Good Trouble

“Do not get lost in a sea of despair. Be hopeful, be optimistic. Our struggle is not the struggle of a day, a week, a month, or a year. It is the struggle of a lifetime. Never, ever be afraid to make some noise and get in good trouble, necessary trouble.” —Rep. John Lewis, former US Congressman

Anyone remember the movie 2020, where a global pandemic strikes, repeated police brutality against unarmed Black citizens sparks global antiracism protests centered on fighting social and racial injustices, and family medicine faculty, residents, and students rise up to combat systemic racism on behalf of their patients, their communities, and themselves? Wait, that wasn’t a movie; it is real life—right now. 2020 has unearthed a festering wound of the underbelly of America and laid bare the infectious, purulent cesspool of social injustice, racism, hate, and disparity that has continued to ferment for centuries. It may appear as hyperbole, however the dramatic impact of this year’s events requires a statement of truth, and no less.

The late and honorable Representative John Lewis, who dedicated his life to the fight for racial equality and social justice, reminded us not to despair, especially as we fight the good fight. He charged us to “make some noise and get in good trouble, necessary trouble.” Racism is a health crisis and the time is now for family medicine to get in “good trouble” and answer the call to action.

Family medicine as a specialty is well positioned and best poised to lead action and meaningful antiracism change because we understand our patients not only in terms of their pathophysiology, but also in terms of their relationships, their communities, and their social context. As family medicine educators, we practice and teach the biopsychosocial model of care accounting for social and physical determinants of health, and we understand the impact on our patients’ ability to live healthy lives. With the brutal murders of George Floyd, Breonna Taylor, and Ahmaud Arbery in the past few months, our whole nation has been shocked to our deepest core with outcries to end racism and the racist systems and policies at its very foundation. Police brutality and its devastating and disproportionate effects on the Black community are at crisis levels. Racism and the repeated trauma of experiencing racism has a direct influence on physical, mental, emotional, and spiritual health, and we must recognize its detrimental effects on our patients, our communities, and our society. In health care, we see the short-term and long-term effects on the overall health of our Black, Indigenous, People of Color (BIPOC) who face racism along with macro and microaggressions on a regular basis. The actions we take cannot just be about not being racist, but must be focused on being antiracist and reconstructing a system of policies, practices, attitudes, and actions that will yield equitable outcomes, power, and opportunities for all people, irrespective of race. The hope is that family medicine can take these action in our own practices, in medical education, in our communities, and even beyond to bring about change, better health, and justice.

Key actions for antiracism change include these four areas: building partnerships, changing policies, addressing practice, and leveraging positions. Dismantling institutional racism and its inherent structures requires partnerships and full engagement of all racial, ethnic, and cultural groups with collective and shared power to develop solutions and break down barriers. Family medicine educators and learners can identify and work with community partners, governmental agencies and elected officials, organizations, and businesses actively engaged in antiracism efforts as a part of educational curricula and clinical training programs.

Racist behaviors and actions, whether overt or covert, are frequently embedded in long-standing policies that may intentionally or unintentionally enforce the oppression and denial of rights of BIPOC communities. These policies exist at local departmental, organizational and governmental levels, and at the state and federal level. Educators and learners can actively engage in changing policies by reviewing current organizational policies and practices for potential bias and examine the current environment for opportunities to develop new and equitable policies. Policies may include human resources/work-related policies, advancement, promotion and tenure (APT) policies, educational curricula, patient questionnaires and procedures, and community-based policies (ie, housing, transportation, and immigrant health). People of color and/or members of the disenfranchised group must be included with equal power and representation in the process of changing and developing policies.

Sustainable change requires practice change. Decades of doing the same things and expecting different results has brought us to this moment in which the apathy and acceptance of the status quo will no longer be tolerated. Putting policies into practice requires each of us to address changing our practice and our behaviors. This change in practice must be reflected in the exam room as we care for our patients embracing their identities (race, ethnicity, culture, pronouns, etc). We are urged to inquire about, affirm, and address their experiences of racism in health care and in society, and the overall impact of racism on their health and well-being. The change in practice must be reflected in our clinics and organizations as we investigate our patients’ experiences as they interface with our established systems and scrutinize our disparate patient health outcomes for system failures rather than ascribe such health gaps to patient noncompliance.

Politics drive policy, therefore leveraging positions is critical. Representation has power and having family medicine leaders in positions of power within academia and within health systems may transform practices and educational models to be better aligned with community medicine and population health principles centered on diversity, equity, inclusion, and antiracism. Additionally, family medicine leaders may serve in legislative roles on school boards, city council, and state legislatures achieving broader policy changes. Family medicine advocacy and our communications with our local, state, and federal legislators are fundamental actions for antiracism reform.

During this unprecedented year, we have been tested and tried through the most daunting and difficult of circumstances and the prevailing commonality that exists is racism. Racism is a shameful and nefarious constant impacting the lives of BIPOC communities. The realities of the pandemic and the killings of unarmed Black Americans continue to hit people of color again and again, compounding perceptions of threat, fear, anxiety, distrust, anger, trauma, and pain.

The struggle is of a lifetime and this is the time for family medicine educators and learners to make some noise and get into “good trouble, necessary trouble.” We cannot do it alone. We need partners. We must change policy. We have to address how we practice. We must and we will lead the way.