertile soil. Highlighting the dramatic effects of racism on the health of racial minorities does not negate the reality that health disparities can affect all skin colors. And although racism is not the only "-ism" affecting health equity, Jones has pointed out that it is foundational in our nation's history. We must not ignore past and present iterations of racism as components of the soil in which Americans grow, live and die.

As family physicians, we are on the front lines of delivering primary care services that ultimately help to level the proverbial playing field. The AAFP has launched the Center for Diversity and Health Equity to assist family physicians in realizing the valuable leadership role that they play in eliminating health disparities in their communities, emphasizing seven major objectives that promote health equity. Looking ahead, we must embrace our role as gardeners, becoming increasingly mindful of how our clinical decisions may disproportionately impact our patients.

To my fellow 2017 medical school graduates: Welcome to the garden club. May we cultivate social justice and empower communities to grow to their full potential.

Lauren Abdul-Majeed, M.D., M.P.H., is the student member of the AAFP Board of Directors.


"social determinants can impact the health of individuals and communities much more deeply than any clinical intervention"

And when we ask the AAFP why they so enthusiastically promote payment methods such as MACRA that are designed to punish those physicians who treat patients with challenging social determinants, we get nothing but silence.

Maybe you, Dr. Abdul-Majeed, can talk to us where your fellow board members have declined to do so?

Posted by R Stuart on June 01, 2017 at 04:35 PM CDT #

Thanks for these thoughts. The Gardener's Tale allegory is an especially useful communication tool.

As a fellow classmate, I look forward to pitching in.

Like R Stuart above, I am curious about how we reconcile our social mission with the policy frameworks that we sign onto (whether we know it or not) governing our day-to-date operations. After all, good intentions only go so far.

Posted by Kevin Hu, MD on June 01, 2017 at 09:50 PM CDT #

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