Innovations In Primary Care #1: Introduction

As part of my family medicine residency training, I’m taking a month-long elective called Innovations in Primary Care. This month is an opportunity for primary care doctors from family medicine and internal medicine residency programs in Seattle to explore some of the different primary care models being trialed in the Seattle area and to use those experiences to fuel discussion about how primary care (and really, all medical care) can be improved in the United States.

Today was our first meeting, during which we gathered to collectively write an H&P for our current medical system. For those reading this who are not in medicine, the History and Physical or H&P is a semi-standardized note-writing structure that doctors use to describe the subjective and objective information about a patient’s health, assess why  the patient is experiencing illness, and describe the next steps we need to take (diagnostic tests and/or treatments) going forward. It’s a structured way of thinking about a patient that helps us be rigorous and methodical.

It was a gratifying process because each of the doctors at the table shared a passion for making our health care system better, but brought a different set of experiences and priorities to the conversation.

Some of the take-aways I had from this conversation are as follows (in no particular order):

  1. The insurance framework for paying for health care, while originally conceived to improve access to surgical services which would otherwise be prohibitively expensive to most people, was quickly recognized by doctors as a way to extract larger fees for patient care. After all, when a third party (the insurance company) pays the bills, people tolerate much higher fees even if the end result is steady rise in out-of-pocket costs for everyone. Doctors, hospitals, and pharmaceutical companies have abused this system so greedily under the previous usual-and-customary payment system that increasingly rigid cost-containment measures have had to be implemented to control costs. We now live in a society where the average doctor makes $294,000 per year–more than 98.9% of Americans–while medical bills bankrupt patients and health insurance cost suppresses wage growth. Recognizing and holding ourselves accountable to how capitalism in medicine has brought out the worst in us is necessary before we can even begin to conceptualize a new system.
  2. The costs of most important and effective interventions to improve health, including primary care, are recurring and predictable costs that are best paid for through public health funding, NOT through health insurance. Access to clean water, nutritious food, safe housing, and preventive medical care is necessary for All People at All Times.
  3. America fails to invest in public welfare programs because of racism. The idea of the racialized-and-thus-undeserving Other benefiting from public welfare programs (e.g. the racist specter of the Welfare Queen that Reagan so infamously promoted) is fundamentally intolerable to White America. We are comfortable with 1 in 7 people in the United States facing food insecurity if it means we can prevent one person from buying steak with food stamps. There is no justice without racial justice.
  4. Many participants are needed to transform our medical care system into a true health care system. While there are only physicians in this particular group, the real work requires public health professionals, community health workers, housing experts, policy wonks, political activists, artists, chefs, personal trainers, behavioralists, and many others to both design an implement a better system.

I’m looking forward to the experiences and conversations this month will bring, and I hope to walk away with greater insight into how I can be a better advocate for effective and equitable health care in this country.

Critical Race Theory in Medicine: A Reading List

Inspired by this letter by Jennifer Tsai and Ann Crawford-Roberts, I’m working on putting together a reading list to jump start conversation about Critical Race Theory in medicine at my family medicine residency. The goal of such a conversation is to develop a more effective anti-racism praxis in our medical system and our lives more generally. I’ll update this list as I get more recommendations. Please let me know if you have recommendations to add.

Professor Adrienne Keene’s open-access course in Critical Race Theory at Brown: Introduction to Critical Race Theory 2017

Recommended by Michelle Munyikwa
Recommended by Jeremy Levenson

If you are having trouble accessing any of these articles, let me know!

In support of Professor Tommy Curry

Associate Professor Tommy Curry at Texas A&M (my alma mater) is the latest academic targeted by White Supremacists in their campaign to silence scholars of race and racism.

Four years ago, in a podcast conversation about the movie Django, he gave a brief summary of scholarly work about the role of anti-White violence in the path of Black liberation. White Supremacist groups have now taken quotes out of context from that interview and are claiming that he was inciting racial violence.

Texas A&M President, Michael K. Young, found these White Supremacists’ argument compelling and decried Mr. Curry’s words as “in stark contrast to Aggie core values.”

