Physicians have long lent their voices to issues of concern to the health of the public, many of which were politically and socially controversial at the time. Physician organizations were instrumental in formulating recommendations that led to policies around alcohol and driving. Such policies are normative in much of the world today, contributing to reductions in motor vehicle–related morbidity and mortality and resulting in one of the greatest public health triumphs of the 20th century.1 Physicians have been deeply involved in advocacy around tobacco control, resulting in comprehensive tobacco legislation that has contributed to substantial declines in tobacco-related morbidity and mortality over the past decades.1
Physicians have also been engaged in what is perhaps one of the most pressing and contentious issues of the present moment: gun violence. Physician organizations here have led the way. The American College of Physicians, the largest medical specialty group in the United States, has long advocated for a policy-based approach to address firearm morbidity and mortality in the United States, culminating in a set of recommendations published in 2014 about approaches to reduce the effects of gun violence.2 The following year, the American College of Physicians joined a group of 52 organizations in a call to action to consider gun violence as a threat to the health of the public.3 The American Medical Association, the largest physician organization in the country, endorsed a variety of gun control measures in 2018.
Individual physicians have capitalized on more modern means of communication to engage on the issue of gun violence. Galvanized, perhaps ironically, by a tweet from the National Rifle Association that urged physicians to “stay in their lane” and away from the issue of guns, thousands of physicians tweeted their experience of treating those who have experienced gun violence, appropriating the hashtag #thisismylane, and arguing that physicians had a unique perspective on the consequences of gun violence, and, as such, that their voices matter in the broader societal debate about gun safety.4
Yet, this picture of physician involvement in public health issues of consequence omits complexity around this same physician engagement. Gun violence has been essentially endemic in the United States for the past 20 years, long before physician groups endorsed policy efforts that may mitigate the consequences of guns. The new wave of physician voices about guns trails the public conversation that has been raging since the Sandy Hook massacre in 2012. Physician voices have been weak on a range of other issues that occupy the present public health moment, including, for example, the roles of racism and income inequality in shaping health.5,6
Several factors may contribute to physicians’ hesitation when considering engagement with issues of public health consequences.
First, the physician’s role centers on the individual patient-physician relationship. This is canonical in medical school training, inculcated in physicians from the first day of medical school. Much about the role of physicians flows from this orientation. At core, physicians see their responsibility as being to the patient in front of them and, as such, are concerned with the determinants of health of the individual. These determinants, it turns out, are often quite different than the determinants of health of populations.5,6 While comprehensive efforts to limit unfettered access to guns may be essential for reducing the burden of gun violence, such policies are not particularly relevant to the health of an individual patient for whom depression may be a much more important risk factor for potential suicidal ideation. Therefore, the physician’s focus on individual health requires physicians to focus on causes that differ than those that preoccupy population health scientists.
Second, physicians are protective of the integrity of the patient-physician relationship. This leads to appropriate caution about creating barriers between physicians and their patients. At a mundane level, this extends to issues of physician dress and manner.7 Physicians are trained to behave in a way that makes the patient comfortable so that patients may be forthcoming in their conversations. It is not unreasonable to imagine that a patient will be reluctant to discuss safe gun storage with the physician if the physician is well known to have voiced perspectives about gun safety. Ultimately, the need of the physician to be seen by patients as a welcome listener on all aspects of concern to the patient may be at odds with a public presence on contentious issues.
Third, physicians have traditionally not been trained or prepared to lend voices to issues that extend beyond the clinical interaction. Medical journals are replete with articles about the clinical encounter, and physician scholarship has predominantly been concerned with the foundational role of physicians as healers. Although some innovative programs around the country have aspired to train a new generation of physicians in broader advocacy and public engagement, these remain few and far between. Physicians may then be neither prepared for, nor comfortable with, lending their voices to issues that are drawing substantial attention and controversy in very public debates about their merit. The democratization of communication via digital media adds weight to this concern. Physicians are all too aware of the perils of leaving a long digital footprint, in formats that may lull the user to make extemporaneous statements, that then may label a physician in perpetuity.
These 3 forces suggest caution for physicians weighing public engagement around issues of public health concern and may explain the relative slowness with which physicians have engaged such issues over the past few decades. However, there are equally important countervailing forces that urge that physicians do lend their voices to the public debate and that, indeed, physicians may have little choice but to do so.
First, and most centrally, physicians continue to be seen as the keeper of the public’s health. While medical professionals recognize the distinction between the clinical encounter, the role of the physician, and the role of the public health practitioner, this distinction is largely lost on the general public, including on policy makers and politicians. Leaders of chief health departments and agencies remain predominantly physicians and the surgeon general is charged with leading the Public Health Service; hence, the silence of physicians on issues of public health consequences is not value neutral. Although the medical profession may have its reasons for not engaging around issues of gun safety, the absence of physician involvement is seen in the broader public as a marker that the issue is not of health concern. In the context of guns, for example, it suggests that guns are primarily a criminal justice issue and not a public health issue, substantially impeding efforts to create a policy framework that can mitigate the consequences of gun violence.
Second, physicians have unique access to the population. It is the role of physicians to engage in conversations with individuals from all walks of life around issues that may harm their health. While public health professionals may create campaigns to sway the public conversation and influence legislation, ultimately, physicians have access to people that no other profession has. By way of analogy, while public health efforts may resemble advertisements for a candidate for political office, the patient-physician interaction may resemble the door-to-door canvassing that is well-recognized to be key to the election of any candidate. In other words, it is inaccurate to see the role of physicians as separate from the role of public health professionals. Insofar as efforts to improve population health require policy actions that rest on individual implementation, little will be achieved without physicians’ engagement.
Third, and building on the latter, physicians have an important moral responsibility to engage around issues that produce health. As former Surgeon General David Satcher said on the issue of gun violence, “If it isn’t a health problem, then why are all these people dying from it?”8 Ultimately, physicians have an important responsibility to engage around issues that harm health and there is no substitute for physicians lending their voices to these issues, no matter how difficult or controversial they may be.
The observations that physicians have valid reasons for hesitating before lending their voices to issues of public health concern and that these issues need physicians’ engagement present a challenge to the medical profession. It is, however, a challenge that may be long overdue. Widespread availability of digital communication has made public communication faster and more immediate for a much larger portion of the population. This puts pressure on the physician community to come to terms with their engagement with pressing issues of concern faster than they may have had the luxury of doing so in previous decades. Grappling with this tension, ie, between the challenges inherent in lending physicians’ voices to issues and the need to do so, shall require an honest reappraisal of the role of physicians now and during the third decade of the 21st century. This would extend from teaching medical students, through the role of the individual physician in day-to-day practice, to the responsiveness and engagement of professional societies. This will require some time and discussion. It will be time and discussion well spent.