Fight for a More Equitable Future and Commit to Our Social Contract: Advice to the Medical School Graduates of 2023
This commentary is adapted from commencement speeches delivered by Victor Dzau at the University of Pittsburgh and Tulane University.
Graduates, as newly minted health care providers, researchers, and educators, you join thousands of others around the globe connected by the ethos of health and medicine. Like all of us drawn to this field, you chose this profession because of a deep desire to help the sick, relieve suffering, save lives, make new scientific discoveries, find cures, and guide patients through some of the most profound moments of their lives.
Today, you have completed your education and training, and you are ready to finally begin your career. However, this moment is even bigger than that. As the newest participants in our health and biomedical system, you have also been empowered to help shape its future. This may sound a bit grandiose, but I believe that by doing so, you’ll be shaping the future of our entire nation as well.
It is astounding to think about all the medical breakthroughs I’ve witnessed since I first became a doctor. But, as amazing as these developments are, the health challenges our society faces today and in decades ahead simply cannot be addressed by medicine as we currently know it.
Our current approach focuses on treating disease and illness. But we need a fundamental shift to deal with pandemic threats, climate change, systemic racism and health disparities, population aging, and the growing epidemic of chronic disease.
To address these existential threats, medicine and research must expand their missions to consider the systems, environment, communities, and world in which we live and function. We cannot strive to improve health without addressing the corresponding social and economic factors that shape it.
Similarly, there can be no health equity without social equity. Just look at the decline in life expectancy in the United States over the past few years.[1] It’s hard to believe something like this could be occurring here, in one of the world’s richest countries. But it is clear we are going backwards on decades of progress.
What is driving this trend? The COVID pandemic, to an extent, but far more to blame are the social determinants that fuel health inequity – factors such as poverty; food insecurity; and lack of access to health care, good education, or adequate housing. We now know that zip code matters much more than genetic code. Patients living just a few miles apart can expect life expectancies that vary by 10, 20, or even 30 years or more.
We see that in Pittsburgh, PA, for example. The Squirrel Hill neighborhood is overwhelmingly White and well-educated, with median incomes in the triple digits. Residents can expect to live well over 80 years on average. But just a few neighborhoods over in Homewood North, residents earn an average of $20,000 per year and are less likely to have health insurance, with average life expectancies closer to 65 years.[2]
Think about it – individuals in low-income neighborhoods could die as much as 15 years earlier than those in more affluent areas.
These two groups – the “haves” and the “have-nots” – are headed in different directions with respect to health. And to a large extent, this is due to social inequity.
On top of this, science and medicine are being politicized in ways that I have never seen before. Research and evidence – which have long been the bedrock for everything we do – are being disregarded at times in favor of political agendas. I am the president of the National Academy of Medicine, a nonpolitical and independent organization that provides trusted and objective advice to the nation irrespective of who is in power. We do not take political sides, and we work with each administration and Congress to provide our best advice.
However, we do speak up when government policies negatively impact science, health care, and health. Recent legislative and judicial actions determining what kind of care our professions can or cannot provide, what type of research can or cannot be conducted, or when and how we can engage in these activities can threaten the autonomy of medical practice, the nature of scientific research, and the integrity of our health system.
Medicine has a social contract with society. Society grants scientists and practitioners trust and respect, but this is predicated on the understanding that we draw on our evidence-based expertise to address the needs of our patients and our communities. These political actions are an immediate threat to this contract.
The U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization raises important concerns for patient care. The ruling opened the door for state legislatures to pass highly restrictive laws that can have significant negative impact on reproductive and prenatal health care for hundreds of thousands of women. I am concerned about the potential consequences of this decision on equitable access to reproductive care, especially for women of color, women with low incomes, and people who live in rural areas. I am also concerned that it forces physicians to grapple with difficult ethical and legal questions about how to provide safe care under regulations not rooted in science.[3]
In another example, in March, a Texas judge reversed the provision of the Affordable Care Act which requires health insurers to cover many basic preventive services at no cost to the patient. If upheld, this ruling would make prevention harder to access and more difficult to afford, and will no doubt further drive the United States closer to being a nation of sickness, versus one emphasizing prevention and wellbeing.[4]
Research is not immune, either. Until recently, Congress prohibited federal funding of all research on firearm violence and injury, including research focused on public health approaches to prevention, identifying risks and underlying causes, and intervention and injury reduction.[5]
Actions like these are threatening our ability to provide the best care and research we possibly can. What’s worse, this is happening when we are already facing so many other daunting challenges in health and health care today.
Graduates, as you can see, we really need your help. As a field, we must move in a different direction. Abraham Lincoln once said, “The dogmas of the quiet past are inadequate to the stormy present …. As our case is new, so we must think anew, and act anew.”[6]
The same is true today. We need to make a fundamental shift – to not only treat disease, but also treat inequity and indifference in our society.
To today’s medical graduates – to truly help our patients, we must become active participants in reimagining our role so that we are improving community and population health. We must learn to drive social change and build social cohesion and trust. And we must push back on political interference and defend our autonomy in practicing evidence-based medicine.