I’ve signed this petition and am writing this now because I disagree with that assessment in the strongest terms. The Aggie honor code calls for us to “not lie, cheat, or steal, or tolerate those who do,” and yet the history of racial violence in America has been one of theft of Black people’s lives and livelihoods. If we are to live in this country as honorable Aggies, we must reject that path a form a new one. Doing so requires the thoughtful academic scholarship and leadership of people like Tommy Curry.

Why I wear a Black Lives Matter pin



This is the badge where I choose to display a Black Lives Matter pin. I wear this pin to work each day because I believe that Black Lives Matter is a message that is essential for all Americans to see and hear on a daily basis. I’ve distributed almost a hundred of these pins to my co-workers and every month I order more. It was brought to my attention that my employer has received anonymous complaints about seeing medical staff wearing these pins, so I wanted to clarify why I as a doctor make the choice to wear this pin.

Black Lives Matter became a prominent slogan during nationwide protests against police violence.  According to the federal Bureau of Justice Statistics, between 2003 and 2009 4,813 Americans died at the hands of police. Black people are disproportionately the victims of these police homicides, accounting for 32% of these deaths despite constituting only 12.6% of the population.

In this context, #BlackLivesMatter was used to remind the White American public that Tamir Rice, Sandra Bland, Freddie Gray, and Walter Scott are precious souls to be grieved, not mere statistics. However, the slogan gained a life of its own as a push back against the myriad ways in which Black life is denigrated in our country. It is a pinprick to the conscience meant to call attention to the cynicism with which too many of us receive news of the deaths of our Black neighbors.

This is a message that we healthcare professionals need to hear as we are all too often oblivious or callous to the enormous health disparities that exist between Black and White people in this country. A 2013 CDC report showed that rate of deaths from heart disease and stroke is 20% greater for Black people than White. That’s 6,942 deaths every year that could be prevented if racial inequality was addressed. The same report showed that the infant death rate is 130% greater for Black children than White. That’s 4,576 Black babies that don’t live to see their first birthdays because of racial disparity.

When I say that racism kills, I am speaking to these thousands of deaths that occur every year because of the racial injustice that permeates our nation. When I wear that pin, it’s because the deaths of four thousand Black babies every year is a tragedy and an injustice and it matters.

As a profession that is committed to preserving health and prolonging life, we have a duty to push back against all things that threaten the well-being of our patients. That is why I wear this pin and will continue to do so.

If you wish to take a stand in your workplace as well, I encourage you to order your own Black Lives Matter pin here:


EDIT 5/16/17: An earlier version of this post stated that “4,813 Americans died at the hands of police every year.” This has been corrected to state “between 2003 and 2009 4,813 Americans died at the hands of police.”

Holding Professional Societies Accountable

Shortly after Donald Trump nominated Dr. Tom Price to serve as Secretary of the Department of Health and Human Services, the American Medical Association, the Association of American Medical Colleges, and the American Academy of Family Physicians released statements supporting his nomination without reservation or qualification.

Many doctors were shocked to see these endorsements from their professional organizations knowing Dr. Price’s legislative track record as Representative from Georgia’s 6th district since 2005. As the New York Times editorial board describes in detail, Dr. Price has repeatedly acted against the interest of Americans’ health and well-being during his time in Congress. For example:

  • He repeatedly voted for legislation to dismantle the Affordable Care Act, threatening to eliminate the health insurance of tens of millions of Americans.
  • He introduced legislation to defund Medicaid for millions of low-income patients who rely on it for life saving medical care.
  • He voted against expansion of the SCHIP program which provides health insurance coverage for children.
  • He repeatedly voted for legislative interference in women’s medical decision-making around their reproductive health and is rated at 0% by the Planned Parenthood Action Fund.

In other words, although Dr. Price earned his MD from an accredited institution, his actions have demonstrated little respect for the Hippocratic oath.

The reaction of physicians was swift and fierce. Thousands of doctors publicly denounced the AMA. An equal contingent of medical students condemned the AAMC. The National Physicians Alliance joined the fray. In response, the AMA and AAFP privately sent emails to their members reassuring them that these organizations’ values remained unchanged, but without public advocacy for those values, what meaning do they have?

