The Power of Policy

How would you catalog the following US laws and acts? ¹

• 1788, the US Constitution is ratified—Article 1, section 9 prohibits Congress from restricting the importation of slaves.
• 1862, the Homestead Act—Encourages mostly European immigrants to move westward, providing them with land and education.
• 1882, the Chinese Exclusion Act—Barred immigration from China.
• 1907, Expatriation Act—American women who marry foreign nationals lose their citizenship.

What does this list of policies have to do with the discipline and education of family medicine?

Recognizing policies seemingly unrelated to health as structural determinants of health is the basis of structural competency—our capacity as health professionals to recognize how social, political, and economic forces and structures drive health, illness, and inequities. ² Structural competency builds upon a social determinants of health framework by examining the historical and contemporary structural context that has created and continues to sustain disparities. This type of framework resonates naturally with our lens as family medicine professionals. After all, providing comprehensive care for our patients regardless of the type of problem—be it biological, behavioral, or social—is our core value. ³

I find that our trainees increasingly remind us of the importance of embodying these core family medicine values ⁴ and at times seem to have a deeper understanding of concepts like structural violence and structural racism. As diversity, equity, inclusion, and antiracism become more broadly recognized by academic institutions, programming, training, and scholarship increasingly carry these themes. ⁵ As colleagues in other specialties embrace these concepts, students previously drawn to family medicine are increasingly drawn to live out these core values in other fields. However, recruiting student leaders committed to these values will impact our patients’ well-being for generations. Identifying effective ways to uphold these values in today’s health care landscape is crucial for family medicine education.

In patient care, we can now code for some social determinants of health. Acknowledging the role these determinants play in how our patients can, or cannot, achieve clinical measures of health (eg, lower A1Cs) is indeed a first step. But as family physicians, care team members, educators, and researchers, we can do more. We witness the impact firsthand as we provide care, and our deep commitment to our patients' health equity leaves us wanting to do more. So how do we achieve more? And how do we achieve more without overburdening ourselves as primary care doctors in settings that may or may not be helping us meet the social needs of our patients?

During the peak of the COVID-19 pandemic, I saw how my low-income patients were being inequitably affected by the need to limit in-person care, receiving care primarily by phone, while their counterparts were back to receiving in-person care, or receiving care through video visits. I studied telehealth policy, examined the disparities I was seeing, and wrote a policy report. Soon, I found myself informing state-level telehealth policy—and realizing how influential I could be as a family physician. My voice had the power to transform the health care delivery my patients received. While influencing state-level policy can feel out of reach, family medicine professionals are well-positioned to do so because: (1) we witness firsthand how health-related policies impact our patients, (2) we observe how non-health-related policies are intrinsically health policies, and (3) we are seen as leaders with a credible, well-respected voice, and as such are graciously given the platform to use this voice.

Through policy, we have the power to promote access to beneficial social institutions such as education or material conditions such as working conditions, affect access to health care, and correct social and structural inequities. Our representative organizations offer various opportunities, both short-term and long-term, for us to inform policy locally and nationally. ^6-8 Our local institutions have government relations offices through which we can be a resource and leading voice on health care policy. The Robert Graham Center has avenues for us and our trainees to contribute to the research that brings the primary care perspective to health policy decisions.⁹ The Center conducts and supports analyses on issues affecting our patients, our workforce, our trainees, and primary care as a whole. However, even if we are not yet able to participate as AAFP Key Advocates or Robert Graham Center Visiting Scholars, opportunities to inform policy lie in the problem-solving we already do. Through our own scholarship we too can leverage findings to enhance primary care and the health of patients and communities. We can perform analyses on important issues to bring forth data and patient voice, shedding light on the realities our patients are facing. And in this way, we can shape not only the future of family medicine, but also society.

We can also shape both family medicine and our patients’ lives by engaging our learners in health policy curriculum and action. Students desire training in advocacy and health policy, and they energetically seek out opportunities to improve health care. ^{10, 11} Through experiential learning in health policy, we can leverage this enthusiasm; engender additional commitment to these efforts; foster leadership skills; and concretely influence institutional, state, and national policies. ^11-13 Engaging our trainees in health policy and advocacy is also incentivized by the Accreditation Council for Graduate Medical Education (ACGME). ^{14, 15} For resources, we can find examples of pilot projects for medical schools and residency programs in the literature. ^{2, 11, 13, 16} Additionally, our organizations offer practical resources to support our and our trainees’ learning, such as the STFM free online Legislative Advocacy Course and the AAFP’s State Legislative Issue Backgrounders. ^{17, 18} We have the tools at our disposal, and it is up to us to use them.

Our patients deserve our advocacy. The social and structural inequities they face require it. Being truly committed to advancing equity means we will use our voice and our scholarship to speak out on matters of public health, policy, and social justice. The core values of our specialty urge us to elevate our patients’ voice and experiences to create systems change and improve individual and community health. Let us equip our trainees with the knee-jerk cognizance that non-health-related policies are intrinsically health policies, and illustrate with our own research and policy advocacy activities how to create lasting impact beyond our clinic walls. Here at Family Medicine, we enthusiastically await reviewing and disseminating your scholarship on this subject.