In Politically Turbulent Times, Where Are the Boundaries for Physicians?

With health care under the legislative microscope, some organizations encourage political involvement for doctors — but outside the office.

Dhruv Khullar, MD, MPP, is an advocate for physicians diving headfirst into politics.

Dhruv Khullar

He says abstaining from elections and legislative processes equates to decisions about the American health care system being made — unchecked — by people who work outside of it.

Physicians historically have low turnouts during elections. An October 2016 report by the Annals of Internal Medicine says doctors vote at rates 9 percent lower than the general population and 22 percent lower than lawyers — a trend that hasn’t changed since the late 1970s.

Khullar hopes that changes.

“My view is that it would be better to try to influence that discussion and those policies rather than sit back and let it happen to us,” says Khullar, a resident physician at Massachusetts General Hospital, whose writing on the intersection of medicine and politics has appeared in USA Today, the Washington Post and other general-interest publications.

It’s an intersection that seems to grow more contentious by the month.

In addition to debate over the Affordable Care Act and failed efforts to replace and repeal it, other points on the medical-political spectrum include abortion, vaccines, end-of-life care, medical marijuana, Medicare and Medicaid funding, LGBT care, undocumented-immigrant care and gun ownership.

“As much of our society becomes politicized,” Khullar says, “all these things enter the doctor-patient relationship, as well.”

It all raises questions: Is there still a place in modern medicine for a physician to put all of her or his care and worry into just the patient? Or is physicians’ involvement inevitable and even necessary given today’s political climate? And if physicians do get politically involved, where are the ethical boundaries in terms of how it affects the care they provide?

Khullar suggests legislation, regulation and political opinion always will creep into a physician’s practice regardless of her or his neutrality. “If it is your choice to explicitly stay out of the political arena or to not be involved in any way, that is a reasonable personal choice,” he says. “But you also need to recognize that the flip side of that is these forces are still going to impact you and your patient.”

Political activism for physicians — voting, campaigning, donating and even running for office — is supported by the American Medical Association, the United States’ largest physician organization.

Senate Majority Leader Mitch McConnell addresses the U.S. Senate after it failed to pass a "skinny" repeal of the Affordable Care Act in July 2017. | C-SPAN

“Physicians have the right to be political actors in this country; doctors are citizens, too,” says Jack Deutsch, an AMA spokesman. “As such, the AMA strongly believes that physicians are entitled to the benefit of protected political activity, including making their concerns and grievances known and petitioning for change.”

The organization’s Code of Medical Ethics lays out such support: “It is laudable for physicians to run for political office; to lobby for political positions, parties, or candidates; and in every other way to exercise the full scope of their political rights as citizens.”

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The AMA itself is quite active politically: It lobbies heftily, and it will often make public its support or opposition of a person or issue.

But Khullar, the AMA and much of the medical world do have a political stopping point: when interacting with patients.

“I feel very strongly that it should not enter the hospital [room] or clinic,” Khullar says. “So when we’re in with our patients, we need to let our patients drive their decisions about their treatment.”

In these interactions, the balance of power is lower on the end of patients, who might be vulnerable and also want to keep their views private, the AMA’s ethics code says.

The code’s recommendations on expressing political viewpoints to patients and their families are:

• Judge both the intrusiveness of the discussion and the patient’s level of comfort before initiating such a discussion.

• Discuss political matters only in contexts where conversation with the patient or family about social, civic or recreational matters is acceptable.

• Refrain from conversation about political matters when the patient or family is emotionally pressured by significant medical circumstances.

Historically, physicians have leaned politically conservative but have grown more liberal as younger people, women and minorities have entered the medical workforce, Khullar says.

By analyzing more than 20,000 physicians across 29 states politically affiliated by voter registration, Yale researchers put the split at 35.9 percent Democrat, 31.5 percent Republican, and 32.6 percent independents or third parties, according to their 2016 article in the Proceedings of the National Academy of Science of the United States of America.

Between those registered as Democrat or Republican, the split was 53 and 47 percent, respectively.

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Among physicians affiliated only with either of the two major parties, the study revealed noticeable disparities among specialties: On the most extreme Republican end were surgeons at 67 percent, and for the Democrats, it was those who work with infectious diseases at 77 percent.

“These findings suggest you are going to get different care” depending on a physician’s political leanings, study co-author Eitan Hersh, PhD, told the New York Times. The average patient wouldn’t see much of a difference, Hersh said, but he or she would be more likely to on issues involving sex, reproductive health and drug use.

Especially for physicians like him who have great interests in politics and medicine, Khullar says the intersection is a “very difficult balancing act to strike.” But the best way to combat any influence from personal biases is to be conscious of them and then mentally set them aside, he says.

“I try to remind myself even more than most people [that] I need to allow my patient to drive this decision,” Khullar says. “I need to allow my patient to express their values and their interests and be very careful about the way I am navigating the situation.”

Michael Stone is a freelance health care writer based in Florida.