As physicians, doing everything in our power to promote the health and well-being of our patients is not a corny mission statement to copy-and-paste onto a website and ignore when it’s inconvenient. It is the driving force of our clinical, academic, and political practice.

In 2016, when there is so much at stake for our most vulnerable patients, it is a time for personal and professional courage. It is time to call upon our professional societies to stand with us in the fight to ensure that all Americans have access to high quality medical care without legislative interference in the doctor-patient relationship. It is time for these organizations to state clearly the patient-centered principles that they believe in most strongly, and to advocate for these principles on every level.

Opportunities for action (list will be updated)

  1. Call your congressional representatives and voice your support for the greater access to healthcare services and opposition to Tom Price’s nomination. 
  2. Open letter to the AAFP from family doctors
  3. Open letter to the AMA from physicians
  4. Open letter to the AAMC from medical students


Subverting Whiteness

This article on John Brown and White people’s anti-racism is really thought provoking and I strongly recommend reading it, especially if you identify or are identified as White.

In the essay, the author argues:

“The “white” subject position is formed by and predicated on an assumed superiority over “non-white”. The entire history of whiteness is produced towards this end. More specifically “white” was/is produced, originally, in counterposition to “Black” and “Native” providing the ethical basis for African Slavery and Indian Removal. Alternately put, white supremacy is inhered in whiteness and there is no articulation of whiteness that is not also an articulation of white supremacy. This is to say that whiteness is defined by its subject position, not cultural production; it is the product of the colonization of Turtle Island and enslavement of Africans rather than an accumulation of traditions and influences. Whiteness’ only real tradition is white supremacy.”


“If, as white people committed to ending white supremacy in all its manifestations, we are serious, then we must consider our subject position forfeit. This is not the same as pretending positionality doesn’t exist and must not be carefully navigated. We must continue to undertake anti-oppression practices that somewhat mitigate our subject position’s power while doing the work to abolish it.”

I agree with the author that it’s not possible to subvert Whiteness by ignoring it. This “colorblindness” was the strategy of my own upbringing. There was never any explicit mention of my family’s Whiteness. Yet, it was also clearly demonstrated that non-Whites were an Other to be avoided. We were moved out of integrated public schools into segregated Catholic schools. We lived in segregated neighborhoods. Each action was done with good intentions, always with the pretext of “safety.” But by never discussing or asking why Black neighborhoods were unsafe or Black schools were inferior, I was taught that this is just the natural order of the universe. This silence taught its own lesson.

Rather than colorblindness, I think it is important for White people to be attuned to how Whiteness plays out in their lives, and utilizing this awareness take active efforts to dismantle the White subject position and cultivate an alternative subject position in its place.

This means speaking openly and honestly about the sociopolitical structures that privilege the position of Whiteness, particularly as they play out in our own lives. The purpose of this exercise is not cultivating guilt or shame, but to achieve a clarity of vision about how race works in the world.

Once we have gained some clarity on how Whiteness plays out in our lives, then we can work to subvert and sabotage the sociopolitical structures that privilege our Whiteness. This means calling attention to and actively resisting any space that we occupy that is disproportionately White. This means recognizing when we are offered credibility, congratulations, or promotions over peers of color and rejecting those benefits.

And if one feels that an alternative subject position must replace that of Whiteness, let that subject position be that of the anti-racist. Identity as action and action as identity. Such action will get you labeled as Race Traitor and likely care with it financial and interpersonal penalties. However, if one’s resistance to racism is only to the point of discomfort, then one is not resisting racism at all.

If you’re a White-identifying person interested in subverting Whiteness, here are some resources to start with:

White Blindness and Liberal Racism

On Friday, the New York Times published an op-ed by Mark Lilla in which he calls for an end to “identity liberalism.” Couching his thesis in flowery praise for surface-level diversity intended to establish him as part of the liberal in-group, Lilla argues that the individuals who constitute America’s diversity are too focused on fighting for their own self-interests and in the process have lost sight of the common good. He goes so far as to blame this movement for the prominent visibility of White identity politics in the most recent election. White people have, by his reckoning, worked tirelessly only for the common good up until now and have just now decided to press for their self-interest in reaction to the selfishness of the Others.

