Primary care medicine should be and is the bedrock of American healthcare. As a family physician and chairman of a department of family medicine at a medical school, I admit to being biased. Nonetheless, I am concerned that we are losing two essential bedrock elements of successful patient care: the biopsychosocial model of effective primary care and the concept of shared decision-making between clinician and patient.
The term biopsychosocial speaks for itself. A good clinician must thoroughly understand and examine the patient’s biology to address any concern, equally essential is respecting the patient’s psychological and emotional circumstances at the time of the clinical encounter and finally it’s essential to fully acknowledge the patient’s social structure and their economic, cultural, educational, occupational and living environment.
Sounds like a tall order, doesn’t it?
The foundation of successful primary care medicine is the establishment of a long-term and trusting clinician-patient relationship. This will absolutely include the elements of the “tall order” I just presented.
What then follows over time and in every patient clinician encounter is the process of shared decision-making. Shared decision-making is a collaborative process in which healthcare providers and patients work together to make decisions about the patient’s care. It is especially vital to pursue this approach. The provider shares medical information, both individuals discuss the care options, often bringing in significant others and ultimately a mutual decision is made that supports the patient’s preferences and the provider’s best clinical judgment.
This fundamental tenet of primary care medicine is also foundational for a functioning democracy. When collaboration and cooperation is not modeled in our society, the ramifications are far-reaching and damaging, including to the functioning of our healthcare system.
Autocracy and shared decision-making represent two opposite ends of the spectrum in governance and leadership. Our healthcare system is highly fragmented and administratively burdened. These elements often drive healthcare providers to provide care autocratically without patient engagement and modeling the top down decision making style now seen in our government.
One example of the harm to the health of our American citizens this behavior will produce is the “One Big Beautiful Bill Act” submitted by our current presidential administration and passed by the House and Senate.
The nonpartisan Congressional Budget Office (CBO) projects 13–16 million Americans will lose health insurance coverage (Medicaid and Affordable Care Act marketplace effects) by 2034.
The One Big Beautiful Bill will:
- Massively reduce insurance coverage —both via Medicaid and ACA marketplaces.
- Increase preventable deaths (by an estimated 51,000 annually) and worsen chronic disease outcomes.
- Cut access to gender-affirming and reproductive care, marginalizing vulnerable populations.
- Strain public health infrastructure, escalating emergency room use and hospital uncompensated care burdens.
The PBS network recently aired a special on the German American Bund titled “ Nazi Town USA”– a pro-Nazi group widely represented in the United States in the 1930s. Expressing Nazi ideology, the group was virulently, anti-semitic, anti-Catholic and anti-communist. It promoted white racial superiority and opposed immigration from non-European countries.
There are themes of this ideology expressed in today’s Republican political administration through ICE activities which include wider deportation reach, rapid deportation and crackdown on lawful immigrants.
In Charles Dickens’ A Christmas Carol, Ebenezer Scrooge makes a particularly cold remark about the poor, saying, “If they would rather die, they had better do it, and decrease the surplus population.” In the Academy-award winning movie South Pacific the song: ” You’ve got to be carefully taught” features these lyrics in part:
“You’ve got to be taught to hate and fear,
You’ve got to be taught to be afraid
Of people whose eyes are oddly made,
And people whose skin is a different shade
You’ve got to be taught before it’s too late,
To hate all the people your relatives hate…”
The tone and actions of our current Presidential administration and most Republican members of our House and Senate blatantly demean, denigrate and devalue the humanity of individuals less fortunate through the attitudes and actions I’ve described above. We must take a step back and preserve the fundamental rights of our American democracy that include:
Dignity of the person: The idea that every human being has inherent worth, Independent of majority opinion or public vote. This underpins anti-discrimination laws and protections for marginalized groups.
Justice and moral order: The responsibility to protect vulnerable populations. We cannot and must not further disenfranchise these population groups if we wish to continue to call ourselves a functioning democracy.
Howard A. Selinger M.D. is Chair of the Department of Family Medicine at the Frank H. Netter, MD School of Medicine at Quinnipiac University. These views are solely those of the author and do not necessarily reflect those of Quinnipiac University.