By HAYWARD ZWERLING
I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads a productive life. Watching this transformation has been both professionally rewarding, personally enjoyable, and I look forward to our periodic interactions.
At this visit, he was sporting a MAGA hat. I was confused. How can my patient, who has so clearly benefited from America’s healthcare system, support a politician who has tried to abolish the Affordable Care Act, used the bully pulpit to undermine America’s public health experts, refused to implement healthcare policies which would mitigate COVID-19’s morbidity and mortality, and who minimizes the severity of the coronavirus pandemic every day. Why does he support a politician whose healthcare policies are an immediate threat to his health and longevity?
My brain says, “You are the physician this patient trusts to take care of his medical problems. You must teach him that COVID-19 is a serious risk to his health and explain how the President’s public health policies threatens his health. You must engage in a political conversation.”
It is currently taboo for physicians to discuss politics in the exam room, especially when political opinions are discordant as it risks creating a rift in the patient-physician relationship. Reflexly, I answer myself “Do not engage in a political discussion, you need to deal with his immediate health issues.”
During the visit, we reviewed his medicines and test results and agreed on a treatment plan. At the end of the visit, I told him that it is in his best health interest to wear a mask, socially distant, wash his hands frequently, and defer visiting his favorite bar and gym. I consciously decided not to address his support for the President.
Back in my office, I reviewed the encounter and immediately had misgivings about my decision to avoid discussing the health ramifications of his political proclivities. I knew he was mistakenly informed about the science of COVID-19, as his primary source of information was Fox News and his peers. I was concerned that this misunderstanding led him to support a politician whose public health policies will adversely impact his health.
Every day physicians teach their patients the scientific truths they must understand to enable them to make informed healthcare decisions. Is it not also a physician’s responsibility to teach their patients the science underlying relevant public health policy and explain that there is a linear connection between political choices, public health policies, and their health and longevity? Would not a more comprehensive understanding of this relationship enable our patients to make more informed political decisions, including the option to choose political leaders who will implement better healthcare policies?
While politics has become hyperpolarized, most patients still believe their physicians tell the truth about science and medicine; thus physicians are in a unique position to educate their patients about the ramifications of science.
By selecting me as his physician, he was implicitly telling me that he had confidence in my judgment. In return, I should have emphasized that the coronavirus is an immediate risk to his health, I should have explained how COVID-19 spreads and how he can reduce his risk. I probably should have breached the “no politics in the exam room” taboo and told him that the President’s refusal to implement public health measures recommended by every public health expert has resulted in the needless death of tens of thousands of Americans and is part of the reason that 1,000 Americans die from COVID-19 every day. I should have explicitly connected the dots and stated that the President’s COVID-19 public health policy is an immediate threat to his health.
The medical profession now understands that social determinants of health are probably the most important driver of a patient’s overall health and these determinants are largely the result of political decisions. Clearly, we have a professional responsibility to teach our patients the science underlying their health issues. Don’t we also have a professional obligation to ensure that our patients understand the health ramifications of their political choices? If that is the case, do we not have a professional obligation to initiate a conversation about the political issues which impact our patients’ health?
If we fail to breach the taboo of “talking politics” in the exam room, are we not shirking our professional responsibilities to our patients and society?
Hayward Zwerling is an endocrinologist with an interest in health information technology, health care policy, woodworking, and politics.
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An example of Talking Politics in the Exam Room from yesterday…
On the morning of the first Presidential debate I walked into my exam room and there was a woman in her 60s. She was neither wealthy nor highly educated. After some small talk, and unsolicited, she asked what I though would happen in the Presidential debate that was going to take place in the evening and whether I was going to watch the debate.
I said that I may not watch the debate because it’s not to going to change my opinion and I started to talk about her health issues.
She then said “if you don’t mind, can I ask who you going to vote for.”
I replied “I believe in science.” Her immediate lack of response told me she was a Trump supporter. Sometime later she said “I am on the other side.”
I think I asked her why she supported Trump and she said that she liked him because the economy was doing so well until the coronavirus and it wasn’t his fault that the coronavirus destroyed the economy.
With respect and as non-judgmentally as possible, I said that if Trump had followed the advice of the scientific community, as was done in most countries, there would have been far fewer American COVID deaths than have occurred.
The rest of the visit was devoted to her healthcare issues.
At all times, I tried to be respectful, calm and I tried to limit my comments to scientific facts which were explained in a way that I thought she would understand.
“The ACA made undelivered promises (e.g., choose your own doctor and lower premiums) and with increased ACA regulations, it resulted in job loss for thousands.”
The ACA is nothing but government subsidizes for existing insurance carriers. The “choose your own doctor” argument, which Republicans love to pin on Obama as a failure of ACA, does not exist in private sector insurance. Ever change plans and find your old preferred doctor was not covered in the new plan?
The lower premiums are only for those getting government subsidies based on income, which IS a lower premium than they would have had trying to buy on the open market – if they could get insurance if they had a pre-existing, condition, which the ACA banned.
As to the “job loss for thousands” you’ll have to explain that and provide evidence.
There are failures with the ACA, but just ask the Trump supporters who rely on it for their coverage if they want it taken away to go back to NO affordable health care options.
As for the MAGA hat, when I see those, they tell me everything I need to know about the person wearing it – and its not good.
It’s not too late. I imagine you have a way to contact them, you still have time to reach out and have this conversation. Please let us know how it goes 😉
Kelly,
Thank you for your comment.
I am a bit uncertain as to why you are concerned.
There is a linear connection from science which leads to public health policy recommendations that are designed to optimize everyone’s health. These public health policy recommendations are then presented to our political leaders, who receive recommendations from many sources, and then our political leaders decide which public health measures should be implemented. In the end, the implemented public health measures will impact my patient’s health.
I’m glad you understand this connection but I can assure you that not everybody does, as it is a complicated chain of events.
In the end, I want my patients to have all the information they need so that they can make decisions that best meet their individual goals and needs, even if that means they do not prioritize their health.
But knowledge is always good.
All the best.
Dr. Zwerlinger,
I disagree with you! According to your report, as soon as you saw the MAGA hat you made a variety of assumptions about your patient. At this suggestion, I have serious concerns with your ability to make unbiased decisions regarding the health and well-being of your patient. I also question how well you research healthcare. The ACA made undelivered promises (e.g., choose your own doctor and lower premiums) and with increased ACA regulations, it resulted in job loss for thousands. In terms of COVID19, I have liberal friends who go to the casinos and do not wear a mask when they go to the store. I have a liberal physician friend who traveled between states during the height of COVID, and even though the state she traveled asked for no travel from our area to their state, she did not disclose and traveled there anyway. A major problem with the political landscape is bias and generalizations. This is a form of prejudice that is dangerous.
If I were your patient and you were to began to share your politics with me, I would immediately lose confidence in your ability to properly research my medical problem and I would be highly concerned about your bias against me according to other areas in life (e.g., my gender, my religious affiliation, my race). Moreover, I do not go to the doctor for a political view but to be “heard” about my health issues. The ability of physicians to hear their patients is becoming a rare phenomenon. You are not an expert in politics, you are a physician. Even in this area, your expertise is limited to your level of current research in the area and your experience.
Hubris is not a virtue.