Such a view is, of course, ahistoric. So it is in some ways bizarre that Lilla–who is in fact a professor at Columbia and presumably has at least a 10th-grade level understanding of American history–would sign his name to it in the paper of record. As admittedly petty as that last sentence is, I don’t actually want to accuse Lilla of stupidity because I don’t think that is what’s at play here. Rather, I think his issue is White Blindness, which is the inability to perceive Whiteness in himself or others. Without the ability to perceive Whiteness, the interests of his White community are perceived as simply “the common good,” while those of Others are “special interests.”

In this framework, as institutions and culture are modified to meet the needs of a greater number of people, Lilla’s perceived “common good” (which is really just White interest) appears to be damaged and neglected. However much the common good of the larger community grows, White Blindness makes Lilla perceive only loss.

The ahistorical nature of White Blindness makes it difficult if not impossible to appreciate how White-identifying groups have used and continue to use their sociopolitical power to advance their special interests at the expense of non-White groups. On the other hand, tacit understanding of this fact combined with a touch of projection may be the reason that Lilla appears so fearful of non-White groups gaining sociopolitical power.

I want to call particular attention to this piece because as Trump has shifted the Overton Window and brought more explicitly racist viewpoints into the realm of acceptable political discourse, I think we very much risk losing sight of the equally (if not more) pernicious forms of implicit racism (such as White Blindness) that go unchecked in liberal social circles. In other words, as liberals expend energy calling out the obvious racism of people like Stephen Bannon and Jeff Sessions, it’s easy to start believing that the internalized racism that informs our own beliefs and practices is benign or non-existent. After all (to state the obvious), it is not just White conservatives that suffer from White Blindness.

This self-critique is extremely important right now because as the Democratic Party reshuffles and re-imagines its 270+1 strategy in the face of electoral defeat, it will be easy for DNC to return to appeals to the White identity politics of Bill Clinton’s era at the expense of marginalized groups. We must resist this at all costs if there is to be a viable progressive party in US politics and not just two flavors of White supremacy.

Calling attention to the racism of liberals is often critiqued as petty infighting or thought-policing. However, this is a necessary work if we are the continue to build the inclusive coalition necessary to create a just society that serves everyones needs. We need to always be pushing  back against our natural tendency towards self-justification and the ego fragility at its root. In any case, a certain level of humility about these things is necessary if we are to strive for continual self-improvement.

This being a blog which serves first and foremost as a space I’ve given myself to clarify my thoughts through writing, I want to be clear that I myself am the target audience of any advice I give. With that being said, over the next couple weeks I plan on writing a bit more on the types of bias I have seen in liberal circles which I hope will be received in a spirit of humility and self-improvement because we all can and should do better every day.

If you’re a White-identifying person interested in subverting Whiteness, here are some resources to start with:

No Justice, No Peace

Fair warning, I use a lot of we/us in this piece to refer to White Progressives and #NeverTrump Conservatives because that is the intended audience of this writing. I will admit upfront that this is an imperfect piece of writing, and I welcome any and all attempts to refine my thinking on the matter.

I want to push back against something that has been creeping up in my newsfeed lately which is the call to make peace with Trump supporters by looking past the things that divide us and focus on common ground. Normally I’m all about making nice-nice with people (being a softy liberal and all), but I don’t think we can, in good faith, ignore White Supremacy if we are to have a meaning reconciliation that isn’t just unity around mutual Whiteness that throws people of color under the bus.

Just so that we’re all on the same page, I want to be very clear about what I mean when I say White Supremacy, and to do so I’ll borrow this quote from legal scholar Frances Lee Ansley:

By “white supremacy” I do not mean to allude only to the self-conscious racism of white supremacist hate groups. I refer instead to a political, economic and cultural system in which whites overwhelmingly control power and material resources, conscious and unconscious ideas of white superiority and entitlement are widespread, and relations of white dominance and non-white subordination are daily reenacted across a broad array of institutions and social settings.

