Family Medicine, Community, and Race: A Minneapolis Practice Reflects

Abstract

The uprisings for racial justice that followed the brutal murder of George Floyd on May 28, 2020 in Minneapolis, Minnesota damaged the physical building where a family medicine residency is situated. We discuss the emotions that follow that event and reflect on ways that family medicine should address racism and discrimination. We also call on those in family medicine to work more in the communities that we serve, and to make advocacy a core part of the identity of family medicine.

On May 28, 2020, Broadway Family Medicine (BFM) clinic, the physical building in which our family medicine residency is situated, was looted and vandalized during the now infamous Minneapolis, Minnesota uprisings for racial justice in the aftermath of the brutal murder of George Floyd by an officer of the Minneapolis Police department. Throughout the next day, we waited powerlessly as our clinic manager asked us to not venture near the clinic because security cameras still showed ongoing looting. Following that event, we felt a deep sense of loss and began reflecting more deeply on the important work the clinic and the residency program that it houses has done in the community, a vibrant and predominantly Black neighborhood with as much complexity and beauty as one of its most well-known native sons, the rock icon Prince.

As we entered the building 2 days later, a host of emotions arose: a sense of loss and grief, a feeling of being violated, and the foreboding sense of uncertainty about how we would continue to take care of our patients and teach our residents. But the overwhelming sense we felt was deep pain and a gnawing acknowledgment that our community had been let down many times over and over.¹ The anger, pain, and frustration local residents felt after years of marginalization, disenfranchisement, and disinvestment were now manifested in the broken windows, flooded rooms, ripped security cameras, and the charred remains of small fires throughout in our building.

Before George Floyd’s humanity was ignored and silenced, before Ahmaud Arbery was hunted down and killed in the street, and before Breonna Taylor was murdered in her bed—all victims of the deadly effect of racism—Minnesota had Philando Castile. Castile, a beloved nutrition services supervisor at an elementary school in St Paul, Minnesota, was gunned down by the police during a routine traffic stop on July 16, 2016. While many at our clinic the next day were distraught, one of our wise elderly Black patients said “… Doc, this is new to you. You are hearing more about this because of Facebook and Twitter. This is not new to us. Our parents warned us about this. We tell our kids about this. We tell them … don’t expect fairness, don’t trust the system, expect oppression. …” The resignation in those words was striking.

We take pride in our feeling that our community makes us relevant. In the past, whenever there have been suggestions to move our clinic to more affluent suburbs, we have reiterated the importance of working with the North Minneapolis community; we have worn it as a badge of honor. So then, if the community is what makes us relevant, should we not look at look at how relevant we have been to the community? Over the years we have addressed the clinical needs of community members who have come inside the walls of our clinic. The frustration evident in the aftermath of May 28th indicates that there is much more we must do to fully address the needs in the communities in which we work.

ADDRESSING RACISM AND DISCRIMINATION

As medicine and society become more aware of overt racism in everyday life and reflect on the subtle racism that is insidious and pervasive, we should be talking about structural racism within health care. Fellow family physician Dr Camara Jones’s words “We cannot address the impact of racism without recognizing its many faces and forms, and its self-reinforcing nature,” reminds us to be vigilant. The disparities in coronavirus disease 2019 (COVID-19) care and George Floyd’s murder are part of the same continuum—a lack of access to quality care, and discrimination and sustained inequities perpetuated by systems of which we are a part. Family medicine’s and organized medicine’s complacency in this as we have engaged in clinical care makes us complicit in the racism and discrimination that we see around us. We renew the call for understanding and addressing structural racism in health care to be a core part of the training in family medicine. Family medicine also needs to recognize that racism is but one form of discrimination in society and to be vigilant in recognizing, addressing, and mitigating intersectional oppressions our colleagues and patients face. Family medicine training and practice must include the recognition of power, the challenges of discrimination and historical trauma, utilizing frameworks of structural competency, cultural humility, and cultural safety.^2,3

WORKING IN COMMUNITIES

The significant stress that health care systems have faced with COVID-19 has led to a recognition that organized medicine is “person-centric rather than community-centric.”⁴ We have looked at our communities as loose affiliations of individual data points; most of what masquerades as population health in the United States is management of panels being churned through a productivity-driven health system. It is time for family medicine to look at working in true “populations” holistically. This would mean that we will see communities as the true denominator in population health studies; that patients will be treated in the context of the communities in which they live and that the society in which we work is “the total network of relations between human beings.”⁵ Modern health care has been accused of being dissociated from communities. Family medicine should be the discipline that blurs the lines between the 2 worlds of clinic and community. We have done well in incorporating clinical medicine and quality metrics into our everyday existence. After all, clinical knowledge is relatively more concrete, quality metrics are more mathematical. We have not, as a rule, paid enough attention to our role in the community, often engaging in unorganized ways—volunteering, and as advocates. Engaging directly with communities is one of the most effective ways to address social, structural, and political determinants of health.⁶ It should be the mainstay of the practice of family medicine, not a cute side-project. Future training and practice of family medicine should ensure effective community engagement strategies, work with organized public health, and work outside the clinic. We must ensure that clinical medicine and community engagement are 2 equally important structures that define our field, and that we will be weaker as a discipline if we do not.

ADVOCACY

The fact that family medicine grew as a countercultural movement in the United States is an important legacy for us to consider. We must be catalysts for the change we want in our health systems. Engaging and understanding the challenges of our patients’ communities should be at the core of our professional identity. If it is not, we will have to revisit an admonishment by one of our founders, Gayle Stephens, from 30 years ago: “I have sometimes thought that our cumulative effect on the body politic of medicine has been conservative more than liberal or radical. In many ways, by our success, we have ‘taken the heat off’ the medical profession from the public; therefore, the status quo is being preserved. …”⁷ Family physicians must be at the forefront of advocating with communities and patients. Being effective advocates, to engage and influence the political and policy structures, should be part of the training that a family physician undergoes.

A sign outside the church across from our clinic reads, “You can’t heal what you can’t reveal,” a quote attributed to the musician Jay Z. The uprisings for racial justice that resulted in damage to our clinic revealed a much deeper pain and anger in our community than we had been able to acknowledge or even begun to address. Our community in North Minneapolis is leading the healing, and as family physicians, we must be a part of this healing.