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Should Doctors and Nurses Be Patient Activists?

When the eminent physician Dr Cliff Cleveland wrote his memoir about his years in medical practice, he entitled his book, “Sacred Space.” Yes, it’s a bit sentimental, but he pays rightful homage to the idea that that relationship between patients and their doctors and nurses is something exceedingly precious. Medical professionals appropriately go out of their way to keep that space neutral, private and nonjudgmental, because patients are often at their most vulnerable.

A patient of mine recently told me about a genital symptom that was bothering her. She’d had it for two years, but had been too embarrassed to bring it up. We had to build up our trust bit by bit, until she felt comfortable revealing it to me. Happily, it was something easily treatable. It’s situations like these that remind me how critical it is to protect this space.

Like most doctors and nurses, I try to keep the outside world firmly outside the exam room. I don’t talk about politics, religion, money, or sports. I don’t even gripe about the mayor. Most medical professonals avoid political activism for the same reason. But could that reticence be harmful to our patients?

I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

What would I do, I asked myself, if I started to notice a dangerous side effect of a medication that my patients were taking. The answer, of course, is easy. And it wouldn’t even be a question; it would be an obligation. If I see a threat to my patients’ health, it’s in my job description to speak up.

The ACHA and BCRA suddenly seemed like the same thing—a threat to my patients’ health. Yes, I value political neutrality, but this no longer seemed like politics to me. It was a medical threat.

When the Ebola threat was on the horizon, medical professionals geared up even before it arrived. (As it happened, it was my exam room that was chosen as the “Ebola room,” so was stocked with gear and had a window cut into the door so staff could observe patients without putting themselves at risk.) And although the epidemic was ultimately safely contained, out staff was completely prepared when the fourth and final US patient with Ebola was admitted to our hospital.

If I suspect that one of my patients is suffering abuse at home, I am obligated—in fact, legally mandated—to speak up.  If I suspect that my patients’ health will be harmed by legislation, I believe we are equally obligated to speak up.

Whether a medical threat is from a virus or a medication or a natural disaster or legislative action is ultimately irrelevant. If our patients could be harmed, then medical professionals have a duty to weigh in.

I wrote an op-ed for the New York Times to that effect, that doctors and nurses need to speak out about the ways this legislation could harm their patients. And that was about as far into the waters as I felt comfortable wading. But the editors decided to title the piece “Time for a Doctors’ March on Washington.” From the outpouring of response that I received, it seemed like medical professionals were ready to gear up, just was we’d done for Ebola. It was time to take a step beyond the exam room.

Along with filmmaker Catherine Stratton and her talented colleagues at Resistance Media Collective, the HouseCalls Campaign was created. We decided that there needed to be an organized effort to bring the voices of practicing clinicians to the ears of Senators have little clue about the realities of healthcare.

I’ve thought long and hard about whether this violates my commitment to political neutrality with my patients and I’ve concluded that it does not. I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor. When I leave the hospital, I start calling Senators about BCRA because that is also my job as their doctor.

Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients. It’s a medical emergency, and medical professionals need to behave as such.

Danielle Ofri, MD, PhDis an internist at Bellevue Hospital and an associate professor of medicine at NYU School of Medicine, as well as editor in chief of the Bellevue Literary Review. Her newest book is What Patients Say, What Doctors Hear and her TED talks include Deconstructing Perfection and Fear, A Necessary Emotion. Her current efforts are focused on the HouseCallsCampaign.

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24 replies »

  1. What part of

    “I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor.”

    do you not get?

  2. I think you walk a fine line when advocating pro/con healthcare policies with patients.

    Much of what I am seeing is that although the BCRA is not perfect, by no stretch was ACA perfect. To point out the flaws in HCRA/BCRA and not to point out flaws in the ACA is an obvious bias.

    I am all for advocating healthcare policies with patients, but perhaps an approach where we try to get to the best solution in a non-partisan way is in the best interest of our profession.