The New York Times put together a handy illustration of White Supremacy in response to the #OscarsSoWhite campaign back in February. That such disproportionate representation of White people in positions of social, economic, and political power does not strike most White folks as unusual or bothersome reflects the internalized belief that this is the normal and natural order of the universe.

Conversely, when a state of White Supremacy is disrupted (such as by the election of a Black President or by the increased prevalence of people of color in previously segregated communities), it is taken as evidence that something has gone terribly wrong and must be corrected. As the adage goes, “When you’re accustomed to privilege, equality feels like oppression.”

Thus the potency of a slogan like “Make America Great Again” which promises a return to the nostalgic era in which White men were in control of the levers of power in this country, and people of color were more firmly locked into a permanent underclass away from White communities.

This is not to say that all or even most Trump supporters identify as White Supremacists or racists. I do not believe that to be the case. You do not need to identify as a White Supremacist to support White Supremacy in your words and actions.

This is also not to say that preference for White Supremacy is unique to Trump supporters. I think it is endemic in America and affects the vast majority of (if not all) White people, including White Progressives.

I am also not saying that Trump supporters are unkind in their everyday interactions. While the rise in hate crime correlating with Trump’s prominence is not to be ignored, I do believe that most Trump supporters are just as capable of politeness and decency as anyone else. However, politeness and preference for White Supremacy are not mutually exclusive.

What I am saying is that the ease with which a large proportion of the voting public fell in line behind a demagogue who scapegoats people of color as a threat to social order reveals a preference to return this country to stronger form of White Supremacist society. Even for those whose stated priorities are other aspects of the Trump platform, the vote represent at a minimum a blasé attitude towards White Supremacy. Likewise, the rapidity with which White Progressives have called for a unity that ignores (and thus leaves in place) White Supremacy reveals this same willingness to throw people of color under the bus by perpetuating a White supremacist social order.

It is for this reason that I reject and call others to reject this false peace which perpetuates White Supremacy. In the words of Martin Luther King, Jr., “True peace is not merely the absence of tension: it is the presence of justice.”


More reading on White Supremacy can be found here:

Physicians in Solidarity

Since Donald Trump’s election on Tuesday, I have seen a renewed call to solidarity and resistance amongst my friends and colleagues in medicine. As I did with racial justice activism, I wanted to put together a post to consolidate the opportunities for action. This is both to help me clarify my own thoughts on action in the coming years, but also to help anyone else in medical professions who are trying to figure out how they can best work for a healthier and more just America in the coming years. This list is geared toward the particular expertise of medical professionals and is not meant to exclude work that the more general population needs to fight for such as the incredibly important work of dismantling White supremacy.

The Affordable Care Act

One of the more obvious threats of a Republican-dominated legislature is to Obama’s signature piece of legislation. Although it was developed as a near-duplicate of Republican Mitt Romney’s healthcare access effort in Massachusetts, Congressional Republicans decided that repeal of the ACA was the hill they wanted to die on and now that they actually have control of the legislature and the executive branches, they now have the power to follow through on their threat. There’s a lot of great writing on why complete Repeal and Replace would be incredibly difficult and likely extremely politically damaging, but if we’ve learned nothing from this election its that the predictions of experts should not let us become complacent. Here are something things you can do:

  1. Call (not write, not email…call) your congress people at their local offices and talk to their staff member in charge of health policy about what the coverage expansions under the ACA have meant for you and your patients. I’ve been in residency for 6 months and I already have about a half dozen powerful stories of people who only have access to life-saving care because of either Medicaid expansion or subsidized marketplace insurance. Use these anecdotes, This is doubly important if you are represented by Republicans who need to understand just how many people ACA repeal would hurt.
  2. Write op-eds the same and then shop them around and get them published in local or national newspapers. When they publish these letters, work your social media networks and make it go viral.
  3. Call up your professional organizations (AAFP, AMA, ACP, AAP, etc.) and make sure they are going to DC to keep pressure on the legislature to maintain the core benefits of the ACA. If you have time, travel with them to DC to speak to congress in person.

