Medicine has changed. As an emergency doctor, I have too. | Perspective

One year ago, doctors across the country pushed back against what could have been an easily overlooked tweet from the National Rifle Association. The organization told doctors to “stay in your lane” on gun laws, after noting that articles in a medical journal advocated for safer gun policies. That prompted a loud affirmation from medical professionals, including emergency physicians like me, that we have a unique and supremely qualified understanding of how policy — in this case on guns — affects patients. And we want to use our voices to fight for better.

This was perhaps the most public reflection of physicians’ advocacy work in recent months. But my own journey from physician to physician-advocate has taken years.

Physicians have not always been seen as advocates of broad issues, but rather as authorities in one realm. Doctors have historically been trained as experts to identify pathology in the cells, organs, and organ systems that make up the human body. We focus on one-to-one patient interactions and treat their health information with confidentiality and respect. In so doing, doctors have typically worked within the fortress of the medical system. Collaboration beyond the walls — with other professions and other realms — was limited.

As an emergency physician, I don’t have my own patients, but instead am available to whoever needs me in emergency care. In this role, I have realized the system I work in is ideal for rapid response to immediate crisis: heart attacks, strokes, gunshot wounds. As harrowing as those life-or-death crises are, what is far more difficult to tackle are the long-term problems facing my patients: flawed social systems that constantly left them vulnerable. Lack of insurance coverage didn’t prevent me from responding to medical emergencies, but it certainly shrank the resources available to my patients once they left my care — what medications they could afford, or where they could follow up for reevaluation.

I soon learned I had to tailor my treatment to not only the specific illness, but also to the context of the whole patient. What could be a simple infected cut, easily treated with antibiotics, in one person could turn into a large festering abscess in someone living on the streets with little ability to keep their wound clean and dry.

Nothing in my career made this clearer than the overdose crisis in Philadelphia. Before headlines reported on the rising death toll, I worked with nurses, techs, and security to pull people, blue and lifeless, out of cars stopped in the ambulance bay. Before it was commonplace for police and ambulances to be armed with naloxone, we would try to revive people brought in by paramedics. We did this daily in South Philadelphia, sometimes every hour.

These experiences made me realize that my best work as a physician would not come from staying within the fortress of medicine.

But again, the most straightforward part of the treatment was revival, the immediate response. We struggled with how to help after the person was awake and alert. Many did not understand how close to death they had come and wanted to walk out the door without any further medical care.

When social workers talked to these patients, they asked questions I never heard for other medical conditions: What county do you live in? Do you have ID? Have you been using heroin for at least a year and has this been documented? Even worse was when I didn’t hear these questions, which meant the patient just received a dense information packet with phone numbers to call. Those people were more or less left to navigate the system alone.

These experiences made me realize that my best work as a physician would not come from staying within the fortress of medicine. It would require informing policymakers on the gaps in systems — from insurance to mental health to housing — that I saw hurting my patients on a daily basis.

I entered the policy realm, first to answer questions as an expert on subjects like opioid use disorder. In the world of medicine, decisions hinged on data and clinical evidence. But I was surprised to learn this was not always the case for policy decisions that would affect entire populations. I couldn’t believe I was often the only practicing physician at many of these discussions. With an increasing sense of responsibility, I ended up serving on the Mayor’s Task Force to Combat the Opioid Epidemic in 2017, and several related committees and advocacy tables since.

I am not alone in this work, although sometimes it still feels lonely. Increasingly more doctors in the United States are, like me, a woman. That change has tracked with a political shift in doctors going from “America’s quintessential Republicans” to being mostly Democrats, as the Wall Street Journal reported this month. I think this political shorthand is oversimplified. It feels natural that as the profession becomes more diverse, physicians are bringing new perspectives and missions to the field. My approach is based on data and clinical knowledge, and also my experience as a mother, person of color, daughter of immigrants, and resident of South Philly.

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And as a physician, where other people might look at recent headlines and see political infighting, I see patient crises: the defunding of reproductive health services, family separations and other immigrant safety issues, astronomical health-care costs, gun violence, the rise in “deaths of despair.” The urgency of these issues demand that physicians elevate issues, voices, and stories from the front line of care to the desks of those in power.

My view of “my lane” as a doctor has grown. I now see it as making my knowledge and skills available to those who need them most, whether patients or policymakers, large hospital systems or community organizations. This work most often includes people — such as those living in poverty and mental illness, and nonwhite communities — who have been marginalized by our medical system and the policies governing it. While I still question where my lane fits in neatly, I believe that work is needed now more than ever before.

Priya E. Mammen is an emergency physician and public health specialist.

Priya changed her mind about her role as a doctor. The Inquirer’s opinion team is looking for more stories of changed minds — a time when you shifted perspective, whether on your job, family life, politics, personal preferences, or any other issue large or small that affects your life. We will run a collection of these essays in our Thanksgiving Currents on Dec. 1, hoping to capture a spirit of resolution for the holidays. Have ideas? Email us: opinion@inquirer.com.