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Join medical student Elizabeth Picazo to explore the intersection of health care and politics. Elizabeth shares her insights on the implications of Proposition F in San Francisco, discussing its impact on marginalized communities and the role of physicians in advocating for equitable health care policies.

​Elizabeth Picazo is a medical student.

She discusses the KevinMD article, “Medicine is not apolitical: Your vote dictates your ability to practice medicine.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Elizabeth Picazo. She’s a medical student, and today’s KevinMD article is “Medicine is not apolitical: Your vote dictates your ability to practice medicine.” Elizabeth, welcome to the show.

Elizabeth Picazo: Thank you so much for having me.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Elizabeth Picazo: Yes. So before medical school, I was born and raised in San Francisco, California, to a Mexican American family. Grew up in Northern California my whole life. San Francisco is my hometown, and I have had the privilege of now going to medical school where I serve my family, my community members. And I’m currently taking a leave of absence to get my MPH before I go back and apply to OB/GYN.

Kevin Pho: All right, and best wishes in the rest of your medical school journey. And your KevinMD article is “Medicine is not apolitical: Your vote dictates your ability to practice medicine.” So before talking about this article itself, tell me the story leading up to you writing this.

Elizabeth Picazo: Yeah. So something that’s important about me is that I have never missed an election in voting, and I’ve always followed the local elections in San Francisco. My family, since immigrating from Mexico, they weren’t necessarily politically active in that sense, but they believe really strongly in voting and making your voices heard. Especially my grandfather used to say, you can’t complain about what’s going on unless you actively take part in what’s going around in your local community. And so that extends to voting, and most of my family have been involved with unions their entire lives.

And so it’s really important to me that everyone’s pretty aware of what’s going on locally, because it has such a profound effect on what happens within county and city limits, in addition to state and national elections.

So I was in the middle of finals week. I was following Prop F, which, for those of you who don’t know, Prop F in San Francisco was essentially tying social services and welfare dollars for people who are low income and would need extra supplemental support, including help being able to find jobs, interviews, using different resources to be able to hopefully find housing, and to pay for food and pay for rent, it is now going to be tied to drug testing, which is a very draconian law that originally started out in the 1980s, that San Francisco hadn’t used for years. Mayor London Breed first brought this out in October, and funny enough, she was actually speaking at one of my classes when this news released.

So I’ve been following this proposition for a pretty long time, and then the day after Super Tuesday, which is when California votes, found out that there were enough votes to pass Prop F, and I was understandably really upset. I’d worked in the county hospital for most of my medical school career. These are a lot of my patients that I’d seen, these are a lot of my community members that I see in my neighborhood, that would most likely not be able to access these anymore.

And so what really tipped the scales in me choosing to write was the fact that I’m a young medical student, and so social media is a really important way that we communicate, and some of my classmates were actually really happy that this proposition passed. And one of them was going into a trauma match, in trauma surgery, over in Oakland. And that really bothered me, because understanding your vote and how these propositions work within how you practice medicine is not really taught well in medical school.

But it’s really hard to see the implications at a wider scope until you go into the hospital and see day in, day out how that really affects discharge planning, how that affects how you talk with your patients and the different options you can give, because you can’t really practice full scope medicine with laws and limitations that treat patients and treat people differently.

Kevin Pho: All right, so give us your perspective. You said that you can’t really understand the effects of these propositions and laws without seeing it in real life. So from your perspective, specifically with Prop F, how is that going to affect the patients that you see?

Elizabeth Picazo: Yeah. So in the emergency room, for example, you’re doing a lot of discharge planning for patients who are insecure with housing, who potentially have substance use disorders. Oftentimes you talk to them about these different resources that the city and county offer, and that includes getting a single room occupancy apartment that is either sponsored through the city or sponsored through a local and public program, that really takes people off of the streets and gives them safe and stable housing, to be able to not have to fight for their lives and focus just on surviving, and really start having folks be able to reintegrate into themselves and reintegrate into how they access their health.

Versus when you get rid of that and you tie all those dollars to a drug test, even if someone is not actively using any substances at all, it’s still another barrier to have to go through, to submit to. It’s in fact really dehumanizing, and a lot of people are not going to go seek out those services anymore. And so with that you just take a complete option off the table for people.

And so it’s really hard to say, OK, you’re going to take your medication, and we’re going to get you back on this antihypertensive, and we’re going to get you some stable housing, stable food, when you can no longer access stable housing and stable food. If someone is on the street, they’re at risk for someone stealing their medication oftentimes. So with that you’re just taking out a complete, you’re stuck in limbo, essentially, because understandably someone cannot focus on improving their blood pressure, improving their diabetes, when they’re focused on, where am I going to sleep at night, or where am I going to get food?

