Response to “‘Family Medicine’s Task in Population Health: Defining It and Owning It’ Begins With the Community” and “Family Medicine and Social Determinants”

We welcome and agree with Drs. Michener, Bradley, Martinez-Bianchi, and Andolsek in their comments on the importance of community engagement and collaboration in the conversation around population health and the role of family medicine.1 Our title’s emphasis on “owning” population health2 was intended as a rallying cry for our specialty to not eschew the current opportunities to improve the health of our communities. We would reiterate that we should be partnering with anyone and everyone who works to improve the health of groups of people.

Highlighting the importance of a community-engaged approach is an essential ingredient in this work and we appreciate the way that Michener, et al emphasize this element. Whether we are working on population health, advocating for policy change, or working in research, we face dilemmas and quandaries in how best to do this work.3 We must ensure that we have engaged deeply, avoided token participation, and adequately included individuals and communities. Listening generously, learning from the community, and reflecting on the process with humility are not approaches unique to family physicians, but it is with gratitude that we recognize these as virtues we strive to cultivate in ourselves, our learners, and our teams.

The letter from Drs Campos-Outcalt and Pust4 suggests that the majority of family physicians will not use the skills needed to address population health and so we should focus on the care of individual patients in residency training. Their suggestion that most family physicians will never need or use skills in community engagement, patient empowerment, community organizing, collaboration and teamwork, or the skills for conducting community assessments and identifying adverse social determinants of health saddens us deeply. Not only are these skills identified as necessary in the ACGME Family Medicine Milestones,5 they are identified as ideal in the selected role definition that informed strategic planning and communication efforts of the Family Medicine for America’s Health (FMAHealth) movement.6 The foil definition that stated “the family physician is not responsible for patient panel management, community health, or collaboration with public health” was rejected.

Drs Campos-Outcalt and Pust list one of their desired competencies for residents as “referring patients to community resources that can help address an individual’s adverse social determinants of health.” Collaborating with and referring patients to community resources is important and necessary, but not sufficient for promoting health equity. Overall, their approach suggests a minimalist version of family medicine that avoids the comprehensiveness, adaptability, and community-responsiveness that have been suggested as necessary for rural7 and underresourced settings. This is reminiscent of the debates held about the role and relevance of maternity care in residency training and the existential crisis we face around comprehensiveness in general.8

To mitigate the existential angst for trainees and practicing family physicians alike, we would turn to Kurt Stange’s holarchy of health care in which he proposed a pyramid akin to Abraham Maslow’s. In Dr Stange’s pyramid, we address fundamental health care needs but also move up into the higher levels of integrated and prioritized care that include community and system needs.9 Drs Campos-Outcalt and Pust suggest that we should not add more to the plate of our trainees until they have mastered more basic levels of care, but we would argue that trainees need us to articulate the vision of what it means to be able to foster healing in our health care system. Unless we keep our goals at the aspirational level of community-engagement, fostering healing, and working toward health equity, we will lose our way as a specialty.