Political conversations with patients

Questions about politics are inevitable in clinics and hospitals during this election season.

I was discussing discharge instructions with my patient and her husband. We shared a great rapport, and our conversations had ranged from her medical condition to other shared interests like food joints and dogs. Then her husband casually asked, Did you watch the convention last night? What do you think about the upcoming elections, Doc?”

Not wanting to open a can of worms, I said, “It was late at night. I missed it. I am happy to answer if you have a particular question, though. But before that, let me go back to the discharge instructions and explain to you one more thing.” We discussed the patient's postdischarge follow-up a little bit more before I left the room. I was happy to have safely discharged my patient and successfully dodged a political question.

It's that time again when people are focused on political conventions, charged electoral debates, and voting. Caring about certain things more than others, like health care policies, comes naturally to me as a physician, a parent, and a woman. Though I personally have many emotions related to elections, I prefer to steer clear of political conversations professionally.

There is a consensus among physicians to refrain from political discussions with patients. However, with this election's prominent focus on health and stark divides on proposed health care policies across and even inside political parties, confusion and questions about politics are inevitable in our offices, clinics, and hospitals. How to navigate them depends on an individual's preference but is also supposed to align with the ethical codes of one's institution and medical and professional associations. These guidelines typically leave a good deal to interpretation.

The ACP Ethics Manual, Seventh Edition, does not specifically address political discussions with patients, but it does note that physicians have a special obligation “to serve the patient's interest because of the specialized knowledge that physicians possess, the confidential nature of the relationship, the vulnerability brought on by illness, and the imbalance of expertise and power between patient and physician.” The American Medical Association's Code of Medical Ethics Opinions, Section 2.3.4, says, “Physicians should refrain from initiating political conversations during the clinical encounter due to the imbalance of power in the patient-physician relationship, as well as to the patient's vulnerability and desire for privacy.” It also states that it is not inappropriate to engage in political discussion when the patient initiates it and both patient and physician are comfortable having such discussions.

This approach does require some judgment on the clinician's part. Clinicians are expected to judge the intrusiveness of the discussion and the patient's comfort, to discuss politics only in acceptable contexts (social, civic, and recreational), and to refrain from such conversations when patients are emotionally pressured. In specialties like hospital medicine, where we often lack long-term physician-patient relationships, it might be harder to gauge comfort and intrusiveness.

Concern that political opinions may affect care is also real. A study published in the Proceedings of the National Academy of Sciences in 2016 found that primary care physicians who voted Democrat or Republican responded differently to patient vignettes on the hot-button health issues of firearm safety, marijuana use, and abortion. With implicit bias already rampant in health care, we certainly do not want to add another potentially avoidable source of it. Yet no matter how much we try to restrict politics from exam rooms, it can make its way in. We often encounter patients who cannot afford medications or face health problems because of their race or sexual orientation. We treat victims of gun violence and police brutality, and some clinicians refuse to provide certain services, citing conscience clauses. Arguably, these situations often result from clinician- or patient-specific factors, but the influence of politics cannot be denied.

The politicization of health has only increased recently. People choose or refuse to wear masks based on their political beliefs. Public health organizations like the FDA, CDC, and WHO have come under scrutiny about potential political influences in their recommendations and approval of therapeutics related to COVID-19. Assuming clinicians can be completely apolitical and unaffected by the political environment today is naive.

We can choose to try to keep political conversations off-limits in medical encounters or to take a responsible, but less rigid approach. Clinicians are expected to be well informed about proposed or current policies concerning health care access and quality, medical research, and public health (rightly so, I believe, in order to advocate for patients). To guide our conversations with patients, we need to recognize our roles in and boundaries associated with exam-room politics.

When patients raise the topic, educating them about relevant medical ethics policies and the potential for bias could be beneficial and may ease future medical encounters with clinicians who have varied political beliefs. A prepared script, like those we have for other difficult conversations dealing with addiction, goals of care, or bad news, could also come in handy here. It may make clinicians feel more confident, whether they choose to participate in political discussions or not. Focusing the conversation on patient care and related concerns rather than personal political beliefs may help. Talking exclusively about a particular topic is preferable to differing or agreeing on a broader political scheme. Concerns about availability and affordability of care and coverage, which depend on health care policies and reform, are often genuine and relevant and should be addressed by provision of appropriate resources for help or information. It's also always an option to respectfully agree or disagree by shifting the conversation to the patient's health.

Finally, whether a patient wears a red “MAGA” hat or a blue “Build Back Better” shirt, it is best for physicians to refrain from initiating political conversations, to be mindful of our own biases, and to avoid letting political beliefs affect our care.