DPC News

DPCs Inherent Advocacy vs. Activism Struggle Among Its Doctors. Opinions Abound, Patients [and Physicians, as of late] Now Find It ‘Off-Putting.’

There are so many grumpy 😡 opinions in healthcare, often exhibited in comment threads by young Physicians as well towards older Physicians. Let this be a simple but caring reminder of the basics of debate courtesy of my visit to the 7th grade last night. 😀 #familymedicine #wecandobetter #internalmedicine #patientburnout #docscandobetter #fundamentals #FORDOCTORS Photo Credit: The DPC Journal; 2019

Even DPC is not immune to free market forces and is it developing a reputation? If so, what type of reputation? The Inherent Advocacy vs. Activism Struggle Abounds Among Young Medical Doctors. Patients Find It Off-Putting …


HOW THE DEMOGRAPHICS of DPC ARE CHANGING AND GETTING YOUNGER [eg Patients and Doctors] (C) The Direct Primary Care Journal | All Rights Reserved.

“While sad, it’s true. Today, most young Doctors will quietly hold their nose and accept their [employed] fate [after residency],” says a northeastern United States Physician who wishes to remain anonymous whom we reached out to for comment at the writing of this article. “There is a strong focus in medical school by professors on the social benefits of medicine and being an employed Physician. Additionally, there is a shift in medical school towards urban healthcare and Team-based Primary Care. A lot more young Doctors are also becoming more content with socialized medicine as the status-quo and are willing to adopt and accept the teachings they receive from their medical school professors.”

The 2019 Free Market Healthcare Delivery and its family tree is much larger than simply DPC alone. Credit: DPC Journal (C) 2019

By Michael Tetreault, Editor, The DPC Journal (The Direct Primary Care Journal)

Updated April 2019 – A friend recently said to me ‘Offend as little as possible, and BE offended as little as possible.’

I love that philosophy.

Today, the free market healthcare delivery market is competitive and yes, that includes DPC. A Patient doesn’t have to wait long at most Doctors offices these days to find that empathy, compassion and respect for ones needs is hard to find in healthcare. One observation in this space and DPC is not immune and can at times, fuel the fire of debate … is that young Doctors are leading the charge of change in healthcare. While this is great in many respects, young Doctors (and sometimes even more passionate voices) leave a wake of brash commentary that makes a lot of others look just as colorful.

So let’s examine and unpack this Inherent Advocacy vs. Activism Struggle which Abounds Among Young Medical Doctors today and why Patients Find It Off-Putting.

Generally most people graduate college at age 22 and medical school at 26. Then after 3 years of internship and residency, many physicians begin their career at age 29. However, the training for some specialties can last until the physician’s early to mid 30’s. Today, more and more younger Physician’s in their 30’s and 40’s are finding themselves at various forks in the road.

(EDITOR) Halo and Horn Effect: the Differences & Similarities Between Concierge Medicine and DPC and Today’s Cognitive Bias By Some Young Doctors

Their much older colleagues and mentor-like Physician’s have written over the years and said that they [e.g. young doctors] graduate and complete their residency and must now face the inevitable inexperience which awaits them. They’ll be asked to handle the nuances, difficulties and challenges that being an employed Physician brings, choose whether or not to participate in managed care, opt or stay in with Medicare, accept declining reimbursement year after year and the litany of issues as you know could fill pages of our publication. With numerous forms to fill out, patients to see and other urgent problems to be on the watch for, many young doctors probably will not find the time to use the resource book they studied.


”Physicians are inherently activists,” said Dr. Lurie to the New York Times in 2003. Dr. Lurie works for the health research branch of the consumer advocacy group Public Citizen. ”These are people who say, ‘I’m going to do everything I can about a patient’s condition,’ ” he said. ”What we’re doing is bringing that instinctual activism all doctors have to the social arena.”

So what do they do?

It’s an intersection that seems to grow more frustrating and contentious by the week.

Ideas Are Formed In Medical School.

2019 | Latest Polling Stats

In a recent 2018 Position Paper published in: Ann Intern Med. 2018;168(7):506-508., DOI: 10.7326/M17-2058 at www.annals.org on 27 February 2018, the ACP concluded … The educational and social milieu of medical learning environments is a complex system of influences. Role models across peer relationships and the hierarchy of medicine contribute to the formation of professional identity, behaviors, and attitudes of future physicians. The best solutions to the influence of the hidden curriculum will uncover it, integrate its positive aspects into the formal curriculum, and lead to development of approaches to understand and mitigate its negative aspects by educators and practicing clinicians. The hidden curriculum in medicine presents challenges but also opportunities to help reshape not only education but also the culture of medicine.

