We Need to Talk about Doctors’ Politics
By Max Jordan Nguemeni
Image by Jason Silverstein.
Last month, the American Medical Association held its National Advocacy Conference, during which participants had the opportunity to meet with various lawmakers and national leaders in healthcare. To kick off the conference's last day, Kansas' Senator Roger Marshall (R) shared his perspective on issues that matter to physicians, and on their Twitter account, the AMA thanked him for "being a leader on health care in congress." But Senator Marshall is indifferent to the suffering of poor Americans. "There is a group of people that just don't want health care and aren't going to take care of themselves," he once said, arguing against Medicaid expansion. As a member of the GOP doctor caucus, sure, he's a leader in healthcare in congress, as the AMA tweet said. A leader in making healthcare less accessible.
Before joining congress, Dr. Marshall was, unfortunately, an obstetrician-gynecologist, and in congress, he has been staunchly opposed to abortion. So how could the AMA, which professed its commitment to protecting the right and access to abortion, welcome this guy in a post-Roe world? In any case, despite the indignation and righteousness of young progressive physicians like myself, there are far more Drs Marshalls among our ranks than we'd guess. They are active in our professional societies like the AMA. They make up the majority of physicians in elected positions. And we seriously need to discuss it as a professional duty to our patients.
The discourse around physician political engagement among progressive doctors appears optimistic. Emblematic of this is the rise of organizations like Doctors in Politics and Future Doctors in Politics. Yet progressive doctors often don't want to join AMA, despite being the largest and most powerful lobby in organized medicine! The idea that we need more doctors in politics, or that *all* doctors need to be more politically engaged, coming from progressive doctors, stems from, I think, a blunt assumption that we as doctors are a mostly inherent force for good when it comes to both healthcare and social policy. After all, we went into medicine "to help people," or so we tell ourselves and assume of our colleagues. But a sober look at doctors' political engagement and the impact of politics on physicians' attitudes and practices in patient care should require us to rethink these naive positions.
The American Board of Internal Medicine Foundation defines medical professionalism as "the daily expression of the desire to help people and society as a whole by providing quality care to those in need." While many assume that "helping people" is a common goal among people who seek to enter the medical field, we are unfortunately not all committed to helping everyone. Twenty years ago, about 10% of graduating medical students did not consider access to basic healthcare a fundamental human right. Some might think of 10% as negligible – likely a conservative estimate because of desirability bias – but it isn't, considering we're talking about basic healthcare, not access to cosmetic surgery. You might think attitudes have changed over the years. But a more recent study of incoming medical students found that conservative medical students were less likely to report wanting to care for the poor, people of color, and LGBTQ people by graduation. They were also less internally motivated to control racial prejudice, had lower levels of empathy toward patients, and lower levels of patient-centered attitudes.
Beyond their ideological stances at the beginning of medical school, going through medical school impacts medical students' support towards initiatives that would help improve healthcare, especially for the poor. While fourth-year medical students support making healthcare cheaper, they're less likely to do so if it means even a small reduction in what physicians would be reimbursed. However, even the lowest-paid physicians make significantly more money than most Americans. A key predictor of this dissonance was the amount of debt students had taken on to complete their education. In her book Doctor’s Orders: The Making of Status Hierarchies in an Elite Profession, Sociologist Tania Jenkins describes medical students’ contract with society: work hard, for some, take on debt, delay gratification more than most, and in the end, earn near-guaranteed employment with a high salary. Those most afflicted by the debt burden of medical education, especially if already less progressive, likely experience health policy efforts that would reduce physician compensation as a breach of contract. This is consistent with the AMA's ethos, where physicians' political engagement, and the implicit message, is that the organization's advocacy should be about physician compensation before patient advocacy.
The impact of conservative ideology among physicians is thus felt strongly. While multiple factors shape students' specialty choices, in the end, those who enter the most lucrative specialties are also the most conservative. And they are vocal about it. For example, studies show that yearly income is tightly correlated with physicians' political contributions by specialty: those who earn more donate disproportionately to the Republican party. Physicians with the lowest earnings — pediatricians — consistently donate the most to Democrats and have a strong record of advocating for policies that would ostensibly improve everyone's health. For instance, when I started medical school in 2016, the American Academy of Pediatricians’ political platform focused on addressing childhood poverty. Almost all of its campaign contributions during the 2020 election cycle went to Democrats.
In contrast, of the ten million dollars surgeons donated to political campaigns in the 2020 election year, nearly 60% went to republican candidates amid a pandemic, despite the GOP's continuous efforts to repeal the Affordable Care Act in the preceding years. So, while in numbers, most physicians may side with and donate to democrats; we have a very powerful conservative minority among our ranks. The power of this conservative minority manifests itself among those who are elected officials, such that 14 out of 17 physicians elected in congress are republicans and disproportionately from higher-earning specialties.