Kirsten Bibbins-Domingo, the Editor-in-Chief of The Journal of the American Medical Association, and colleagues have written about how medicine must evolve a new type of clinician: the physician – public health practitioner – a physician who is not only focused on care delivery, but on prevention and health promotion.[7] I have written in the Lancet that tomorrow’s physicians must be community connected, culturally and racially sensitive, and socially responsible.[8]
To those who are pursuing research fields, you must consider how to accelerate the translation of basic science. It is no longer enough to focus your efforts solely on the process of discovery. You should also consider research questions within a societal context, and from there, work backwards to find a solution. You must design studies with social good in mind and consider important issues like access and affordability.
So, graduates, how can you become these scientists and physicians of the future, and how can you affect population and societal change? I want to offer a few pieces of advice.
First, for physicians, see your patients in context. Of course, you must try to understand how their lifestyle contributes to their health or their illnesses. However, you should also pay attention to the confluence of systemic variables that determine where and how they live, work, and play, as well as the systemic privileges or inequities which drive these factors.
We can no longer stay in the ivory tower after we leave the hospital, the clinic, the lab, or the classroom. If we hope to help our patients, we must understand how people are struggling, and why. Which neighborhoods do they live in, and how does this affect their health? Can they access affordable housing, healthy food, adequate transportation, high-quality education, or job training? We must take action to try to make those conditions better for our patients and for everyone.
Second, your work should be better integrated with community and public health. Join forces with community health workers, public health professionals, and social workers. Coordinate your clinical care with community services such as counseling, outreach, and social programming – or advocate for these partnerships within your system.
And to all of you – physicians and researchers – be champions of science and evidence. I’m reminded of the words of Albert Einstein: “The right to search for truth implies also a duty; one must not conceal any part of what one has recognized to be true.”[9] You have been fortunate enough to receive a first-class education – and with that fortune comes the responsibility to speak up and share what you have learned with others.
However, to do this effectively, physicians and researchers must also do a better job of engaging with and building trust with patients and communities. We know that lack of trust in medicine provided fuel for the rampant spread of misinformation during the pandemic. It caused many to reject vaccines and avoid seeking out the medical care they desperately needed. Building trust is crucial if we want to enact sound health policies and combat disinformation and miscommunication about science and medicine.
To gain trust, you must meet people where they are. This requires not just talking but also listening; being willing to hear concerns without judgement. It means asking the right questions and giving people time to feel comfortable enough to answer. These individual efforts can go a long way in building preparedness and resiliency within our communities.
Finally, don’t stop at creating positive changes only for those that you serve – go further and activate change in your communities. For one, speak out when you see policies that are detrimental to health and science. But even more importantly, get involved in shaping these policies in the first place, so that we can be confident that they are good for our patients and communities.
Graduates, you have chosen your career wisely. As physicians and researchers, you are truly capable of making a difference. We need leaders who not only are able to solve problems and treat individuals but also can also effect societal change. I believe each of you can become such leaders. As Lincoln said, you can help us all “think anew, and act anew,” at a time when we really need it.
I am truly excited for you. You are the leaders of tomorrow, and you hold the future of our health and health care system in your hands.
References
[1] Centers for Disease Control and Prevention. 2022. Life expectancy in the U.S. dropped for the second year in a row in 2021. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220831.htm (accessed May 30, 2023).
[2] Associated Press. n.d. Local life expectancy. https://interactives.ap.org/local-life-expectancy (accessed May 30, 2023).
[3] McNutt, M., and V. J. Dzau. 2022. Decision to overturn Roe v. Wade could worsen reproductive health in U.S., exacerbate health inequities. https://www.nationalacademies.org/news/2022/06/decision-to-overturn-roe-v-wade-could-worsen-reproductive-health-in-u-s-exacerbate-health-inequities (accessed May 30, 2023).
[4] Dzau, V. J. 2023. Coverage of preventive services in crucial to protect health and contain health care costs. https://nam.edu/statement-by-nam-president-victor-j-dzau-coverage-of-preventive-services-is-crucial-to-protect-health-and-contain-health-care-costs (accessed May 30, 2023).
[5] Dzau, V. J., and A. I. Leshner. 2018. Public health research on gun violence: Long overdue. Annals of Internal Medicine. https://doi.org/10.7326/M18-0579 (accessed May 30, 2023).
[6] Lincoln, A. 1862. Annual message to Congress, final remarks. https://www.battlefields.org/learn/primary-sources/abraham-lincolns-1862-annual-message-congress-final-remarks (accessed May 30, 2023).
[7] Bibbins-Domingo, K., and A. Fernandez. 2022. Physician–public health practitioners – the missing academic medicine career track. JAMA Health Forum 3(3):e220949. doi:10.1001/jamahealthforum.2022.0949.
[8] Dzau, V. J., M. H. Laitner, and C. A. Balatbat. 2022. Has traditional medicine had its day? The need to redefine academic medicine. The Lancet 400(10361):1481-1486. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01603-8/fulltext (accessed May 30, 2023).
[9] National Academy of Sciences. n.d. The Einstein memorial. http://www.nasonline.org/about-nas/visiting-nas/nas-building/the-einstein-memorial.html (accessed May 30, 2023)