After residency, some young Doctors show their inexperience and unprofessional colors by turning immediately to social media because it’s quick and easy. Could it be the dopamine of “likes” to follow from other unhappy Doctors that enables today’s social media rants by today’s Physicians?

Jonathan Cabin, MD writes a great article last April where he writes The disruptive nature of social media is putting a dangerous damper on this delicate and finely-tuned ability. When we go back-and-forth from the intensity of operating to Facebook Live narration, or spend regenerative time between consults mindlessly scrolling through Instagram, we are suffering an expensive switching cost, ultimately upending the vital flow of focused thought. Absent this flow, I fear we are practicing medicine beneath our potential. A recent New England Journal of Medicine Perspective piece put it succinctly: “It’s ironic that just when clinicians feel that there’s no time in their daily routines for thinking, the need for deep thinking is more urgent than ever.”

Dr. Eric Van De Graaff, a cardiologist at Alegent Health who blogs at the Alegent Health Cardiology Blog wrote this recently is an article entitled Why are so many doctors complete jerks? He said…

We doctors have chosen professions that are inherently filled with stress, deadlines, and treading in deep emotional waters.  None of that grants us a free pass to behave like spoiled toddlers.  As I see it, doctors should always follow two simple rules:

Rule #1: It is simply not allowable to be impolite, mean, nasty or snippy with staff or patients even when you are in a stressful situation.

Rule #2: Whatever is stressing you is probably stressing those around you as much or more.  Under those circumstances you have to go out of your way to be kinder and more understanding.  As a doctor, you control the mood in the clinic and operating room even if you can’t control the situation.

I freely admit I am unable to always adhere to these rules, but I at least recognize them and intend to spend the rest of my career trying to do better.  My mother passed away many years ago, but I’m hoping that somewhere up there she can look down and see that I didn’t turn out to be so terrible after all.

Bias is “as natural as breathing” says AAMC

The AAMC and The Ohio State University Kirwan Institute for the Study of Race and Ethnicity convened a forum in 2014 to examine how unconscious bias affects academic medicine and to identify strategies to mitigate the impact. Those discussions are the basis of an upcoming publication, Unconscious Bias in Academic Medicine: How the Prejudices We Don’t Know We Have Affect Medical Education, Medical Careers, and Patient Health.


In Politically Turbulent Times, Where Are the Boundaries for Physicians?

“If we want to address disparity and quality of care, we have to tackle bias,” Castillo-Page said. It is not only physicians who need to be aware of it; a receptionist can be the gatekeeper in a medical setting, too, she noted. Similarly, patients have biases that affect care providers, such as when a female physician is mistaken for a nurse or a patient refuses treatment by a doctor from another country.

Training students to keep biases in check “This is an area where a lot of schools can grow.” ~AAMC, 2014

LaTanya Love, MD, said AAMC programming inspired her to develop workshops on unconscious bias for medical students and faculty at the University of Texas Health Science Center at Houston (UTHealth). “This is an area where a lot of schools can grow. [Unconscious bias training] is expensive in time only and can be done for minimal cost,” said Love, assistant dean for admissions and student affairs and diversity and inclusion at UTHealth Medical School.

Social Media Is a Drug. Should Doctors Act Accordingly?

A Huffington Post writer said recently, Activists do themselves a disservice if they alienate advocates who believe just as passionately as they do, but choose to go about implementing change in a different way. There is still a role for the advocate who walks into the building while activists make their voice heard outside it. For further clarification, the Huffington Post writer wrote There is an important role for those that express their First Amendment right to protest; to disrupt traffic and commerce; to line a building with picket signs. And I hope it never stops. But there is also a role for the advocate willing to sit across the table from an object of a protest to build a road map for reform. These days, the most successful models demonstrate that you have to reform the system from within the system to change the system.