Beyond political engagement, physicians' political ideology directly impacts patient care. Dr. Marshall, a staunchly anti-choice obstetrician-gynecologist, is an example. Anti-choice obstetrician-gynecologists arguably oppose patients' agency and autonomy, core bioethics principles. In a study of physicians' attitudes and treatment approaches to politicized health issues, Republicans were likelier to encourage the patient not to have an abortion. The study also explored other pressing health issues. For example, on firearms, now the leading cause of death among children and teenagers, Democrats were more likely to recommend that parents store them away from home. More recently, a study found that conservative critical care physicians were five times more likely than their liberal and moderate counterparts to say they would treat COVID-19 with hydroxychloroquine, a treatment promoted by former President Trump without robust evidence (leading at the time to real-life increased prescriptions in Republican-leaning counties), and since proven ineffective. Abortion, firearms, and COVID-19 might seem too polarizing for some, allowing us to turn a blind eye to these partisan differences. But even on less politicized matters, conservative ideology among physicians is associated with less patient-centered actions. One multi-state study showed that Republican physicians were 75% less willing to assist depressed patients' requests for exemption from Medicaid work requirements than their Democrat counterparts.
The optimists might argue that things will improve, assuming that younger physicians will be more progressive. After all, the share of physicians who are registered republicans has continued to decrease over time, matched with a steady increase in the number of registered democrats. Though financial contributions to political campaigns for some specialties have swung toward the left (partly due to an increase in women joining the field), the most recent estimates suggest that about 20% of medical students identified as conservatives. The expectation that younger generations of physicians will be, as a whole, more patient-centered than the older ones isn’t entirely true. For instance, a 2018 study found that medical students were more likely than practicing physicians to agree that physicians should sometimes deny costly but beneficial services, in line with more conservative ideology. Medical students were less likely to prioritize patient welfare over cost-consciousness than practicing physicians, thus normalizing scarcity. In other words, younger physicians may embody the kind of medicine the late Paul Farmer was a staunch critic of: one where well-intentioned people are socialized to think of scarcity on behalf of others as normal, but not for themselves or their loved ones. We may be willing to deny expensive but beneficial services to save costs but are less willing to endorse cost-saving initiatives if it means taking a little pay cut. Many would rather not take care of the poor, and a well-intentioned majority has been too socialized for scarcity. This does not bode well for our hopes of expanding access to high-quality care, especially for the poor, and addressing health disparities, as the AMA and AAMC committed to in 2020.
Physicians’ biases against the poor are highly prevalent across the political spectrum, as the majority come from high-income households. Research has shown that most medical students hold negative attitudes toward the poor. Liberals often hold conservatives in contempt, especially poor, rural conservatives. However, a key difference along the political spectrum is that, unfortunately, conservative trainees are less motivated to mitigate their biases, which ostensibly would affect how they treat (or refuse to treat) marginalized patients.
The responsibility to address the impact of doctors’ politics on patient care should not rest on individual trainees and physicians alone. Medical training is a prime opportunity to address physician attitudes toward the poor. Embedding service learning (e.g., working in a free clinic) in medical school curricula is associated with increased intention to practice in underserved communities. White students at more racially diverse medical schools become more likely to rate themselves as highly prepared to care for minority populations and value equitable access to care more strongly. Conversely, negative role-modeling from faculty (such as making fun of patients, negative comments, etc.) and an unwelcoming racial climate contribute to medical trainees’ worsening attitudes towards Black people.
Increased workload also impacts the care physicians provide along racial lines. Symptoms of burnout are associated with increased implicit and explicit anti-black biases among residents. One study found that increased cognitive load leads to physicians prescribing opioids for chronic back pain inequitably. Additionally, among the aforementioned physicians who were asked whether they would assist depressed patients with their Medicaid work exemption application, besides the impact of politics, those who described the administrative effort as neutral or appropriate were far more willing to help the patients in need with their application, compared to those who found the administrative work cumbersome. In other words, physicians’ politics impact our fulfillment of professional duties to serve patients. This impact can be mitigated or worsened by the quality of the training or work environment and experiences.
Still, while we may think of our colleagues as good people regardless of their politics, what they choose or plan to do with their power – like a lack of intention to care for the poor for various reasons, including different insurance reimbursement rates – is what they should be judged by when they are evaluated for admission into medical schools and residency programs. I recognize that is easier said than done. And certainly, people can change. But the few studies that have been done on medical trainees' attitudes suggest that our political stances don't evolve much, and our attitudes toward the poor and other marginalized groups mostly worsen during medical school, all other things being equal. It is high time that we seriously consider intentions to care for all people equitably, the internal motivation to control prejudices, and patient-centered attitudes as matters of professionalism. Furthermore, medical schools and training hospitals should build and sustain initiatives to improve trainees' and providers' attitudes toward marginalized patients (service learning, improving institutional culture, etc.) and reduce the impact of bias on patient care (such as decision-making aides, reduced workload, and increased utilization of protocols whenever possible).
Implementing a multilevel approach to addressing the impact of physicians’ politics on patient care may take a while as we generate the best evidence and best practices. But it should be of high interest to our profession, the general public, and the federal government, given how much it invests in medical education. It's worth asking: should we spend taxpayers' money on training doctors who, in turn, can pick and choose who they want to care for to maximize their earnings? Or who may use their power to restrict some patients' autonomy against bioethics principles? To borrow a phrase from my cost-conscious colleagues, Is it a good use of healthcare dollars? It's too bad nearly every doctor in congress is a Republican, working hard at limiting access to healthcare for the poor. There's no way they'd ask.
Max Jordan Nguemeni is a resident physician in internal medicine at Brigham and Women’s hospital/Harvard Medical School. He also conducts environmental health & health services research with a health equity focus, and has an interest in issues at the intersection of science/health, technology and media. His lay writing has appeared in The Washington Post, The Boston Review, and Undark Magazine. Twitter: maxjordan_n. He is also editor-at-large for Peste Magazine.