Seize Leadership for Sake of Public's Health

Take the reins of community health initiatives, FP Eduardo Sanchez, M.D., M.P.H., told FPs-in-training at the National Conference of Family Medicine Residents and Medical Students, held here Aug. 2-5.

Sanchez, commissioner of the Texas Department of State Health Services, recognized Texas FPs who spearheaded relief efforts for evacuees from hurricanes Katrina and Rita last year. He hammered home the bonds between family medicine and public health.

"Family physicians practice public health every single day, whether it's providing vaccinations, treating infectious diseases or managing chronic diseases," said Sanchez. "But I say to you that family physicians are practicing public health every day in a new and different way, now in the era of preparedness, whether it's bioterrorism, avian influenza or hurricanes. We help manage emergencies."

Sanchez said he visited shelter after shelter, many of them filled with thousands of people, as, according to him, almost half a million Louisianans sought refuge in Texas after Katrina struck Louisiana and Mississippi on Aug. 29, and again later, when 3.2 million Texans fled inland from the eastern coast to escape Rita, which arrived Sept. 24.

"There were family physicians on the floor in leadership positions in every shelter I visited," said Sanchez. "They put up spontaneous shelters and took care of people. They weren't given the role of leader. They assumed it."

Those family physicians had the broad skills set that let them identify mental health needs in addition to physiologic problems such as skin lesions, Sanchez recalled. Also, he said, FPs would ask patients with diabetes what medicine they'd been taking, and, when patients said it was the blue pill they took in the morning and at night before a meal, the FPs could identify it. "The urologist had no clue what the blue pill for diabetes was," said Sanchez. The subspecialists in the shelters "marveled at what we knew," he noted.

He called the Texas FPs "extraordinary physicians in extraordinary times," applying the meeting's theme, "Extraordinary Physicians in Extraordinary Times: Family Medicine Answers the Call." Sanchez's address was the annual Stephen J. Jackson, M.D., Memorial Lectureship, named in memory of the AAFP Division of Education assistant director who died in 1993.

Education Front

Sanchez zeroed in on illiteracy during his speech. "Many of you have patients who cannot read, and you don't know it. They fake it," he told residents and students. "We family physicians are able to get that figured out better than some of our other colleagues. Why? Because we establish trusting relationships with people that are based on respecting them and treating them with dignity."

Sanchez used education as a barometer for health. "Lower education equals unhealthy behavior, and lower education equals a higher (premature) death rate," he said.

"Ought we not be trying to get more people graduated out of high school just to protect their health?" he asked. In this country, African-Americans and Latinos are less likely to graduate from high school than whites, he added. "Yet we have a shift where African-Americans and Latinos are becoming a greater part of the population."

Shifting gears from literacy to health literacy, Sanchez said the Institute of Medicine has reported that nearly half of all American adults have difficulty understanding and using health materials. "It is important that you as physicians understand this health literacy issue because it is part of our challenge in terms of getting to where we need to get with health promotion (and) disease screening," Sanchez said.

Also on the education front, Sanchez advocated promoting healthier lifestyles by working to raise the nutritional value of foods sold to students in schools and by defending physical education. "This notion that we should take physical education out of schools is nonsense," said Sanchez. "Doctors can play a role in helping inform that discussion."

Adverse Childhood Experiences

In a health promotion effort in the 1980s, Kaiser Permanente sponsored an obesity program, finding eventually that the program had a high dropout rate. The program facilitators discovered that a history of sexual abuse was common among the dropouts, and they found that, among those persons, the abuse "always predated obesity," said Sanchez. Kaiser Permanente teamed up with the CDC and has conducted 19,000 interviews with predominantly middle-class, middle-aged adults in a study on adverse childhood experiences, or ACEs.

These adverse experiences included growing up in a household with physical, emotional or sexual abuse or having a household member who had chronic depression or mental illness, who abused drugs or alcohol, was imprisoned, or committed suicide. The study found that ACEs seemed to be associated with behaviors such as smoking, obesity, suicide, alcohol and drug abuse, STDs, self-injury and eating disorders, said Sanchez.

"Those things then correlate with the next phase of what happens in the pathophysiology: heart disease, cancer, chronic lung disease, emphysema, HIV/AIDS, mood disorders, anxiety disturbances," said Sanchez. "As you enumerate the number of adverse childhood experiences and measure it against smoking, the more experiences, the higher the likelihood that you will be a smoker. The same is true for attempting suicide. The same is true for intravenous drug use," said Sanchez. "What does that tell us? For me, that's about the psychosocial context in which an individual's life evolves."

Sanchez challenged residents and students, saying, "If we can create caring, nurturing, positive-stimulation-rich environments for all kids, what the ACE study tells me is we might be able to reduce not only behavioral disorders in schools but some of the behaviors we believe are responsible for a large number of chronic diseases and premature deaths in our country."

Think Change, Think Leadership

"We spend $6,280 a year on medical care (per person); we are the most expensive medical care system in the world, and we're not the healthiest people in the world," Sanchez said. However, he told the residents and students, "There are people who have come to understand that in the equation of how do we get more bang for our buck, primary care looms large. And the role you will play in the medical care delivery system and as part of the public health system will prove invaluable to this country in the need to reduce medical care costs."

Sanchez's final comment further revealed how much he identifies family medicine with public health. "Any one of you who's thinking of being a family physician has all it takes to become a state health officer," he said.