Women’s Health

Another prominent goal of the Republican party is to make it more difficult for women, especially poor women, to have access to birth control and abortion. As physicians, we bear witness to the impact of unintended pregnancy and cannot stay silent on this issue.

  1. As above, call your congress people, write op-eds, and work with your professional organizations to keep pressure on the legislature to protect access to affordable birth control. A great talking point here is emphasizing that access to affordable birth control is the most effective way we know of to decrease the rate of abortion.
  2. Set up a recurring donation to Planned Parenthood. With public funding under threat, private financial support of Planned Parenthood is more important now than ever. This is a vital organization which provides

Social Determinants of Health

As much pride as we take in our work in the diagnosis and treatment of disease, when it comes to improving the quality and quantity of our patients’ lives, healthcare is a drop in the bucket. Directly addressing many of these social determinants of health may feel like it is outside your purview as a medical professional. However, we also have an obligation to Do No Harm and without an understanding of social determinants of health we can inadvertently counteract the health gains we make through our clinical work. Hopefully I can do more to flesh out this list over the next few weeks. Please send me items you think I should include here!

  • Anti-Racism
    • As a society founded on the mythology of White supremacy, every one of us is socialized into White supremacist beliefs. This is not a question of being a Good or Bad person, but rather about the cognitive biases we can’t help but internalize. The first step in any anti-racist work is introspection into the ways in which we’ve been socialized into White supremacy and act on that socialization without realizing it.
    • White Coats For Black Lives has put out a call for medical professionals to commit their time and energy to anti-racism. Answer that call here.
    • Learn more about anti-racism efforts by following these people on Twitter.
    • Wear a Black Lives Matter lapel pin. However, make sure that it’s not performative allyship but rather a constant reminder to demonstrate that Blacks Lives Matter through your clinical and public works.
  • Immigrant Health and Rights
  • Anti-Poverty
    • Welfare programs and their beneficiaries are easy political targets. Using the above methods, speak up for high quality programs to promote economic safety net programs, especially cash assistance. A promising advocacy target here is cash assistance for all children which you can read about here.
  • Housing
    • Housing is very much a hyper-local issue. Seek out housing-first programs in your city and advocate for them.

Get on Twitter

I know it’s fun to dismiss social media, but there are some amazing physician activists on there whose writing has been incredibly helpful in broadening my thinking about where healthcare fits into the larger goals of a just society. Here’s a follow list of medical activists to start with. While you’re at it, check out this list of great anti-racist writers.

Welfare and Wellbeing

I’ve been listening to The Uncertain Hour by Marketplace’s Wealth and Poverty Desk. This season, they’ve taken a deep dive into the United States’ welfare system and the consequences of welfare reform in the 90s.

The podcast provides a great introductory education about American poverty, a topic where opinions are strong and facts are frequently scarce. Interviews with families receiving cash welfare benefits reveal the daily compromises and anxieties which are the lived reality of America’s poor.

Equally disturbing, however, are the interviews with the middle and upper class people who maintain political control of America’s welfare system and the profound contempt for the poor which suffuses their conversations about poverty and welfare.

It’s easy to understand why we have failed to develop a coherent, evidence-based system for addressing poverty in America when you listen to these people and realize that their primary goals are to shame and punish the poor for daring to seek joy or create life, actions that lie at the core of our common humanity.

Two thousand years ago, Jesus of Nazareth pushed back on the prevailing idea that poverty was God’s punishment for sinfulness. Today, in a country where nearly half of the population claims loyalty to his Good News, we remain in this punitive mindset.

I am biased in this conversation because my daily work brings me face-to-face with the suffering that poverty creates, the shorter and sicker lives the poor live out in the midst of abundance. But I truly believe that if our anti-poverty initiatives were crafted by people with direct experience with poverty and designed specifically to promote joy and reduce suffering in our fellow human beings lives that they would be radically different than the systems we have today.

%d bloggers like this: