Saturday, June 9, 2012

Family Medicine: Coming Out of the Closet

When Kentucky Academy of Family Physicians Executive Director Gerry Stover sent out the call for delegates to the National Conference of Special Constituencies (NCSC) that I wrote about in my last post, I figured I would be the only one to apply as the Kentucky delegate for the gay, lesbian, bisexual, transgender (GLBT, or LGBT) caucus. After all, there are only ten physicians and nurse practitioners in Kentucky listed on the GLMA website that serves as a guide for patients looking for providers welcoming of gay, lesbian, bisexual and transgender patients.
Many of these providers are not GLBT themselves, nor do you have to be to serve on the caucus, but usually those of us who do identify as part of that community are more motivated to assume advocacy-related positions.

 I still don’t know if anyone else applied for the position, but imagine my surprise when our International Medical Graduate delegate sought me out at the conference only to tell me he himself was gay and wanted to be an advocate for GLBT and IMG physicians being more active in organized medicine. “I can’t get any other doctors to get out of their offices and into the world,” he complained. “I’m in the Rotary Club, I talk at the schools, and I’m here to make policies that will improve things for all of us! Don’t they understand how important their voices are? I’m frustrated because it seems that they just want to sit and complain instead of working to change things.”

 Of course low participation in civic life is a result of everything from being overwhelmed with work to the belief that efforts would be wasted because nothing ever changes. But my colleague was so desperate for participation from his fellow minorities because the voices most visibly absent in the conversation are the ones most likely to stay in the proverbial closet. The closet typically refers to gay or transgender individuals’ ability and choice to represent themselves as straight or gender “conforming” in certain public places, but we’re not the only ones who have such a closet. Other minorities, including International Medical Graduates, may face similar pressures to conform to cultural norms about what physicians should look like or how they should participate in society. The closet also implies that coming out of it is something not only disruptive, but also too personal, too selfish. It’s the old argument: social status recognitions for minority are perceived by them as civil rights while the majority view these recognitions as undeserved special privileges.

 How does one “come out” appropriately? What is the level of disruption that creates positive progress in achieving social justice and what level is just self-serving attention-seeking? All of us GLBT-identified physicians have experienced our own discernment concerning coming out. Many of us can’t or don’t want to “pass” as straight. I have had colleagues who found it important to look “gay,” partly to advocate for their right to be themselves but also partly to avoid awkward ambiguities in which colleagues or patients would wonder about their orientation but be afraid to ask. They feel that patients who are uncomfortable having a GLBT physician will either gain acceptance and appreciation or go elsewhere for care.

 Others of us, however, do not necessarily appear stereotypically gay, lesbian, or transgender. I for one, was still in my own discernment process during medical school and early residency, and in medical school was embedded in a culture that was implicitly but distinctly, “don’t ask, don’t tell.” When I returned to the same school to work a number of years later, I was relieved to find that a small group of more courageous students and residents had taken the lead in creating an LGBT organization and effectively introduced “outness” as an acceptable value in the medical school. But I had also accumulated a network of colleagues for whom I wasn’t officially out to, and faced the perpetual question of whether to actively hide, passively hide, or reveal my orientation to both colleagues and patients.

 And this process has made me wonder whether this same kind of discernment is what Family Medicine has been going through for the last 15-20 years. Our specialty has been politically active and flush with visionaries and accomplished researchers since its inception in the 1960’s, but it has really only been since the health care cost crisis and the rise in the “top research university” culture of the major medical colleges that specialties have competed so directly with each other and have begun to be “valued” for their ability to bring in financial windfalls rather than valued for outcomes for patients.

 In the 1990’s the Clinton administration gave voice to a movement for a return to Primary Care as the basis of the health care system. About the same time, the Future of Family Medicine project launched a major study of what patients wanted from their care and then crafted a plan to have Family Physicians change systems of care to better serve patients. Yet, years later, when we introduce ourselves as Family Physicians, most people still respond with, “so you’re a GP?”