Kevin Pho: Now, you said that this proposition was voted on Super Tuesday. What were the numbers for and against the vote? What were the results?

Elizabeth Picazo: Yeah, so this was actually the lowest voter turnout that San Francisco had seen in about the last 10 years. So, about, I want to say the last time I checked it was 43 percent of people turned out to vote, and it was a pretty strong majority at 60 percent, last time I checked, of folks voting for Proposition F. Which, in reality, we don’t know if this would have passed if the entirety of San Francisco had come out to vote.

There’s a lot of theories as to why this was the lowest voter turnout in a while. There’s a lot of political strife happening in San Francisco, and a lot of discourse that makes folks really distrustful of the government and what’s currently going on. And we’re going through a really big political shift, which is surprising to say. Most people think that San Francisco is a very liberal place, a very strong Democratic utopia. But growing up there, there’s a lot of different realities of what happens and what people think is right, and really moving away from a lot of these community-centered values, unfortunately. And you’re seeing that actively now, and how this is playing out in our elections and politically.

Kevin Pho: Now, for those in favor of Proposition F, and you mentioned one of your classmates or colleagues was in favor, what were some of the arguments that they presented in favor of this proposition?

Elizabeth Picazo: That’s a great question. So understandably, they’re going to trauma surgery, they had done about four months of trauma rotations back to back, and they’d seen some pretty horrible things happen, and experiences. And so I’m pretty sure a lot of this contributes to frustration and burnout with the current system and how they’re interacting, especially because substance use disorder is only rising in this country, especially with the amount of overdoses, and San Francisco is no exception. I believe last time I checked, we’re still creeping up, and this is the worst year of fentanyl and opioid overdoses in the city that we’ve seen in a really long time.

And the theoretical practice behind it is, well, if you deter, it’s kind of this idea of economics where you want to reduce moral hazard, which is where you don’t want people to be rewarded or to have access and make decisions based off the fact that someone’s going to save them. And so if you cut off different resources, you’re essentially forcing people to choose between, OK, are you going to want to pass this drug test, or are you going to want to access money for rent or food?

In reality, what you see play out, and this is something that we talk about in health economics a lot, is that for this population and for this particular set of circumstances, that is not the case. And so I really understand why someone would think this is the solution behind this, but what the research and literature says is, we’ve tried this, this doesn’t work.

It’s not that they’re unsympathetic to the patients. In fact, I think it’s the fact that they’re just really frustrated with what they’ve been seeing day in and day out. It’s just that there needs to be better policy and better practices that involve bringing in community members and actually talking through what needs to be done, versus being really prescriptive of how to solve this problem.

Kevin Pho: So what’s happening next? So Proposition F passed. What is going to happen in the foreseeable future?

Elizabeth Picazo: So Proposition F is not going to take place until, I believe, January 1st of next year, but I could be mistaken. And so that means that they’re going to start drug testing folks who are accessing these different services at the county level, which is usually a urine-based drug test, and based on whether or not someone passes, and that has a whole bunch of sensitivity issues with that test to begin with, it’s going to determine if someone’s going to be able to access these services.

And so we likely wouldn’t see how this is going to be affecting people in San Francisco for at least nine months. If it starts happening in July, which is another potential start point, we’d see it as early as this summer. And it’s going to be very interesting to see. It’s going to actually be a pretty big lift on a lot of the social workers in San Francisco, along with the many different organizations through the county and through the Department of Public Health, and also individual programs that specifically work with folks who are housing insecure and work with folks who do use different drugs and substances, and how they’re going to mitigate the lasting effects of this.

And this would need to go to another vote, essentially, to remove it. And so the next time this would need to be written, and to be either struck down or reapproved by the city if they choose to do so, would be two years from now. So we would have two years of this program before we’re able to even take it away from the community, if that’s the way that the voting population of San Francisco would like to go.

Kevin Pho: So I want to zoom out. Let’s talk about, in general, political activism during medical education. Talk about what it was like during your first few years of medical school. What proportion of the students would you consider politically active, or really pushed and advocated for certain policies in addition to their medical education? What was that like?

Elizabeth Picazo: Yeah. So I am fortunate to go to a school where they tend to recruit and admit a lot of people who are very politically active in different streams. And so a lot of folks are very focused on community activity, working with populations, working with local communities and clinics, and really focusing either on advocacy within the hospital or advocacy at a local or state level. And so it’s not uncommon for my classmates to be engaging with this politically.

I think the overall trend in medical school, however, we are overall as a population becoming more politically active and really focused on this outward advocacy, but it’s still not as common. I just happen to go to a school where the environment really fosters that, and I have a lot of mentors who do that day in and day out in addition to their clinical practice.

