In the fall of 2008 I was chatting with a woman I know about the upcoming presidential election. She was in her 60s, single, a funky dresser, world traveler, and amateur artist—what my mom would have called a “free-spirited Auntie Mame type”— so I was surprised by what she had to say: She was voting Republican. And furthermore, George W. Bush, she told me, was the finest president we’d ever known and she thanked God every day he’d had the courage and wisdom to invade Iraq.
Courage and wisdom? Hadn’t she heard of the lies about WMDs? Abu Ghraib? Warrantless wiretapping, Katrina, Harriet Miers..? Under normal circumstances I would have expressed disbelief. Horror, even. But the circumstances weren’t normal. I was this woman’s doctor, she was my patient, and the conversation took place in my examination room. At the time, one of us was not fully clothed.
I bit my tongue and resolved never to raise the subject of politics with a patient again. A couple of years later, shortly before the 2010 midterm election, I wrote a decorous and mildly self-castigating blog (with the same title as this essay’s, as it happens) in which I recounted my conversation with that patient. I avoided tactfully any revelation of the patient’s politics or mine, and ended with the prim conclusion that appropriate professional boundaries must be respected and that, within them, the doctor’s political opinions have no place.
As the 2012 presidential campaign looms, after months of Republican assault on women’s reproductive rights, in this week during which the Supreme Court considered the constitutionality of the Affordable Care Act, I am no longer so sure that what I wrote in that blog is true.
Forty years ago, my dad, an orthopedic surgeon, did not hide his political convictions from his patients. A photo of him holding a STOP THE WAR poster appeared in Time magazine. He’d taken a few days off from setting broken bones in Brooklyn to serve as a delegate for Sen. Eugene McCarthy at the 1968 Democratic convention in Chicago.
Perhaps his medical practice and his politics coexisted so comfortably because in that era it was less obvious than it is now that the two had anything to do with each other. He started practicing in the 1950s, before Medicare, third party payers, and the Surgeon General’s report on smoking and retired in the 1980s, years before HMOs, coordinated efforts to overturn Roe v. Wade, and Rick Santorum’s pronouncements about contraception.
There are still physicians who are visibly active in politics—Howard Dean and Ron and Rand Paul, to name a just few. Thousands of doctors participate in organizations such as Physicians For A National Health Program, Physicians’ Committee for Responsible Medicine, and Physicians for Social Responsibility that advocate, respectively, for universal health insurance, animal welfare and veganism, and nuclear nonproliferation—all at the intersection of public policy and health.
But I can count on one rubber-gloved hand the number of conversations I’ve had in the hospital hallways with my colleagues—much less in the exam room with my patients—about the impact of politics on the daily practice of medicine. And we’re not exceptions. A recent, widely circulated blog post by an anonymous M.D. remarks on physicians’ surprising silence about proposed laws to force women to undergo medically unnecessary and invasive transvaginal ultrasounds before having abortions. The blogger recommended that doctors perform acts of civil disobedience when such laws are enacted.
Overloaded schedules may explain some of doctors’ a-politicism. It’s hard to be Thoreau when you have ten people in your waiting room and your beeper is going off. Also, it doesn’t feel right for a doctor to get on his or her soapbox when someone comes in seeking help for a medical problem. Plus, many of us went into medicine with the idea that simply taking care of patients, even for a handsome salary, is in itself a kind of activism—“doing good while doing well” was the pithy rationalization, as I recall. We wouldn’t have to lobby or march. We’d be curing smallpox!
The problem is, no one gets smallpox anymore. They get beaten up by their husbands and boyfriends and shot on the way home from convenience stores. They get cancer from smoking and eating saturated fat and heart disease from obesity and lack of exercise. 50 million plus Americans have no insurance or are underinsured and at risk for rotten teeth, poorly controlled diabetes and hypertension, inadequately treated psychiatric disorders.
The World Health Organization estimates that by 2020 two-thirds of all illness will be chronic and largely preventable—diseases such as cancer, coronary artery disease, stroke, and respiratory ailments against which our most powerful weapons are reforms in agriculture, urban planning, and access to primary and preventive health care.