 What happened to the Future of Family Medicine movement? It strikes me that we were too afraid to really come out of the closet at that point. We knew that fewer and fewer Internists and Pediatricians were doing true primary care. We knew that Family Doctors were almost single-handedly providing primary care (as well as a decent slice of obstetrics and surgical care) to the vast expanses of rural Americans. We knew that medical school admission processes and physician compensation inequalities were driving a relentless trend toward specialization rather than primary care. But coming out then might have risked too much backlash from specialty organizations, powerful health insurance companies, or policymakers at a time in which it seemed primary care in general might actually get enough investment to really modernize. So we lumped ourselves into the vague “primary care” pool. We changed our name slightly but only marketed to specialty colleagues instead of to patients because we didn’t have the resources to do both. And mostly we stayed semi-closeted because we don’t believe in being self-serving. We aren’t in this for outrageous salaries or high prestige; we believe that specialty care and technology are important even if over-used, and we want to play well with others. Coming out more as a distinct and critical specialty or pressing for recognition and media attention legitimately risks appearing to compromise our stance as working for patients instead of ourselves. So, notwithstanding an outspoken few in our midst, we stood in the closet doorway and hoped the system would change enough that we could sneak out quietly. 

Wouldn’t it be nice if we didn’t need non-discrimination statements or laws that specify civil rights? Wouldn’t it be great if we all recognized each other’s role and talents in the world, or in the health care system? If we all just understood that we need at least 30 and maybe even 50% of our physician workforce to do true primary care if we hope to give most of our citizens quality care without us all going bankrupt? If all sorts of health providers could just meet regularly and endorse the policies that are most likely to benefit as many patients as possible long-term? Unfortunately we know that it is not that simple, and so my IMG colleague is correct – to make change we have to make our voices heard. I genuinely believe that Family Physicians want to reform the health care system for the benefit of patients, but to do that we have to advocate voraciously for the changes that will move us in that direction. Under the current system of health care financing and organization, we will never get people to access health care appropriately or efficiently. Family Physicians may have to claim more rights and recognitions in order to gain the legitimacy we need to effect change.

 Now that the economy has worsened and health care costs and “Obamacare” have brought the concept of reforming the system back into the public eye, Family Doctors’ leadership in the primary care medical home and accountable care organizations are getting attention and the kind of financial support they need to conduct real trials to see if these systems can improve care. But to keep this movement going, we have to step out of the closet for real. It doesn’t mean that the coming out will look the same to the public, to medical students, to policymakers, or to our colleagues. Clearly we don’t have a characteristic look or mannerism that will make this easy. And the public’s equivalent to a Family Doctor “gaydar” must have been blocked by the American Medical Association years ago. But perhaps our ability to pass as the friendly generic docs of the medical system gives us a little more leverage. We can come out on our own terms. The myth of coming out is that it happens all at once in some big declaration, but that isn’t the case at all. It is a complex process over time that does indeed involve personal, social, and political considerations. In the end, I made declarations over a period of years to myself, my parents, and most of my friends and colleagues, some of whom had helped me in my discernment. But while I don’t actively hide my orientation now, I still do choose to “pass” to some of the patients or even sometimes colleagues for whom declaration at a given time does not seem worth a risk to the relationship.

 One of the tools that has made this more balanced and subtle coming out process possible has been the Internet, specifically social media and email. It is has been much easier for me to be myself and let people know my orientation in ways that are non-confrontational and more comfortable and effective on both ends. Similarly, these tools hold out hope for Family Medicine to come out as ourselves – as a myriad of voices rather than one large organization. As people declaring that we are not somehow more important than other pieces of the health care system, but that we form an invaluable cornerstone that needs investment and a fighting chance to make this system work for patients, families, and communities.

 Many of us who went to the NCSC continue to send this message to the higher organization in terms of pressuring the AAFP to promote Family Medicine directly to the public. In the meantime, we send the call of #FMRevolution through the Twittersphere and repost on our Facebook pages every article that dares to use the words “Family Physician” instead of “PCP.” Larry Bauer of the Family Medicine Education Consortium leads a group of Family Medicine doctors and associated professionals dedicated to using the media to come out little by little both locally and nationally. Mike Sevilla interviews FM leaders on his blog and satellite radio program while many other Family Docs have started emphasizing their specialty and what it means on the radio call-in shows or local newspaper columns they’ve done in their hometowns for years.

 Just this week, my Family Physician journalist colleague Ranit Mishori had this excellent article published in the Huffington post. We’re all now proverbially slipping it under the doors of our patients and friends through our own email, Facebook, or Twitter.

 One of the most satisfying experiences that a gay or lesbian person can have is finding out that someone who held negative views of LGBT people changed their mind after knowing you. Many of those people become the most valuable allies in speaking out for civil rights and institutional change. I hope that Family Medicine converts can and will do the same. Even if our patients don’t seem to know that we are Family Doctors at first, once they get to know us, we need to come out to them. We need to make them into our most valuable spokespeople. One patient at a time or at the highest levels of leadership: it’s your choice, all of you Family Physicians out there. Your choice, but please make your voices heard.

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