2019 Insights | Analysis | Trends

Historically, physicians have leaned politically conservative but have grown more liberal as younger people, women and minorities have entered the medical workforce, Khullar says.By analyzing more than 20,000 physicians across 29 states politically affiliated by voter registration, Yale researchers put the split at 35.9 percent Democrat, 31.5 percent Republican, and 32.6 percent independents or third parties, according to their 2016 article in the Proceedings of the National Academy of Science of the United States of America. (Source: American Association for Physician Leadership, October 29, 2017)

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians

This was taken directly from the DoSomething.org website.

What is an activist/advocate? What is the different between the two, and which am I?

Activism and advocacy are terms that are often used interchangeably, and while they do overlap, they also have distinctly different meanings. It’s important to remember the distinctions especially if you plan to participate in either activity, so that you know what you’re talking about, and so you know how your actions are different.

An activist is a person who makes an intentional action to bring about social or political change.

Example: Rosa Parks was a civil rights activist who challenged racial segregation in 1955 by refusing to give up her seat on a bus for a white man.

An advocate is one who speaks on behalf of another person or group.

Example: Angelina Jolie is a United Nations Goodwill Ambassador (UNHCR) who uses her talent and fame to advocate for refugees.

Activism, in a general sense, can be described as intentional action to bring about social change, political change, economic justice, or environmental well being. This action is in support of, or opposition to, one side of an often controversial argument.

The word “activism” is often used synonymously with protest or dissent, but activism can stem from any number of political orientations and take a wide range of forms, from writing letters to newspapers or politicians, political campaigning, economic activism (such as boycotts or preferentially patronizing preferred businesses), rallies, blogging and street marches, strikes, both work stoppages and hunger strikes, or even guerrilla tactics.

An advocate can also be involved in controversial activities or issues, but because they are speaking on behalf of a group, they tend to be more likely to follow the paths of lobbying and legislation. They are also often part of a bigger group, such as Angelina Jolie speaking on behalf of the UN, or Don Cheadle speaking on behalf of Save Darfur. This is of course not always the case, but these distinctions are sometimes defined in such ways.

Because these actions often overlap, a lot of the information that we’ve included can be used by and activist or an advocate. There aren’t always specific lines that separate roles or actions, but you should use these guidelines to come up with a plan for effective action that’s best for your organization or group.

Political activism for physicians — voting, campaigning, donating and even running for office — is supported by the American Medical Association, the United States’ largest physician organization.

“Physicians have the right to be political actors in this country; doctors are citizens, too,” says Jack Deutsch, an AMA spokesman. “As such, the AMA strongly believes that physicians are entitled to the benefit of protected political activity, including making their concerns and grievances known and petitioning for change.”

AMA Code of Medical Ethics’ Opinion on Physician Advocacy | AMA Council on Ethical and Judicial Affairs

The organization’s [e.g. AMA] Code of Medical Ethics lays out such support:

“It is laudable for physicians to run for political office; to lobby for political positions, parties, or candidates; and in every other way to exercise the full scope of their political rights as citizens.”


NY TIMES: Medical Students Go Beyond Books to Learn About Activism

Danielle Ofri, MD in an article entitled Should Doctors and Nurses Be Patient Activists? wrote “I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

Do young Doctors vote for the change the write, march, call, comment on and voice their opinions about? The data from the October 2016 report by the Annals of Internal Medicine actually says ‘No, not really.’

Physicians historically have low turnouts during elections. An October 2016 report by the Annals of Internal Medicine says doctors vote at rates 9 percent lower than the general population and 22 percent lower than lawyers — a trend that hasn’t changed since the late 1970s.

“My view is that it would be better to try to influence that discussion and those policies rather than sit back and let it happen to us,” says Dhruv Khullar, a resident physician at Massachusetts General Hospital, whose writing on the intersection of medicine and politics has appeared in USA Today, the Washington Post and other general-interest publications.

Unconscious Bias in Academic Medicine: Overcoming the Prejudices We Don’t Know We Have

“Most young Doctors will quietly hold their nose and accept their fate,” says a northeastern United States Physician who wishes to remain anonymous whom we reach out to for comment at the writing of this article. “There is a strong focus in medical school by professors on the social benefits of medicine and being an employed Physician. Additionally, there is a shift in medical school towards urban healthcare and team-based medicine. A lot more young Doctors are also becoming more content with socialized medicine as the status-quo and are willing to adopt and accept the teachings they receive from their medical school professors.”

