When Politics Enter the Exam Room
By D. Joy Riley, MD, MA (Ethics) | October 20, 2016
by D. Joy Riley, MD, MA (Ethics)
The source of this buzz is a study reported in the September 28, 2016 edition of the Proceedings of the National Academy of Sciences called “Democratic and Republican physicians provide different care on politicized health issues.” Co-authors of the article are political scientist Eitan D. Hersh and psychiatrist Matthew Goldenberg, who “expected to see differences in evaluation and treatment on politicized issues but not on issues with less political salience.” Is the popular news hype justified? A look at the actual study is in order.
The authors obtained political party affiliations of more than 20,000 primary care physicians in 29 U.S. states by linking the names, gender and work addresses of 42,861 physicians with a voter registration database. They were also able to obtain the physicians’ home addresses through the same database, and then they used those addresses to solicit responses to a survey. The authors surveyed a stratified random sample of physicians and reported a response rate of 20 percent. Sample size was 231-233, with slightly more Democrats than Republicans responding. Respondents were not made aware of the political interests of the survey, but they were given nine initial patient visit vignettes to evaluate for seriousness of problems presented and treatment recommended. Those problems included five the authors deemed “not thought to be especially aligned with political partisanship (alcohol use, tobacco use, helmets, obesity, and depression)” and four “which were suspected to be more politically salient (marijuana use, elective abortion, firearm storage and engagement with sex workers).”
In terms of seriousness, Democrats were “more concerned” than Republicans with firearms and sex worker exposure, while Republicans were “more concerned” than Democrats about all the other issues. The differences in perceived seriousness of the problem were most significant for abortion, firearms and marijuana use – all with standard deviation values of 2.3-2.5.
Differences in treatment were present for abortion, firearms, marijuana use and sex worker exposure. Republicans were more likely than Democrats to address the issues thusly:
- Marijuana – refer to counseling, ask the motivation to stop, ask the patient to cut down, and discuss legal and health risks
- Abortion – discuss contraception, refer to counseling, ask about the circumstances surrounding the abortion, discuss mental health aspects of abortion and encourage no more abortions
- Sex Worker Exposure – screen for STDs, refer to counseling, discuss health risks, ask why patient seeks sex workers, urge patient to stop and discuss legal risk as well as impact on relationships
Regarding firearms, the differences were striking in only one area. The Democratic primary care physicians were more likely to “urge patient to not store firearms,” while the Republican physicians were more likely to “discuss risks” of firearms and “ask about safe storage.”
The authors and news media alike seem to find these results concerning. The authors state,
For patients, our study suggests that they may need to be aware of their physician’s political worldview, especially if they need medical counsel on politically sensitive issues. . . .
For physicians, the evidence calls for heightened awareness and training surrounding treatment on politically salient issues. Given the politicization of certain health issues, it is imperative that physicians consider how their own political views may impact their professional judgments.
What are current recommendations? Let us consider them in reverse order:
Firearms – The position of the American Academy of Pediatrics includes
- “Physician counseling of parents about firearm safety has been demonstrated to be an effective prevention measure.”
- “Physician counseling, when linked with the distribution of cable locks, has been demonstrated to increase safer home storage of firearms. The removal of guns or the restriction of access should be reinforced for children and adolescents with mood disorders, substance abuse (including alcohol), or history of suicide attempts.”
Sex Worker Exposure – The Centers for Disease Control and Prevention recently reported 2015 data for sexually transmitted diseases in the U.S. Rates were increased for several: chlamydia had increased 5.9 percent over the previous year, while gonorrhea had increased 12.8 percent. Even more worrying, the reported rate for primary and secondary syphilis was 19 percent higher.
That is not all. In addition to chlamydia, gonorrhea and syphilis, sexually transmitted infections include genital herpes, hepatitis B and C, human immunodeficiency virus (HIV) and human papilloma virus (HPV). Recommendations for screening of women and men can be found at the U.S. Preventative Services Task Force.
Abortion – The American College of Obstetricians and Gynecologists (ACOG) finds induced abortion “an essential component of women’s health care.” The College Statement of Policy on Abortion also states: “The College continues to affirm the legal right of a woman to obtain an abortion prior to fetal viability…ACOG is opposed to abortion of the healthy fetus that has attained viability in a healthy woman. Viability is the capacity of the fetus for sustained survival outside the woman’s uterus….”
The American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) holds a different position: “AAPLOG exists to provide a ‘second opinion’. We make available here readable summaries of what the medical literature actually says regarding the effects of abortion on women. Preterm birth, suicide, depression and breast cancer are only some of the ways in which abortion can harm women. This is information critically important to any true informed consent on the issue of abortion.”
Marijuana – Recommendations regarding marijuana only relate to medical uses thereof, and the Federation of State Medical Boards has assembled some in “Model Guidelines for the Recommendation of Marijuana in Patient Care: Report of the FSMB Workgroup on Marijuana and Medical Regulation.” It reads, “The physician should discuss the risks and benefits of the use of marijuana with the patient. Patients should be advised of the variability and lack of standardization of marijuana preparations and the effect of marijuana. Patients should be reminded not to drive or operate heavy machinery while under the influence of marijuana.”
In light of the various recommendations delineated above, it seems that the primary care physicians who inquire about a patient’s firearms, exposure to sexually transmitted infections, previous abortions or marijuana use are practicing good medicine. The recommendation by the Yale study’s authors that patients need to know the political affiliations of their doctors is surprising in several ways. First, thousands of physicians are either not registered to vote or not American citizens, as evidenced by the numbers reported in the study. There is no recommendation for patients of those physicians. Secondly, two treatment possibilities for the fictional patients needing attention include referral for counseling (regarding marijuana use, sex worker exposure and previous abortion) and a recommendation for no further abortions in light of a history of abortion. One of the authors is a psychiatrist and would presumably affirm referring patients for counseling. It is unclear why a referral would be problematic. Additionally, who recommends further abortions to a non-pregnant woman (as was the woman in the vignette)? Or do the authors view abortion simply as birth control?
Finally, authors Hersh and Goldenberg report no financial conflicts of interest, but do not report their political affiliations. That is a curious omission, considering the topic.
Faith Steps by Jonathan Imbody
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