When family medicine was founded as a specialty 50 years ago, the goal was to redefine primary care. Family physicians led a transition from hospital-based, disease-focused care to a patient-centered model that championed continuity of care for entire families and emphasized care in clinics and the community. In his 1989 essay, “Family Medicine as Counterculture,” G. Gayle Stephens, MD, described the paradox of practicing medicine as part of the medical establishment, while at the same time advocating to change the establishment.1 Family medicine was born with social justice at its core and has brought that sensibility to the health care system as a whole. The result has been improved access to high-quality health care for all patients, regardless of race, ethnicity, age, gender, sexual orientation, or financial circumstance.
Fifty years later, family physicians continue to be on the cutting edge of patient-centered care, while advocating strongly for patients outside of the clinic as well. The COVID-19 pandemic and racial justice protests underscore the continued need for that advocacy and provide examples of the tension of playing both roles. Where do family physicians fit in to the politicized public health debates going on across the country? How much should we take our professional personas into the personal, everyday lives we lead outside of the office?
I was thinking about those questions after a recent trip to the grocery store. As I entered the store, I asked one of the employees where I could find a handheld basket. He replied, “We won't have those back until there is a vaccine for COVID.” I wondered how a handheld basket was different from a shopping cart. Both are touched and can be cleaned before being used by the next customer. Was it my role to point out this faulty reasoning? In this case, I held my tongue. But I certainly would not have stayed quiet if he told me that customers shouldn't wear face coverings.
What's the threshold? As family physicians, when and how should we choose to speak up?
The answer to that question goes back to the origins of the specialty. We are advocates for our patients, whether or not we share their political beliefs. There are various levels of advocacy, ranging from personal support (e.g., completing a disabled parking permit application for a patient) to policy support (e.g., advocating that patients have access to affordable health insurance).2 But family physicians are obliged to engage in advocacy at all levels to support our patients and their families. Advocating for policies that support the health of our patients is no longer countercultural; it is inherent to our roles as family physicians.