Politics in the Exam Room

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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.


Suzanne Koven is a primary care internist in Boston and a columnist at the Boston Globe. E-mail her at inpracticemd@gmail.com and visit her website at suzannekovenmd.com. More from this author →