William Cayley: Where lies greatness?

bill_cayley_2Recently while driving to work, I was bemused (or should I say, dismayed) to pass yet another presidential campaign poster promising to “make America great,” just as I was hearing on the radio a story about the worldwide 2016 Social Progress Index, which rates the US as 19th overall on measures of social and environmental performance and overall “inclusive growth.” Even more concerning, as noted in the radio report, the US is “the one major industrial nation that is significantly underperforming on its social progress, relative to its GDP.”

So what truly makes for greatness? Nationalistic sloganeering or being able to deliver on the foundations of true social and economic security, such as health, nutrition, education, and opportunity?

As easy as it can be to idealistically set out to “save the world,” there still remains legitimate debate over the extent to which physicians should or should not attempt to address the social determinants of health. While the final answer to that debate may be a long time (if ever!) in coming, there are a few things we can say for sure about some specific contributions of primary care to elements of social progress.

Firstly, we know that countries with stronger primary care systems tend to have a “more equitable distribution of health in populations.” Thus, anything we can do to strengthen primary care should improve overall health and overall health equity.

Secondly, even with health related interventions one needs to think carefully about what is best addressed at the level of the individual patient, and what is best addressed at the social or community level. For example, while improving immunization rates is clearly a good thing (and for many of us a “quality measure” on which we are rated), it turns out that the only solid evidence we have as to what measures can actually improve childhood rates of immunization has to do with community discussions, community meetings, and information campaigns. We have no clear evidence that face to face (i.e. physician-patient) interventions do anything at all.

Thirdly, there are interventions that can be absorbed into clinical work that address foundation issues, such as literacy and education. For example, the Reach out and Read campaign provides the processes, tools, and materials to incorporate reading and literacy promotion into routine well-child office visits.

Finally, as described in an inspiring recent piece in The BMJ on the efforts of Dr Gary Bloch, there are ways individual practices can connect with and collaborate with local resources to help address on a patient-by-patient basis some of the challenges faced by those living in poverty.

Call me a “wonk” if you will, but as a believer in numbers, evidence, and patient oriented outcomes, I’d much rather promote greatness through measurable social progress than through the use of nationalism, slogans, and posturing.

Or, to paraphrase Forrest Gump, “greatness is as greatness DOES.”

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.