November 7, 2025
Dear Interested Readers,
Politics, Primary Care, and the Social Determinants of Health
Tuesday’s elections brought a little bit of relief for those of us who have suffered a sense of loss every day since President Trump’s second inauguration. On Wednesday morning, I read Jamile Boule’s opinion piece in the New York Times about the election. He expressed my feelings more eloquently than I could. I have bolded some of his words that resonated with me the most. He wrote:
In 2024, the Americans who decided the election voted for lower prices and a lower cost of living. What they got instead were soldiers on the streets, masked agents leading violent immigration raids, arbitrary tariffs, new conflicts abroad, dictatorial aspirations, endless chaos and a president more interested in taking a wrecking ball to the White House to build his garish ballroom than delivering anything of value to the public. At this moment, in fact, the government has been shut down for more than a month, the House of Representatives has not been in session since the middle of September, and Trump is still talking about defying multiple court orders to restore food assistance to hungry families, even though his own administration announced that it would partially comply.
Both Trump and his administration are less interested in helping ordinary Americans than they are in fulfilling their idiosyncratic program of austerity, pain and deprivation. They are all stick, no carrot.
It’s against this backdrop that voters just went to the polls and cast millions of votes against the president by way of Democratic candidates, moderate and progressive, who stood for both affordability and the nation’s most cherished values, who pledged to use their time in office to protect their new constituents from the provocations and assaults coming from the government in Washington.
Make no mistake, from the president’s war on DEI, “wokeness,” academic freedom, federal support for medical research and public health to his “One Big Beautiful Bill” and choice of Robert F. Kennedy, Jr. as his Secretary of Medical Quackery and Human Diservice, his administration has been systematically undermining policies and programs developed since the sixties. The health of the nation has suffered, and it will continue to suffer as long as he is in office or his MAGA political machine persists in its efforts to redirect the course of our country away from its path toward greater equity and opportunity for everyone who lives here.
No one knows how the government shutdown will end, but I hope that every day it persists, in contrast to his misuse of his office and demonstrated indifference to the needs of our government employees and most vulnerable citizens, we will be one step closer to his political undoing. I view Tuesday’s election results as a small drink of water on a long journey across an expansive desert. There are many miles to go before we emerge from our misery. It is likely that because of the president’s narcissistic personality disorder (NPD), things may get much worse before they get better. It is well known that associations with persons who have narcissistic personality disorder (NPD) rarely end well. If you follow the link, you will read:
DSM-5 criteria for narcissistic personality disorder include these features:
- Having an exaggerated sense of self-importance
- Expecting to be recognized as superior even without achievements that warrant it
- Exaggerating or lying about their achievements and talents
- Preoccupation with fantasies of success, power, brilliance, beauty or the perfect mate
- Believing that they are superior and can only be understood by or associate with equally special people
- Requiring constant admiration
- Having a strong sense of entitlement
- Expecting special favors and unquestioning compliance with their demands
- Taking advantage of others to get what they want
- Having an inability to recognize the needs and feelings of others
- Being envious of others and believing others envy them
- Behaving in an arrogant or haughty manner
- Paranoia
- Total lack of empathy
That is a pretty accurate description of our forty-seventh president. Further on, the article corroborates my prediction that the worst may be yet to come. It states:
Every person has narcissistic tendencies, but it is pathological in the NPD, and ultimately highly destructive to everyone in relationship with that person.
That is enough about Trump, the election, and the shutdown. Last week I introduced you to the podcast offered by the New England Journal of Medicine and hosted by Dr. Lisa Rosenbaum, a cardiologist at the Beth Israel Deaconess Medical Center in Boston, a fellow at the BIDMC’s Smith Center for Outcomes Research, and a national correspondent for the NEJM. Dr. Rosenbaum and her colleagues at the NEJM are focusing on primary care in their current podcast series. The latest edition is entitled Misunderstandings — NOS (Not otherwise specified) Episode 3.3. During the podcast, which you can hear or read by clicking on the link, she talks with several primary care physicians and researchers. I will lift and present to you a few of the most significant comments that I heard in the podcast.
Dr. Rosenbaum’s first interviewee is Dr. Larry Green, a retired PCP, primary care leader, and academic in Denver. He kicks off the discussion by saying:
Relationships are totally unimportant in health care, as far as the medical-industrial complex is — I can tell you that I practiced in the oldest family practice in Denver, for years. I was the chair of that department, I directed that residency, and I’m now a patient in that practice. I cannot call it. It’s impossible. Because when I call the practice, I get diverted to a call center where some very skilled customer service representative asks me who I am, what’s my birthdate, maybe my medical record number. And then I tell them that I want to see my doctor. I can’t get an appointment with my doctor right now for 7 or 8 weeks.