  3. Paraphrasing Rep. Mo Brooks (R-AL): “People who live good lives don’t have Disparities.” (or pre-existing conditions)

  4. About 55 years ago, the AMA made a deal with the tobacco industry that the AMA would not say smoking is dangerous (except smoking in bed), if the tobacco industry helped the AMA fight “nationalized medicine.” We had thousands of advts warning of the dangers of smoking in bed, and no nationalized medicine Ronald Reagan was a spokesman, explaining that socialism would come via control over healthcare.

  5. I’m with David on this one. If a healthcare finance bill affects access to healthcare, it’s a healthcare bill. And doctors should comment on that. After all, we don’t quibble about whether or not to label a bill authorizing the purchase of F-22s as a defense bill.

    Margalit is right that doctors could have tried to address structural issues affecting patients. But the AHCA is much more directly germane to patient care so I understand why this is the hill to take a stand on for doctors such as the post’s author.

  6. Agree with David and Jason and others who support this blog. As has now dawned, albeit slowly, on the public, AHCA and BCRA are primarily trojan horses (containing tax changes that benefit companies and the well off) and outside the bounds of rational or reasonable health insurance reform. They would effect access to and the delivery of care in profoundly negative ways. Both bills deserve an ignominious death

  7. Meant to add, may have seen the Henry Adams quotation that’s, appropriately, going around: power is “a sort of tumor that ends by killing the victim’s sympathies.”

  8. Gotta love the compartmentalizing. E.g., Norton, “leave it to others to change the world” (watch his video), or Jim’s, it’s okay for Ofri to protest as an individual (really/truly the ACA is not a healthcare bill?!?).

    So much for Virchow and “social medicine.”

    Am not at all surprised, e.g., per my THCB posts, the medical industry could care less about climate disruption, that it’s federal policy to torture in mass the the mentally ill, that we’re a rape culture, that we’ve turned others’ poverty into a profit center and the fact the AMA still honors the pedophile, Denis Hastert, for his lifetime contributions to public health.
    We met the enemy and they, definitively, are us.

  9. Two months ago, I was invited to give several talks and participate on several panels of the Annual Meeting of the Royal Australasian College of Physicians in Melbourne. The closing panel had several of us addressing the topic, “Doctors must do more to change the world.” Mine were the closing comments. They might be of interest to Dr Ofri and others:

    https://www.youtube.com/watch?v=OyWPJD7ipsM

  10. I puzzle over the settled science nature of this discussion. The author has taken what is an opinion by some prominent folks and made it Newton’s first law ..

    There is no discussion, no Conversation to be had with those who burn with religious fervor..

  11. The author unfortunately mixes the financing of healthcare with healthcare itself, and the two are decidedly different. This is not unusual. The ACA was not healthcare reform. It was health insurance/financing reform. We are talking here about patients receiving less support from the government–something not uniquely within physicians’ expertise to opine on expertly. This is about resource allocation.

    Who ever posited that able bodied adults earning 4 times the federal poverty level were entitled as a fundamental medical right to receive financial support? These are policy decisions, right or wrong–not medical decisions.

    Of course there is a relationship between the ease of affording care and the care some people choose to get. But the withdrawal of financial support is not medical harm any more than the loss of a job with benefits.

    Of course, if Dr. Ofri wants, as an individual, to protest, no problem. But to stir up her patients on an inherently political question is wrong on many counts, one of which is that it may damage her credibility with at least some of her patients. At least that is my take on it.

  12. It makes me sad that we – and I mean both Democrats and Republicans, as well as many physicians and many patients – have made health care into a political issue. I’m sad because it is now a zero-sum game. I’m sad because it’s a business conversation on par with tax and trade policies.

    There’s some analogy to be drawn with the current climate change debate. Like healthcare, climate change is part science and part culture. The US stands alone against 19 other rich countries in making the climate issue political. Is it a coincidence that we are also alone among rich countries in not having universal coverage as a way to minimize health disparities?

  13. The whole point of her article is that she is questioning giving up that neutrality.

    “Yes, I value political neutrality, but this no longer seemed like politics to me. It was a medical threat.”

