We, the people: About the Village
A career in family medicine means you often have to think outside the box that is created by the traditional clinical encounter. When a patient steps into my clinic room, their chief complaint is laced with social, emotional and historical undertones.
It is my job (and the teaching goal of the Duke Family Medicine Residency Program) to understand each individual in the context of their sociocultural environment. Each individual has their own story about how and where they grew up as well as the traumas and successes they faced that shape them, their attitudes, and their health beliefs. To ignore their history is to do them an injustice in understanding their journey to health and to never fully realize their potential in achieving true health.
As such, at the beginning of another year, in addition to challenging myself to reflect on “me or you, the individual,” I have been reflecting on “we, the people” and the roads that have brought us to 2017.
When we look at American society, we cannot ignore how our nation came to be and how that currently influences the way we deliver health care and what that identity has become for the American people. It would be an injustice to look at American society without understanding its history, its origins and its traumas and successes that have shaped us as a people, our attitudes and our health beliefs (…and invariably the way we execute health care).
I cannot accomplish nearly enough of that truth in one blog post; nor do I intend to. My only goal is to prompt a thought process and a (brief) insightful analysis.
‘We, the people’
Our country was established on the foundation that we were separate and exceptional. Colonists, unsatisfied with feeling unrepresented and used, made a collective decision to declare independence against oppression. We were willing to sacrifice love and life so that the “we, the people” could prosper.
We were founded equally on a democracy; a government of, by, and for the people (i.e. the collective). This is the principle that we hold dearest to our identity and yet in many situations is the furthest from what we actually strive for in this day.
We declared to the world that “we, the people” was stronger, more powerful, and different than an individual, the autocracy. We chose and valued the collective, rather than the individual. And this sentiment, of the collective separatism and exceptionalism, has arguably influenced our behaviors and interactions as a nation.
Internalization of An External Presentation
As an undergraduate in the School of Public Health at the University of Maryland, College Park, I spent a semester learning about how American sport culture was a direct reflection of social sentiment of the time; how society formed sport and how sport formed society. The most obvious examples we still see today are in baseball and football, two distinctly American sports created and elevated as a parallel of the separate society “we, the people” have formed.
If we open our eyes even more, we can see the result of American exceptionalism and separatism all around us as exemplified by the way we measure temperature, length and speed, in our political campaigns and foreign policy, and even in our health care insurance system. However, while in the early century of the establishment of our nation this sentiment was more an external response to other countries, the continued perpetuation of American exceptionalism and separatism has now moved from an international to an intranational image and relations policy. Our constant desire to show the world that we are better and exceptional to them has infiltrated the way we see and relate to one another. This has allowed individualism to grow and collectivism to gradually decline. It is my posit that this attitude is what is leading to the gradual deconstruction, distrust and discontentment of the American people.
Collective Fear
We now look at one another as separate, working hard to make our individual selves greater than the “other,” ignoring the impact of our footprint on our society, environment and relationships. You can see the results of that in the increasing rates of divorce in the baby boomer population, the perpetuation of racist ideals and red lining of impoverished communities, our social definition of success as monetary wealth, and even something as simple as our increased interest in gyms with individual workout equipment rather than community associations and exercise clubs.
We even see it in health care and the historical increase in subspecialization (Graduate Medical Education that Meets the Nation’s Health Needs). In discussing future career plans with the medical students and residents in our programs, my colleagues and I are finding more and more of them are making decisions on specialties based on individual financial incentives of specialties, often prioritizing these over their actual interest in those areas and the demands of the populace where they choose to practice. We are so resistant to meeting the collective demand because of our ingrained fear that collectivism, a once defining principle of our democracy, is now inseparable from communism, “Sovietism,” or socialism.
Lately I’ve been reading the book “The American Healthcare Paradox.” There’s a great historical reflection on the American Medical Association and its lobbying power in the early 1900s.
“The AMA voiced its disagreement through the elocution of Morris Fishbein, editor of the Journal of the American Medical Association, who in 1932 articulated the sentiment in cold war terms, describing the choice to endorse a universal health insurance scheme as being one of “American versus Sovietism for the American people”…The outcome of the debate on universal insurance during this time now seems predictable; the AMA and its supporters were successful in appealing both to the national ideology of individualism and to concerns that expanded government involvement in health care would ultimately be unaffordable.”
About the Village
To come full circle, this policy of individualism is most evident in our health care system by looking at the basic delivery of health care. Our entire clinical encounters and medical education focus on a reactive, downstream intervention based on an individual and their experience of health; we are not structured or determined to look at the population, community and collective as a whole and address common, underlying and preventable structures for the benefit of the greater good.
The kind of health care system we have now can never lead to the health and healing of a nation. We will never realize the full potential of quality and quantity of life in our nation by continuing to ignore each other’s ailments because of our individual hurt.
When we stop holding on to this idea that collectivism is dangerous to our society, we may actually be able to come back to the roots and the good intentions that our forefathers wanted for this country.
The prospering of the collective inevitably brings about the prospering of the individual, but the same is not true vice versa. It may take a village to raise a child but ultimately it’s about the village, or else that child won’t survive.
Sam Fam is a second-year resident with the Duke Family Medicine Residency Program. Email samuel.fam@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine, the Duke University School of Medicine, or Duke University.