But we’re not necessarily taught the tools to understand, again going back to these health economics, what does it take to understand a policy and how it interacts with an entire system before it comes and takes place in the hospital? And oftentimes what sparks a lot of political activism is something that either someone has a lived experience with, a live family member with, or something that someone sees in the hospital day in and day out. And usually they’re really related to public health, which is one of the reasons why I chose to go get my MPH, to get more of these skills in political advocacy, but also how to better understand the system and really analyze policy, to be able to complement what I’m seeing day to day in clinical practice.

Kevin Pho: Now, you said that a lot of medical students aren’t given the tools to implement some of their activism. Is it necessary that they all have an MPH like you do, or pursue an MPH? What kind of tools would you like to see taught during medical school so these students can further pursue and implement some of their activism?

Elizabeth Picazo: I don’t think an MPH is required at all. I think we’re in school for a little too long. This is just something that I know I needed to do for myself, based off of how I want to structure my clinical practice and structure after residency.

I think there’s things that we’re expected to do as doctors regardless. We’re expected to be advocates for our patients, and that means, if someone has mold in their house, how do we write to their landlords to have that removed, and how do we refer them to a lawyer to fight their cases? Or what does it mean to go to your medical society and say, hey, firearms are a problem in pediatric populations, this is the leading cause of accidental deaths, how do we organize around this, and how do we make our voices heard?

And a lot of the times it’s really about, what is the problem, and where can you find the points of entry? And so learning how to write those letters to landlords, learning to go to your medical societies and engage with this. And a lot of the medical societies hire lobbyists and have specific political advocacy arms that do teach folks, and it’s about encouraging people to get involved with that. There’s no need to take course on course of health economics to fully understand, but there are resources that should be actively explored during medical school and actively encouraged, especially when we’re talking about social determinants of health, when we’re talking about what is facing the local community.

I think everyone should at least know who’s representing them on a city, county, and state level, and how to call their office and say, I am a medical student at such and such institution, this is what I see today in the hospital, and I need you to focus on this, and I need you to talk about this.

Kevin Pho: As you know, our political climate in the country is very polarized, and it’s becoming very, very tribal, and there’s very little common ground that each side of the political aisle can agree on. What are you seeing in medical school? Are you seeing some of that polarization play out? Are you seeing some tribal tendencies in medical school among your politically active classmates? What are you seeing there?

Elizabeth Picazo: That’s a great question. I think that overall it depends on the topic, really. I think there are some points that we all can really agree on, like the fact that we are in an opioid epidemic and in an overdose crisis, the fact that there is a high rate of suicides in this country.

I think really the question is, where do we land on trying to solve the problem? And that is where most people are, and that really has to do with values that you grew up with, that has to do with your environment growing up and where you currently live.

And I think that something that I have come to appreciate is that politics and policy are super local, and they should be super local, because they should be responding to the community around them. And so what I would recommend for someone in San Francisco or Boston would not be the same as I would recommend for my family members down in Fresno, California, who are facing a completely different set of circumstances and issues.

And so it’s OK to have different ideas and approaches, but it’s not OK to shut down those ideas and not talk about the realities, and to ignore the science behind them. If something has been proven not to work, unless there are drastic changes to the model, reimplementing that is not necessarily going to make it work again. I think that’s something that we can all agree on.

And so even with the polarization of how to accomplish goals, and maybe what are the priorities, because there are plenty of competing priorities within medical advocacy and political advocacy in general, it’s being able to take a step back and listen and hear the why. And I think that’s something that as physicians in training and as physicians we all are expected to do, because we’re expected to listen to our patients and hear, how did they get somewhere, why is this happening, in addition just to understanding the medicine behind it.

It’s the art of medicine needs to translate over to policy, and give people a lot more grace, and being able to talk to someone without debating them, because debate really does not work in terms of bringing someone over to see your side. It should be really focused on having these open conversations when someone has the capacity to do so, and also acknowledging when you are not ready to have these conversations with people.

Kevin Pho: We’re talking to Elizabeth Picazo. She’s a medical student, and today’s KevinMD article is “Medicine is not apolitical: Your vote dictates your ability to practice medicine.” Elizabeth, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Elizabeth Picazo: Yeah, so the take home today for me is, figure out who your elected officials are, who’s representing you at a city and county level, at a state level, and at a national level. And try calling about something that really has been bothering you when you’re in the hospital day to day, that you see your community members in need.

And if you’re looking into the election packet and you’re seeing a different proposition, do a PubMed search, do a search online, and find articles, because likely there are people working at this intersection of politics and medicine who have really been studying and seeing the data behind what policies will truly work. And bring that in with you when voting.

Everything that is done should be done in a way that is going to best improve your community, and should be focused on improving your patients’ lives. And it’s important to understand how you want to fix a problem needs to be done in a way with prudent methods.

Kevin Pho: Elizabeth, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Elizabeth Picazo: Thank you so much for having me.