I was seeing patients the other day when Mrs. T., a vigorous 78-year-old, recounted her visit with her orthopedic surgeon, who had recommended a revision of her hip replacement. She said, “I suppose that with Obamacare, I won't be able to get this.”
I asked her if the surgeon had told her that the Affordable Care Act would somehow complicate getting appropriate care under Medicare. “No, he didn't say anything about it,” she said. “It's just that it's all about rationing.”
Mrs. T. is a well-insured resident of one of the Bay Area's many prosperous communities. I also take care of her husband, and while I have never talked politics with either of them, I can guess their party affiliation. How should I have responded? Before I tell you how I did, I had to consider the background.
I like politics and have cared for patients through all kinds of politically fraught and fractious times. In October 1980, three months into my year as chief resident and a month after the founding of the labor union Solidarity in Gdansk, Poland, the housestaff at San Francisco General Hospital went on strike, protesting understaffing and outsourcing. The United States invaded Granada in 1983, ostensibly to protect American citizens, including medical students at St. George's University. 1998 saw the first impeachment proceedings against a sitting president since Andrew Johnson. There have been nine presidential elections since I earned my MD, including the contested election of 2000. Through all of this, I can't recall that I have ever initiated a political conversation with a patient; certainly, I have never worn a campaign button or otherwise advertised my political opinions.
There is a consensus that physicians should not inflict their political opinions on their patients. How this plays out in the exam room depends on the physician. Some demur when asked how they will vote, with a noncommittal phrase like “I always try to vote for the candidate who I believe is best for our community.”
However, this is not universal, as Suzanne Koven, MD, a primary care internist in Boston, described in a recent blog post. Part of this is a simple matter of business etiquette, as Dr. Koven points out. Why introduce extraneous content into the patient-physician relationship that has the potential to be divisive or alienating? I suspect that many patients feel the same way and that this is why, in my experience, direct questions about political affiliations and voting intentions are uncommon.
Of course, physicians have the same rights of free speech as anyone else, and they can and do endorse candidates for office, pieces of legislation and actions taken by government officials. In a post at the American Medical Association's Virtual Mentor website in 2011, Thomas Bledsoe, MD, FACP, and Grayson Armstrong, an ACP Medical Student Member, considered the case of a physician who makes a political advertisement in support of a state proposition that would deny educational services to undocumented immigrants and their noncitizen dependents. This is available online.
Noting that physicians have an obligation to provide “expert advice to society on matters of health” and to “advance public health, and encourage access to care for all individuals,” the authors question whether the hypothetical physician is exploiting his standing in his community and encouraging extrapolation of assumption of expertise beyond the borders of his medical training. Even when the domain of the doctor's opinion is more clearly medical, physicians may differ among themselves about whether a piece of legislation will, for example, advance public health.
Whether physicians have an obligation to be politically engaged has engendered more controversy. In a series of papers published in the Journal of the American Medical Association in 2004 and 2006, Russell Gruen, MBBS, PhD, and collaborators argued that, beyond their clinical responsibilities to individual patients, physicians have obligations of advocacy and public participation that extend to issues of access to care and the improvement of socioeconomic conditions that directly affect health.
While professional associations like the American College of Physicians characteristically encourage member engagement by hosting congressional visits, others have argued that public citizenship and political engagement should not be regarded as a professional obligation of physicians.
Dr. Hoven wonders whether medicine has become more politicized. I suppose to some extent it has. The Affordable Care Act placed the organization and financing of medical care in the middle of a vociferous and often rancorous debate, one that is particularly difficult because physicians themselves are significantly split.
However, this is not the first time this has happened. The passage of Medicare in 1965 provoked much of the same vitriol. A divisive debate in the young United States focused on whether it was appropriate for frontier states to have less rigorous standards for medical training, both to expand the workforce and to create opportunities for less educated young men to join the middle class.
And there have always been very political physicians, perhaps notably Benjamin Rush, the distinguished Philadelphia physician who was a delegate to the Continental Congress, a signer of the Declaration of Independence and an ardent and vocal abolitionist.
The College has strongly supported the Affordable Care Act and has worked with chapters to mobilize support for Medicaid expansion. Speaking as a physician, I have seen the Act help my patients. After President Obama signed the bill, California moved promptly to set up a high-risk pool. A patient of mine, relatively young but uninsurable because he is self-employed and has hypertension and atrial fibrillation, took advantage of the opportunity to get coverage. Within a matter of weeks, he was found on the floor with a fever and a petechial rash. After three weeks in the ICU and a bit of time in rehab, he has recovered completely from his meningococcemia and is back at work. His hospital bill, however, was close to $350,000, a ruinous amount had he not been insured.
With all this in mind, I spoke to Mrs. T., the patient in front of me.
“You will absolutely be able to get your hip revision,” I told Mrs. T. “Let's talk about what the Affordable Care Act will and won't do.”