This approach to the system is designed to fill all of those appointment slots as quickly as possible. So when I try to call my practice, I’m offered four alternatives. “Well, we have primary care appointment available at Longtree. Would you like to drive down there?” “No, I want to see my doctor.” “Well, there’s a nurse practitioner who has an opening day after tomorrow at that practice. Would you like to . . . ” “No, I’d like to see my doctor.” Well, if this is bad enough, you can go to our emergency room and the closest one is . . . ” That’s what happens. Now, primary care floats on two boats simultaneously: skillful generalists — clinical generalists who know a bucketload of medicine — and longitudinal relationships.
Dr. Rosenbaum begins her presentation by examining what it must mean for patients seeking help from their PCP when a retired physician, policy expert, and professor of family medicine at the University of Colorado has trouble getting an appointment with his PCP. Dr. Green assumes that his woes are a derivative of the “corporatization” of medical care, which he describes as the “medical-industrial complex,” which is intent on maximizing profits. If you have not been reading these notes since last July, when I began tracking the NEJM’s focus on “corporatization,” I suggest using the search function on this site to catch up with the series or go directly to the NEJM.
Dr. Rosenbaum doesn’t deny Dr. Green’s opinion, but she traces the woes of PCPs deeper and further back in time than the shift to corporate medicine. She states:
…primary care has been in crisis since long before we became fully corporate. And in reminding us that primary care requires these two critical elements —a generalist body of knowledge and relationships…
A little further into the presentation, she presents the definition of primary care offered in 2021 by the National Academy of Sciences, Engineering, and Medicine in their discussion of delivering high-value primary care:
“…the provision of integrated accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”
That definition is a helpful launch pad for several rhetorical questions:
What is primary care, actually? How and why has it been misunderstood? And is misunderstanding really the problem? Or is the problem that the idealized version of the consummate primary care physician, the one who knows as much about you as they do your health, simply a relic of the past — a fantasy people like me need to let go of as we steer primary care, as pragmatically as we can, into the future?
Dr. Rosenbaum is a clinician. Clinicians often convey their teaching points through case histories, and stories are particularly well-suited for podcasts.
The story that came next tried to describe the importance of primary care by her next interviewee’s description of a very complex case that involved a large aortic aneurysm, a renal carcinoma, and esophageal cancer. The PCP’s knowledge of the patient and his family was critical to understanding how to integrate the management of these complex problems within the context of the patient’s personal objectives. The discussion led to a new term for me, “the atomization” of primary care.
Dr. Rosenbaum asks a cultural anthropologist who is also an academic in primary care to clarify the concept of “atomization of primary care” by providing an example. The example she was given was the national focus on hypertension. The decree went out that everyone needed to have a systolic BP under 130. PCPs responded, and hospitalizations for hypertension-related problems went down significantly. A year or so after the report of the decline in hypertension-related hospitalizations, it was observed that hospitalizations for hypotension and related problems had gone up significantly. It appears that the single-minded decree that PCPs should drive down BP readings had some consequences. I think that making PCPs the agents of dealing with an “atomized” list of problems, rather than using their knowledge of the patient to integrate management with the individual realities of the patient, is what is meant by atomization. PCPs often see practice as managing a checklist of metrics and quality scores. Many would prefer to focus on the whole patient and less on hitting the goals they are given in the “atomized” environment. Unfortunately, there are no quality measures for integrating most practice recommendations with patient realities. PCPs’ compensation is often determined in part by numbers about the control of BP, blood sugar, cancer screening, and other issues rather than the more complex and challenging questions of how appropriate the care was to the individual patient when the totality of the patient’s personal profile is considered. Rosenbaum is sensitive to this problem. She states:
Unfortunately, there have long been efforts in this country to distill primary care down to individual parts that lend themselves to standard algorithms. The metrics applied tend to focus on specific diseases or risk factors associated with particular diseases. Which is reasonable, in theory. I would never argue, for instance, that controlling blood pressure or diabetes is unimportant. The problem is that primary care is actually about so much more, and placing so much attention and accountability on these individual parts can come at the cost of the more elusive and unmeasurable whole.
Dr. Rosenbaum’s interviewee adds more:
So if most of the time what you see is not something that has a diagnosis, then how do we say 100% of the time we’re going to hold you accountable to disease-based guidelines? It doesn’t make sense. And if we know that social systems account for 80% of your health, why would we hold doctors 100% accountable for population health outcomes? Why is my doctor held accountable for whether I’m obese or not? She is not here every day checking what I eat or if I exercise, yet somehow that doesn’t matter. She is graded based on the BMI of her patient population. This makes no sense to me.