The truth is, doctors may be relatively a-political, but medicine isn’t. Our patients’ health is no less affected by the outcome of the next presidential election than by the latest medications and newest diagnostic tests—and likely much more so.
So last week, a patient of mine, a jovial white haired guy in his 60s, told me he was unsure whom to vote for next November. “You always give me good advice, doc,” he said. “What do you think I should do?”
And, surprising myself, I told him.
7 responses
Years ago, my GP surprised me when our conversation drifted toward mandatory pap smears for women who are seeking birth control. He was vehemently against them.
“The health care system can be extremely paternalistic, especially towards women,” he said. Most physicians would not have made such a remark to a patient. But knowing that my doctor thought that reassured me that he wasn’t just a shill for the larger medical system.
I agree that it is difficult to conceive of a world where physicians and their patients thoughtfully discuss all the latest political issues. But knowing where your doctor stands on things, as I’ve learned, can sometimes bring great comfort.
Suzanne, firstly I very much enjoyed reading your post. Although I am not a physician, I do work for a company that is part of the healthcare industry. That aside, in our office, political discussions are commonplace. Unfortunately they are completely one-sided and almost to the person pro-Republican. To these people, the Affordable Care Act is the worst piece of legislation to be introduced in their lifetimes. I strongly disagree, but there is nothing I can say that would convince them otherwise. These are the same people that attend Tea Party rallies, which they actually do, they think their tax rates are too high, and that President Obama is the cause of all of this countries debt problems. Like you, when I am asked for my opinion I find that I willing give it even if its not really what they want to hear. This in my view is the only way to get them to think about the other side of an issue. Again, thank you for your personal insights.
It’s difficult, at times, in any business, to keep political opinions to oneself, but the bottom line is: good business practices dictate that partisanship be kept out of the marketplace. What if the Olive Garden put up a banner extolling the virtues of President Obama, or the converse, a Midas Muffler shop urged motorists to vote Santorum? Either way, with gradient fluctuations in given geographical locations (Salt Lake City vs. Berkeley), these businesses would be alienating half their potential customers.
There are plenty of venues by which citizens can speak out on partisan issues without bringing it to the place where income is earned. Some business owners, like the above physician, may decide the issues are too important to stay mum, and they are prepared to risk losing customers.
Instead of “Don’t ask, don’t tell.” I would suggest, “If asked do tell.” I worked in health care in public policy, government and hospitals. Every aspect of the field is political from who does and does not get care to how the care is provided.
I am a family physician providing care in an urban underserved setting. The challenge I see is getting more of the community we serve to be more politically active. So, my political activism in the office involves promoting the political process and encouraging my patients to register and cast their vote. Who they vote for is less the issue than their participation. And on occasion when asked who would I vote for, my generic response has been “the candidate I feel is the best for us”. I still do not feel comfortable changing the dynamic of our patient-physician relationship with my personal beliefs.
Great article, and good for you for standing up for what you believe in – I’m all for professional objectivity, but not at the expense of remaining silent about what you believe to be unhealthy choices for your patients (and your world). I hope more people in influential roles follow your lead.
Thanks for a very thoughtful article.
Physicians have a responsibility to not misuse their unique role which involve a degree of intimacy and degree of authority freely given as a necessary part of the therapeutic relationship.
As part of this I see a duty to not inflict gratuitous political, religious, or other opinions on patients.
On the other hand, I see a responsibilty to comment on matters concerning the medical care system, health policy, etc when asked. For example. many of my patients asked me about the ACA and were shocked to hear that my disappointment was that it was too timid and to hear that many physicaians support a single-payer system even though they know they’d make less money under one.
The question of whether to respond to comments by patients you find politically or morally offensive is an individual one, and I believe the strong urge (?obligation) to not let such comments to go unchallenged must sometimes be constrained by a conscious decision about what is best for the patient within the therapeutic relationship. Not always easy.
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