By Manoj Jain
Special to The Washington Post
Tuesday, October 28, 2008
A few weeks ago, as I was making rounds on the oncology floor, one of my patients asked, out of the blue, "Hey, Doc, who you gonna vote for?"
I would have expected this patient to have other questions on his mind. He's a 32-year-old writer whose leukemia had failed to remit after two rounds of chemotherapy. Now a third, more powerful regimen had dropped his white blood cell count to near zero, making him vulnerable to life-threatening infections.
Chuckling politely, I asked him why he wanted to know. "I'm curious, Doc," he said. "It tells me your worldview." He said that if we agreed on who should be the next president, it would strengthen our doctor-patient relationship. I asked what would happen if we didn't agree. He said, "That would be okay."
I'm not so sure. I have strong political opinions, but I am edgy about disclosing them to my patients for several reasons. For one, I'm in an authoritative position: When I talk about antibiotics, my patients listen and usually do as I advise. As a result, they might give inappropriate weight to my political pronouncements. For another, I fear that no matter how carefully I tread in these conversations, a disagreement could leave a dead zone in our relationship; that would be damaging because doctors and patients have to work as a team.
Later, looking up lab tests on the computer in the doctors lounge, I asked a cardiologist what he would have said to my leukemia patient. "I clearly avoid political conversations in the examination room," he said emphatically. "It raises the patients' stress level, and they're already stressed-out being in the office."
Another colleague, an orthopedic surgeon, also refuses to talk politics, but his reason was purely practical: "Who has the time to chitchat?" That's a good point. As a 2006 study showed, the average primary care visit is 17.4 minutes long and includes discussion of 6.5 topics. Often, I barely have time to spell out the potential side effects of my patients' medications. A political discussion should include more than sound bites.
These colleagues reflected what I think is the norm: that even in this unusually strident election year, medical professionals prefer to keep politics out of the examining room. At our hospital, even wearing a political button is considered unprofessional conduct. (Remember when Ronald Reagan was shot in 1981? He quipped to the doctor who was going to operate on him, "I hope you're a Republican." The doctor replied, "Today, Mr. President, we're all Republicans." That would have been less convincing from someone wearing a Carter-Mondale pin.)
This fall I ran into an oncology nurse wearing a McCain button, and I asked him how his patients felt about it. "I don't know," he shrugged. "Once all the patient's family had big Obama T-shirts on, so I just covered my button with my name tag."
Not all patients are open to political discussion. My editor tells me she deeply resented it when her dentist, drill in hand, began an opinionated conversation about the Middle East, knowing full well she works for a newspaper. So one morning recently I polled my recovering patients (not anybody who was critically ill) on the subject. One man with a heart transplant and an infection where part of his right leg had been amputated had the same reaction as my orthopedic colleague. "It's not a taboo, but I don't want to take up the doctor's time," he said. "I want him to treat my stump."
Since another patient, recovering from a case of severe encephalitis, had short-term memory loss, I added my polling question to the list of simple queries we had him answer every day. This time he knew his name, stumbled on the year ("1998 . . . no, no . . . 2008") and couldn't quite recall the president ("It's a four-letter word, but not Gore.") As for who the next president was likely to be, he was uncertain, and he didn't care if his doctor discussed politics or not.
Another patient told me he feared that patients would be hurt if the doctor did not agree with their views, then went on to tell me how the Republicans had screwed up the economy over the past eight years. Another said it was "okay to talk" and demonstrated his conviction by telling me how he thought the Bush administration should freeze the assets of all the investment bank CEOs and leave them with just $500 apiece.
Back in the doctors lounge (where the TV usually broadcasts Fox News, and conversations tend to be weighted to the right) I'm more willing to talk about the election. And when an ICU nurse paused at the nursing station to ask what I thought of the Democratic and Republican conventions, I gave a 20-minute response, my assistant waiting impatiently for me to finish with the chart of a heart transplant patient with MRSA pneumonia.
Not every doctor would do that. One gastroenterologist I know says: "I'm a blue doctor in a red state. I don't want to anger my referral base for consults, so I just stay quiet [about politics] or avoid going to the doctors lounge."
But this must go on in every office. Employees test the waters or tiptoe around conversations when the colleague, the client or the boss has a differing political view.
I'm a little uncertain how I feel on a related subject: whether I should advise patients on health issues that have political implications. Not abortion rights -- that's way too provocative. But take the case of stem cell research. Evidence shows that this research is a likely source of information that could one day help cure cerebral palsy, muscular dystrophy and other diseases. In the 2004 election, a friend changed her vote solely based on the topic, because her child had been given a diagnosis of muscular dystrophy. Should I inform parents, "Your child's illness might one day be treated if we can speed up stem cell research?" Do I make them aware of each party's platform stance?
One conversation that is germane to nearly every doctor visit, yet does not happen often enough, is about health insurance. One in five of my patients is uninsured or under-insured. Lack of adequate insurance is a proven risk factor for becoming ill and dying -- no different from smoking, excessive alcohol intake or high blood pressure. Should I discuss these facts with patients? Should I tell them which party's plan I believe would be more helpful for their particular condition?
So far, I talk about stem cells only if the patient brings it up. As for health insurance, I encourage patients to get it, and if there's time for a longer conversation, I will share my opinion on which candidate has the better plan.
I can't be sure how most doctors feel about all this. Of the millions of medical articles published, I can find only one that posed the question "Do physicians discuss political issues with their patients?" It described how 36 primary care physicians in the Philadelphia area were surveyed in 2004 after the voter registration deadline and before Election Day. Nearly half of them said they had initiated a discussion about a politically oriented health issue in the past decade, and 63 percent said they were willing to offer voter registration in their office. Interestingly, the male respondents were much more likely to initiate political discussion than the women.
The American Medical Association code of ethics notes: "It is natural that in fulfilling . . . political responsibilities, physicians will express their views to patients or their families. However, communications . . . about political matters must be conducted with the utmost sensitivity to patients' vulnerability and desire for privacy."
So even though the presidential candidates have different positions on certain health-care issues, and even though my leukemia patient assured me that my opinion would not influence his, I didn't tell him how I'll vote.
And I'm not disclosing it here, either.
Manoj Jain is an infectious-diseases specialist in Memphis. Comments: email@example.com.