  14. Not to worry…

    “You’re going to have such great health care, at a tiny fraction of the cost—and it’s going to be so easy.” – Donald Trump

  15. Yes, I fully appreciate the sentiments here and I believe doctors, like all other individuals, should be politically active. The health care legislation issue may feel more like an Ebola, but is it really? And isn’t this a bit late to the political “saving lives” game?

    Without further ceremony, and please forgive me, but where were all concerned physicians during the last few decades when American workers had to watch their wages deteriorate to the point of having to rely on Medicaid and all sorts of other charity just to survive? Where were all the doctors when successive administrations traded away the U.S. middle class at the behest of global corporations and deranged activist billionaires?

    Where were the doctors when our education system turned into third world crap, our inner cities collapsed and entire generations of boys and men of a certain color got carted away to prison? Where were the doctors when wars were/are fought for imaginary excuses and when the goddamn “resistance” is beating the drums of war with the largest nuclear power out there?

    Where were the doctors when tech companies pushed their sick and addictive products on millions of children, who are wasting their lives powering the tech exploitation machine? And recommending optimal “screen times” doesn’t count. Speaking of addiction, where were the doctors when America plunged into an opioid addiction and mortuaries in small towns began to overflow with victims?

    So my question is why now? Why is health insurance different than the other horrific events where your patients were/are literally being killed, not just estimated to maybe be killed in 2037?

    Perhaps if I would have seen doctors marching against poverty, worker exploitation, slave-labor importation, environmental destruction, and such, this newfound political activism would not look so peculiar. And maybe, just maybe, if doctors started marching against those patient-killing evils decades ago, we wouldn’t have to march today.

    Other than that, excellent article, as usual 🙂

  16. Doctors always believe that the alarms they raise about any action by federal or state government, insurers, employers, health plans, hospitals, other medical specialties, other doctors in the same specialty who aren’t as smart/competent/ethical as they are and anything else related to health care are actions undertaken altruistically out of concern for patients.

    As a result, some doctors warn that a single payer system, a la Canada, will kill patients, while other doctors warn just as sincerely that failing to adopt such as system will kill patients. While other doctors, of course, have every other opinion in between.

    Because so many doctors, like Danielle Ofri, are eloquent writers, I believe all of them all at once all of the time.

  17. I agree with Steve2 about not writing off the BCRA.

    Activism sounds more politically motivated than patient-centered. Where was the patient-centered activism when the middle class were straddled with huge insurance premium increases after ACA? Where is the activism when patients in rural areas have reduced access to doctors because of the regulatory over heads imposed on PCPs? Where was the activism when tort drove PCPs, who provided maternal care, out of rural Mississippi?

    Activism sounds fine, but it does seem to be rather selective. So excuse me whilst I shed some crocodile tears for crocodile activism.

  18. I don’t bring up political issues with patients but am happy to offer an opinion if asked. Politics is like religion these days. Very polarizing and can easily get nasty and personal. Selectively, with appropriate patients, a short discussion is reasonable.

    Some say thousands will die from BCRA. Others disagree. Some don’t go to the doctor because they have no money for their copay or deductible. Some can’t afford the copay on their Rx. I suspect many die for these reasons too.

    Personally if I went to the doctor the last thing I would want is a lecture about the politics of healthcare, particularly if from a perspective that I disagree with. If I ask, that’s one thing. But if offered as a way of persuading or converting me, I’ll pass.

  19. What part of

    “I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor…”

    did you miss?

  20. We should avoid politics with our patients. First, and I will argue strongly for what I believe, we should always remember that we could be wrong. You may think the AHCA sucks, but you could be wrong and maybe our POTUS is correct. He promised us a health care plan that will cover everyone and it will cost a lot less. Maybe we have it all wrong and he is correct. Second, that is just not what we are there for. Trust is a fragile thing and it should not be broken over politics, which often comes down to whether top marginal rate should be 30% or 35%. Save it for after work.

    Steve

  21. As our patients’ agents, one overarching obligation has been to continually protest high prices and the complexity of medical billing. Until we have shown trustworthy agency, at least in a few blatant efforts like this, ventures into political actions are going to appear as self serving and inauthentic.

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