The conversation presents an excellent overview of the challenges facing primary care clinicians, even before considering the poor compensation compared to other specialties, the challenges of overloaded schedules, and onerous documentation and preauthorization requirements that comprise a significant portion of their daily workload. Primary care clinicians must strive to navigate a course that addresses the challenges their patients face due to the social determinants of health, with limited options to respond that can make a meaningful difference in the moment. The challenges are enormous. Much of the remaining podcast details the difficult job that PCPs have in helping their patients manage their health in a world where the social determinants of health pose a formidable challenge. Her interviewee believes that practicing medicine and helping patients confront the social determinants of health are two distinct jobs. She says:
They’re just two different jobs. And we need both jobs…We thought that actually it’s not going to work, it’s just going to burn out primary care, people are going to leave, there’ll be a lot more bureaucracy. And the actually good medical care will be compromised by having to basically spend all one’s time making phone calls to figure out how does this person get food every day. And they’re not trained for that.
Rosenbaum responds:
They’re not [trained to confront the social determinants of health]. And basically everyone in primary care I interviewed argues that primary care needs more resources to help patients access social services. But in terms of tracing the roots of this impulse, to hold PCPs accountable for outcomes often driven by social circumstances, I suspect it actually arises from an important recognition that just got lost in policy translation. And that recognition is that a person’s life circumstances are as essential to understand as their medical. Family practice in particular has long been oriented toward integrating the social and the biological.
After much discussion, Dr. Rosenbaum makes a summarizing statement drawn from two interviewees about the challenges of primary care practice that resonates with me:
Listening to Etz and Bradley together helped me better understand not just how primary care has been misunderstood, but why. As Bradley pointed out, medicine is heavily scientific and heavily measured. That’s true — and in many ways, for the better. But family medicine, and by extension I’ll include all of primary care, has this additional dimension that I think often defies measurement. Some of that dimension is the integrative function, the putting it all together…But what allows that integration, and what really sets apart the nature of expertise in primary care, is that expertise, at least theoretically, is inextricable from the relationship…
…And the tragic irony of this atomized, technocratic approach to primary care is that the fewer people who have an actual relationship with a doctor, the worse our population health outcomes are likely to become. Yet rather than invest in a primary care system that supports these critical relationships, its funding only continues to decline.
An important question is whether primary care is doomed to fail. Or like big banks, is it too critical to be allowed to fail? The answer she gets from one of her interviewees is:
Absolutely. I actually wrote a commentary with Chris Kohler that we called “Too Critical to Collapse,” and I had exactly that in mind. Nobody believed that any banks would close, it wasn’t even within our imagination. And then suddenly, Bear Stearns one day was gone. Suddenly, Lehman one day was gone. And nobody thought that could happen. It can happen and it would be devastating when it does. What would it mean for us? It means that we would have health diseases suddenly become deadly when they need not be. It means that health burdens would increase, and our means of taking care of those health burdens would be limited to only the most expensive options available to us.
I look forward to diving even deeper into the problems of primary care. It will be a lengthy conversation, but unless we have clarity about the issues, it will be challenging to find workable solutions. The first speaker, the retired professor of primary care, was not describing a rare problem. I am concerned when a friend or family member presents a medical issue to me. I often hesitate to suggest that they see their doctor for advice because I know that my recommendation is a cop-out. Getting a timely appointment to see their doctor may be a nearly impossible task. They are calling me precisely because they know how difficult it will be to get an appointment.
Many doctors who feel overburdened and patients with financial resources are drawn together in “concierge care.” I have very negative feelings about the practice, but I can understand the temptation for an exclusive solution for both tired providers and patients with disposable income. I hope that in the near future, I will find the courage and skill to discuss this “non-solution” solution in more depth.
A Picture As Metaphor
Peter Bloch, my friend and neighbor, puts out a new and beautiful video about as often as I write this letter. He recently posted a fantastic video that I must share with you, or at least share one picture that I have lifted from the video entitled “Wee Wonder #7 ~ Optimistic Loon Chick.” The picture that I lifted is the header for this letter. You will have to look at the video to learn whether or not the big bass in the loon chick’s mouth was too much for it to swallow. I must admit that the effort, and I hope not the outcome, may be metaphorical for the challenges that face us.
The leaves are dull, brown, and mostly down. We are into “late fall,” and awaiting the holidays. We have had some rain. Our drought is improving after a few storms have passed through. The creek coming out of the lake has gone from a trickle to near its usual full flow as its water rushes downhill toward the two sequential ponds that our water must traverse before it passes through “big” Lake Sunapee to join the Sugar River, which flows into the Connecticut River, allowing our water to end its journey in Long Island Sound. Everything is connected—the seasons, our water, our health, and our political problems.
Late fall is a great time to take a walk through fallen leaves and reflect on tackling big challenges and how we are all interconnected.
Be well,
Gene