Doc Says: “Someone has to say it ‘The cliques in DPC or one way attitude among some in DPC is a turn off to DPCs future Physicians. Grow up.’”

In medical school at the very beginning of my career as a pediatric cardiologist and bioethicist, I was introduced to a famous painting titled The Country Doctor by Sir Luke Fildes. As parents watch and pray in the background, a doctor is sitting solemnly next to a dying child. This painting is classically used to depict the devotion of the doctor, and to remind young doctors in training of the importance of being present for the patient and the family, even when medicine can no longer help.

In an article written by Angira Patel in Scientific American earlier this year [e.g. March 2018], she writes … Physicians are trained to be objective and apolitical. Because the values of scientific objectivity are so prominent in the medical field, physicians are hesitant to join the sphere of advocacy. Certainly, it may be easier to tell ourselves that these issues belong in the space of policy and politics—physicians should simply take care of their individual patients.Many medical societies recognize physician advocacy to be a critical part of medical professionalism. The American Medical Association, in its declaration of professional responsibilities, has stated that physicians must “advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” The American Board of Internal Medicine, in its charter on medical professionalism, called for a “commitment to the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician.” But despite the official recognition of physicians’ value in the political conversation, knowing how to put advocacy into practice remains problematic. There are thoughtful perspectives on what physician advocacy can look like, but no data exist on how many physicians actually participate in advocacy work.

Dr. Van De Graaff writes Now that I’ve been in practice a number of years I’ve finally learned what it was that so intensely turned my mother off about doctors: they can be arrogant, condescending and impolite.  Of course, many of my readers are at this moment wondering if I’m also going to reveal other mysteries such as “birds fly” and “dogs bark.” I had a roommate in medical school who was a great guy.  He studied hard, didn’t party too much, and always managed to put the toilet paper on the right way (rolling out from the top down, in case you were wondering).  Years after we graduated and had gone our separate ways I had a phone conversation with a physician assistant who’d gone to work for my old roommate.  “It must be great working for Dr. X,” I added.  A pause on the phone.  “No,” he said slowly, “he’s a total jerk.  Everybody hates him.” I have two theories.  One is that all medical students believe they will go on to become an Albert Schweizer in their field—kind, self-sacrificing, benevolent—but somewhere along the way a certain fraction of them let the glory of their career go to their heads and begin to treat patients and underlings like chewing gum on a movie theater floor.  What constitutes that percentage is in the eye of the beholder.  For my mother, it was somewhere around the 98% mark.  I’m a little more generous—I’ll say 20%. My second theory is that all doctors believe themselves to be noble, kind, and beloved by all.  Rarely do I come across an arrogant doctor who recognizes him- or herself as such.  Rather, almost all of us think we’re appropriately mannered.  And we are … most of the time.

Is Grumpy, Bad Behavior A Learned Behavior Among Physicians? The data say, “Possibly.”

Graduates Report Differences

Out-of-class behavior by medical school faculty members should match in-class lessons on ethics and behavior, the American College of Physicians (ACP) says in a new position paper published today in the Annals of Internal Medicine. It found that more than half of medical school graduates in 2016 said they saw differences between what they were taught about professional behaviors and what faculty members demonstrated outside the classroom, according to the paper. The authors say that over time, observed behaviors can change the culture of medicine. They describe a hidden systemic bias against primary care, for example, that “contributes to the U.S. health care system being unprepared to meet the needs of an aging population. Negative comments from leadership and greater financial rewards for sub-specialists can discourage students from choosing primary care despite societal need, intellectual rigor, and the importance of longitudinal healing relationships.”

Med School Faculty Behavior Should Match Class Teachings, ACP Says

And so we conclude with these thoughts to ponder:

“As much of our society becomes politicized,” Khullar says, “all these things enter the doctor-patient relationship, as well.”

It all raises questions: Is there still a place in modern medicine for a physician to put all of her or his care and worry into just the patient? Or is physicians’ involvement inevitable and even necessary given today’s political climate? And if physicians do get politically involved, where are the ethical boundaries in terms of how it affects the care they provide?

Khullar suggests legislation, regulation and political opinion always will creep into a physician’s practice regardless of her or his neutrality. “If it is your choice to explicitly stay out of the political arena or to not be involved in any way, that is a reasonable personal choice,” he says. “But you also need to recognize that the flip side of that is these forces are still going to impact you and your patient.”

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