This narrative essay explores the intersection of health care, politics, and identity from my perspective as a family physician on the day following the consequential and polarizing 2024 US presidential election. I recall and grapple with the profound grief, anxiety, and uncertainty expressed by my patients, particularly those from marginalized communities, as they face threats to their health care and very identities. These experiences highlight the tension between professional neutrality and our moral imperative to advocate for vulnerable populations.

It’s nearly 3:00 am on November 6, 2024. I can’t sleep. I check my phone. The Associated Press has just called the presidential election in Pennsylvania. Some quick electoral college mental math and reality sinks in.

A few restless hours later I’m getting ready for the full day of clinic that lies ahead. The familiar voices on NPR confirm my middle of the night calculus. I hear the words I’ve been dreading for months, even years—“Trump wins.” I quickly turn it off, wishing I could return to blissful ignorance for just a moment longer. Flashbacks to 2016, to denial, uncertainty, fear, anger. I pass a scattering of campaign signs along the highway and my eyes well with tears.

The clinic air feels colder and heavier than usual. It is eerily quiet as I try to identify the emotion lingering around me and my staff. It finally dawns on me: grief, profound, overwhelming grief.

8:02 am. My first patient of the day is a transgender man, slumped forward in his chair, looking up at me with weary eyes.

“What do you think is going to happen?” he asks, voice barely above a whisper. “What do you think I should do?”

My heart sinks. He doesn’t need to explain any further. I could dive into a political analysis on federal vs state regulation of health care. I could try to inspire him with a speech on resilience and fighting for what’s right. Instead, I take a deep breath and look him in the eyes.

“I honestly don’t know.”

We sit in silence for a moment under the weight of these words.

8:45 am. A healthy young woman is here for her annual physical. She asks if she should get a pap smear. “I know it’s a year early, but I’m worried about the ACA no longer covering it as preventive care.” I nod. We do the pap.

The grief is settling in now, making itself at home in these clinic walls. But grief needs to breathe, to air out like laundry on a spring day. Instead, it is suffocating under fluorescent lights and low ceilings.

9:20 am. Another transgender patient here to follow up on his hormones. He hands me his PHQ-9 depression screen—24/27, well within the “severe” range. He shrugs, as if to say, “What did you expect on a day like today?” I offer that maybe we could subtract a few points given the circumstances and we both let out a short laugh, followed by a sigh.

A decade ago, in medical school, I was taught to not “talk politics” with patients. Medicine was touted as a field that transcended politics, where we serve all our patients equally, regardless of background or identity. Where the physician leaves their opinions at the door in the name of “professionalism.”

As a family doctor who provides gender-affirming care, reproductive health care, care for patients on Medicaid and Affordable Care Act marketplace plans, and care for immigrants, refugees, and undocumented patients, I’ve recognized the error in this lesson. We should strive to treat all patients with the same level of dignity, respect, and kindness, to advocate for all their needs with fervor. But to practice medicine as if legislation—and, by extension, the political process—plays no role in the care we are able to provide, in ways that disproportionately harm some patients, is to deny the reality of days like today.

And today is very, very real.

We know that systemic inequities have long impacted the health and well-being of our patients and the communities we serve. The COVID-19 pandemic brought these disparities to the forefront and, for many, sparked a surge in momentum to address them. But the deep-seated trauma of our previous neglect lingers. As I sit eye-to-eye with my patients confronting their reinvigorated fear and uncertainty, it feels like I am again failing them. When, in my years of training, was I taught how to doctor in a moment like this? How did I become the person my patients look to for answers, yet feel so unequipped to offer them? I can offer empathetic phrases when sharing a difficult diagnosis or comforting a family member, can counsel in great detail on the risks and benefits of a medication, the odds of a future cardiovascular event, the grading of evidence to support a cancer screening recommendation. But this threat seems more existential than any of those, and I feel woefully unprepared to address it without acknowledging the politics.

12:10 pm. I open my in-basket while eating lunch and see over a dozen gender-affirming hormone refill requests, a sharp spike even for my clinical panel. Some of these requests are accompanied by frantic messages with the same anxious questions I’ve been fielding all day, but I understand the meaning behind all of them. Patients are not only preparing for the worst; they are expecting the worst.

1:05 pm. Back to clinic, now with a patient who needs a birth control refill. She pauses, her feet tapping anxiously, then cautiously wonders aloud about getting an IUD. “They last for 7 years…right?” We schedule the procedure for the following week.

1:30 pm. A young boy with a severe disability. His family relies on Medicaid to cover his numerous therapies, medications, and specialist visits. They are worried what will happen if Medicaid funding is cut or if work requirements are implemented. My face drops to the same defeated look I’ve carried all day. “I don’t know what’s going to happen,” I nearly whisper. “I worry about that, too.” We try to focus on today’s concerns and not think about what lies ahead.

3:15 pm. Yet another transgender patient, this time wondering about the process for legally changing their gender marker both in the United States and when applying for Canadian citizenship. I type an official-sounding letter. I suggest our usual 3-month follow-up and watch their brow furrow as they mentally review their calendar. “Maybe January, before the 20th?” Inauguration day. “Sure, of course,” I reply.

I’m faculty at an academic medical center that, like many universities, espouses “institutional neutrality,” meaning that it is an explicit policy to avoid taking a stance on “social or political issues.” While we are permitted our personal viewpoints in private, in our professional roles we must remain neutral, an increasingly difficult task as politicians continue to wedge themselves into our exam rooms. It’s a phrase I’ve grappled with nearly every day. With every university-wide e-mail notice of the policy, every instance of deafening silence in the name of neutrality, I am reminded of the late Archbishop Desmond Tutu’s quote: “If you are neutral in situations of injustice, you have chosen the side of the oppressor.”

Neutrality implies a middle ground, a space that honors both sides of a debate. I know that, among my patients and colleagues, there are some who feel relief or are celebrating today. I will continue to welcome all patients into my clinic and provide each of them the best possible care. But the grief permeating my clinic walls today knows no political party. There is no counterpoint, no “agree to disagree,” no “2 sides to the story” to what my patients are experiencing. Today, there can be no veil of neutrality as my patients plead for a reassurance that is as much personal as it is medical. We as physicians cannot remain neutral when politics permeates so many aspects of our patients’ health and well-being, their very identities. The communities being targeted by these politics do not have the privilege of neutrality, of remaining silent.

My final visit comes to an end, and I look at my schedule of mostly still open charts. I log off and head home to my family—my wife, a gynecologist with similar fears about the future of health care in our country, and our young son, who is currently obsessed with trains and who I had so recently dared to envision could grow up with a Black woman being the first president he remembers.

After the usual evening routine, when the toddler giggles have quieted for bed, I open my computer—this time navigating to my personal MyChart. Having identified as transgender for over a decade and been on gender-affirming hormones for nearly as long, the thought of losing my own access to care is simply unimaginable. But today, it feels like anything is possible. I start typing a message to my own doctor.

“What do you think is going to happen?”

The cursor blinks back at me as I sit in silence.

“What do you think I should do?”