Domhnall Macauley on Regina Benjamin, the Surgeon General of the US

Domhnall MacauleyOne of her ambitions is to climb Kilimanjaro. It’s a tough climb even for a determined and committed woman like Regina Benjamin, Surgeon General of the United States. And, if the Surgeon General sets a target, people will remember. We met, appropriately, at the American College of Sports Medicine meeting in Baltimore after she had given a short talk and led a walk around the harbour area.

She was introduced to a standing ovation with all the razzamatazz of a celebrity guest to a ballroom overflowing with delegates. American show business. But, when she spoke she captivated the audience. Quietly, simply, and humbly. She began with a story from everyday general practice- a heart breaking story of a simple mistake. In an effort to help a patient who could not afford the blue cross copayment for a medication she prescribed for severe back pain, she paid the balance. In what many in the audience would have considered a kind and generous gesture, she saw on the woman’s face, the magnitude of her misjudgement. She had taken away her patient’s dignity. It had little to do with sport and exercise but it entranced her audience and it was this humanity and understanding that shone through throughout the day. Later, surrounded by television cameras, reporters, and photographers, her walk around Baltimore in support of the ACSM campaign “Exercise is medicine” was pure theatre with T-shirt wearing activists carrying purpose made banners and a staged interview with 1500m legend Jim Ryun. She then symbolically signed a prescription for exercise for the American public.

Afterwards, we had an opportunity to chat. When she took off the uniform jacket- the surgeon general wears a full military uniform- she was everything you might expect of your family doctor; open, welcoming, listening, and attentive. Warm and enthusiastic, she looks much younger than her years. After 23 years working as a family physician in a small community of 2300 in Bayou la Batre , a village on the Gulf coast, her commitment to family medicine is unquestionable and is the blueprint for how she sees her future. It was quite a wrench to leave but her practice has a new doctor and nurse practitioner and her patients, although they miss her, are delighted that she is in Washington looking after their interests especially with the recent oil spill when people living on the Gulf coast feel so vulnerable. Bringing the principles of patient centred primary care to a population of 300 million is a real challenge but, as America’s doctor, she thinks of it as just a larger practice list size. A simple philosophy that will be greatly challenged by the behemoth of American healthcare.

Cost effectiveness in health care, she considers an obvious principle. There will be objections but they will reduce with time and she strongly supports the practice of evidence based medicine. She intends to actively promote primary care research, traditionally greatly underfunded in the US, and support the further development of primary care research networks. She considers these essential for the development of a research infrastructure but she also believes there is a need to develop individuals as research leaders. She doesn’t, however, see primary care in isolation and emphasised the need to work with specialists who are essential for referral and hospital care. And, in the US context, she includes, in her definition of primary care, paediatricians and some internists. She is also acutely aware of social inequality and the needs of the less privileged. Such was her commitment to her community that she herself invested a lot of money in rebuilding her practice after two hurricanes and a major fire. I asked her about gender issues in medicine and she described how, in attending many graduations, she sees a large proportion of female graduates who now expect to have equal opportunities. She was more inclined to talk about gender violence in a broader context and feels this is an important global issue. For an American, she is unusually outward looking and is familiar with UK health care. She admires the UK preventive care model although, when pushed, she was a little unsure of the detail.

As the interview progressed, she relaxed, her media minder slipped away and we chatted about patients and practice and what it means to her. She found wearing the uniform of the Surgeon General initially quite strange and, for a family doctor whose patients often called her by her first name, it took time to get used to military officers saluting and calling her Mam. She is genuine and committed and believes that general practice has equipped her well through her knowledge of most areas of health care. She has clearly navigated very successfully around medical politics in the past and, if honestly and sincerity are the key values, I have no doubt she will succeed in her ambition to make a major difference to people’s health in the US.

Domhnall MacAuley is primary care editor, BMJ