Why we Must Learn About Our Patients’ Communities

When I imagine the ideal physician, I think of Dr. Drew Miller. You’ve probably never heard of him and you definitely won’t see his name in any journals. I found him in a town of 2,500 people in the middle of rural Kansas where he practices as a full spectrum family physician. In one day, Dr. Miller and I rounded on the local nursing home, checked on the half dozen county hospital inpatients, delivered the baby of a family he’s known for years, staffed a couple of emergency department visits, performed two colonoscopies and two endoscopies, and saw a dozen other patients aged eight months to 85 years.

Everywhere we went, we were greeted with warm smiles and deep gratitude from elders and parents who had known Dr. Miller since high school. For that little community, Dr. Miller was a rock, their local son who’d returned to serve
with deep humility and kindness.

When I returned to Manhattan for med school, I didn’t just reacclimate to hectic city life—I acutely felt the contrast in medical practice. My attendings were brilliant. But patients mostly lived in East Harlem while their physicians lived primarily on the Upper East Side. Their families went to different schools and dined at different restaurants. In the fast-paced world of specialists and tertiary care hospitals, longitudinal community relationships were hard to establish and maintain.

Despite these limitations, most clinicians still identify serving their community as a primary motivation for  entering the profession. Almost every physician has a story to tell about patients they’re still in touch with or a family they run into at the local café. Yet taken as a whole, clinicians would admit that most healthcare institutions have complex relationships with the communities they serve, in part because of the divide between the physician population and the patient population.

Dr. Miller was woven into the fabric of his patients’ community. In Manhattan, I realized I was attempting to serve a separate one. That gap isn’t primarily the fault of physicians. There are larger structural issues at play. For one, there’ll always be a disparity in power between clinicians and patients due to many years of specialized training and the language of “medicalese.”

Despite training expenses and industry pressures, physicians are usually some of the wealthiest citizens in America once they become attendings. Given the fact that the majority of doctors still come from affluent backgrounds or relatives who’re physicians, the class divide begins even before the income gap. And in the U.S. that divide is typically racial as well, since generational wealth and access to medical education are still limited for BIPOC individuals. Look around your hospital—physicians rarely look like or live like the people they serve.

To make matters worse, decades of racist public policy have segregated our communities. American cities are defined by middle-class and largely white suburbs surrounding under-resourced primarily minority working-class urban neighborhoods.

Our commitment to our patients’ community cannot stop at the walls of the hospital we commute to. Here are three practical steps to bridge the gap and foster true community integration:

1. Live in the community you serve.

When you first moved to your current city, how did you pick a place to live? Data shows that most of us end up living in areas where the neighbors look like us. It takes deliberate effort to learn from and be shaped by the community we directly serve.

When starting the most intense years of medical training, Dr. Nick Christian, now chief resident at UT Dell
Internal Medicine, made an improbable lifestyle commitment. As an intern, he moved into Community First! Village, a tiny housing community for the previously homeless. 20% of these homes are reserved for “missional” community members who provide support as their neighbors get back on their feet. After work, he found himself drawn into conversations, lending a hand, and jamming out to music with his neighbors. Dr. Christian didn’t see this as a sacrifice. In fact, he identifies his time in this community as the most rewarding part of his life. Over the course of his residency, he helped create a health system-wide buprenorphine initiative that garnered national recognition.

Any physician who has made a conscious effort to live in an underserved community will tell you that
earning trust and gaining cultural understanding is extremely gratifying. But they’ll also tell you that living

in a disadvantaged community is really hard. Food deserts may make it hard to live the lifestyle you want. Crime rates may leave you hesitating to start a family or even go on a jog. The school system and municipal services may be so underfunded that you find it impossible to stay.

2. Invest in the local community.
Even if living in an underserved area is impractical, every physician can consciously and intentionally support their patients’ community. Instead of eating out at a chain restaurant, find an immigrant-run restaurant and ask to meet the owner. Then leave a generous tip. I’ve even met several BIPOC clinicians who’ve consciously chosen to use a portion of their income to develop local real estate and revitalize the neighborhood.

Also,  invest your free time. Meet the local community organizers. Find out who organizes art showings or music nights and make it a priority to attend. Go to cultural events and festivals, befriend religious leaders, and meet elders who remember what the neighborhood looked like 50 years ago.

3. Learn from the community.
Being shaped by a place doesn’t require being born there. We love to praise physicians like Dr. Miller who practice where they grew up. We instinctively grasp that their choice to practice where they have roots gives them incredible trust among the community. Making intentional choices over time will allow you to call any place home.

Relationships take your investment of time and effort. Cultural humility means leaving the comfort zone of like-minded neighbors and friends and earn the invitation to be in spaces we know little about. Medicine has begun to acknowledge and discuss social determinants of health, but we have a long way to go in actually understanding them outside the hospital context.

As you plug into the local area, delve into the history of the place. Learn the labor laws and housing policies that have created the disparities you see in your patient population. Talk to local activists about why certain housing projects haven’t been renovated. Find local historians who can tell you about hospital decisions that may have fractured trust or city leaders who left a trail of broken promises.

If we truly believe that the social determinants of health are critical to clinical outcomes, we must consider understanding the local context as part of our job. Imagine a world where pulmonologists can speak articulately about local pollution regulations as well as asthma guidelines. Where cardiologists can present on rounds about local zoning laws that perpetuate food deserts. Being an advocate for your patients includes being an advocate for their community.

When you meet people in their environment and show interest in the life of their community and engage with their struggle, they’ll respond differently when they enter the strange and sterile confines of the hospital. The small-town family physician may be increasingly rare, but it’s time to make the disconnected clinician a thing of the past.

Regardless of where you live, we can all take tangible steps to be a part of the community in which we practice. It takes intentionality and hard work. It requires humility and time. And it will make you a better clinician for the patients you care for.

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.