Advice on When and How Physicians Can Speak Out If Their Opinions Differ from Their Employer

In July 2022, a white-coat ceremony at the University of Michigan in Ann Arbor made national headlines after a group of incoming medical students interrupted the proceedings with a staged walkout to protest the event’s keynote speaker, a professor at the university who had expressed pro-life views in various social media posts and interviews.

In their pre-event petition, the students had stated that, among other beliefs, the speaker “…supports the non-universal, theology-rooted platform to restrict abortion access, an essential part of medical care.” The university subsequently issued a statement through its public relations department indicating that it “does not revoke an invitation to a speaker based on their personal belief.”

The incident underscored an existing debate that seems to pit the right to freedom of speech against the Hippocratic oath, as physicians grapple with the question of when and how to take a stand on issues about which they feel strongly. Fueling matters is today’s polarized political climate and a growing sense of tribal-like distrust between groups who see things differently. Meanwhile, the prevalence of social media as a communication tool means that it has never been easier for anyone and everyone to broadcast their opinion. As a physician, where should your boundaries lie? When is speaking out a moral imperative? And what are the potential personal, professional, and legal consequences of taking a stand?

Entering the Arena

The definition of “political” has changed dramatically over the past few decades. “The term ‘political statement’ was popularized in the 1960s to refer to any act or nonverbal form of communication intended to influence decisions to be made for or by a political party,” said Julie Wei, MD, a pediatric otolaryngologist and current president of the American Society of Pediatric Otolaryngology (ASPO). “Examples would be participating in a mass demonstration or wearing some visible sign. We would also attribute the term to a political officeholder who chooses to make a statement related to real-time politics, policies, and debate.” Now, however, the public has come to think of the term “political statement” as anyone’s widely shared topical opinion that seems to align with one school of thought versus another.

Meanwhile, added Dr. Wei, the concept of “health” has expanded as society takes a broader view of the factors that influence and affect human well-being, encompassing a person’s mental, physical, and emotional condition, as well as the social determinants of health. “It’s recognized that 80% of children’s health is influenced by housing conditions, food security, educational environment, exposure to domestic violence, sexual abuse, emotional neglect, bullying, and more. It’s all health related,” she said.

It’s very difficult to work in an environment where one’s personal values don’t line up with those of the hospital or institution; over time, the differences can lead to burnout. —Gopi Shah, MD

From this perspective, most, if not all, policy decisions by elected and appointed officials might be considered health related, and there would be plenty of overlap in the Venn diagram of politics and healthcare. “Climate change, immigration, gun control, welfare, subsidy—there are endless controversial topics,” said Dr. Wei, who, together with ASPO leadership, drafted a nonpartisan statement with a call to action to vote. “After the mass gun violence in Uvalde, Texas, and the overturning of Roe v. Wade, I believed strongly that we needed to send a message that would represent our majority and acknowledge our grief,” she said.

Some physicians believe that it is possible, and in fact, vital, to parse which aspects of a controversial issue should be considered health related and which would fall into the realm of political ideology. “For instance, you can be very much in favor of vaccines and yet not support mandatory situations,” said Bradford Holland, MD, an otolaryngologist based in Waco, Texas. “And I know that there are physicians who will disagree, but I think this relates to your opinion as to what the role of government should be, as opposed to not thinking the vaccine is a very good idea—which obviously it is. Is it okay for a physician who is pro-vaccine to say we shouldn’t have a vaccine mandate? I’m not sure those nuances in opinion were ever fully appreciated.”

When, Where, Why, and How to Speak

For physicians, attending to their fellow human’s healthcare needs is a daily reality that requires a neutral approach. “We are constantly in that place of exhibiting tolerance and understanding even as we’re trying to persuade a patient to put down the saltshaker,” said Dr. Holland. “We learn to do this in a way that’s effective but still withholds judgment.” As speaker of the house of the Texas Medical Association, he has found this aspect of a physician’s skill set highly transferable. “I’ve been in a position to work with our state’s medical political action committee, so I’ve become familiar with having to make policy statements that reach across the aisle.”

Gopi Shah, MD, a pediatric otolaryngologist in Dallas, has seen how an ideology-driven political point of view can spur changes that many physicians would consider detrimental to public health. “We have seen rapid policy changes in hospitals and other institutions since COVID-19, but a gradual evolution can also occur with changes in leadership and mission, and, ultimately, culture and values,” Dr. Shah said. “It’s very difficult to work in an environment where one’s personal values don’t line up with those of the hospital or institution. Over time, the differences can lead to burnout.”

Dr. Shah said that the Texas state legislature filed some 50 bills affecting LGBTQ people in 2019 and 2021 alone, with more than a dozen of those bills aimed at transgender youth. Then, in November 2021, the Dallas-based pediatric multidisciplinary transgender clinic GENECIS was closed without notice. “This decision was made by the leadership of the children’s hospital and academic institution against the wishes of the physicians and providers in this clinic,” said Dr. Shah. “The physician lead of this clinic built this program over seven years ago. Since its opening, it had seen more than 1,000 patients and had 600 active patients. The clinic had followed the recommendations of national and international societies such as the Endocrine Society, the American Academy of Pediatrics, and the World Professional Association for Transgender Health. “I saw a program within our hospital shut down literally overnight, with no information regarding this closure except what was published in the media,” Dr. Shah added. “The closure blocked access to care for an already marginalized group of children and families. As a physician colleague, I witnessed injustice at a professional level: how physicians may be blocked from practicing patient care that’s in accordance with updated clinical guidelines and evidence-based medicine, in contradiction to the Hippocratic oath that we took on the first day of medical school.”

In response to the clinic closure, Dr. Shah and others in her community circulated a petition that garnered more than 800 signatures. With permission from the university, they organized a peaceful protest, participated in educational activities such as a university-level grand rounds on health equity specific to LGBTQ people, and, within the otolaryngology department, conducted open discussion regarding the closure and what it means.

Physicians are human and layered with the effects of their life journey—how they were raised, their cultural heritage, their personal experiences. It’s simply a human right to express our unique, individual opinions and thoughts. —Julie Wei, MD

The experience of working with a group that shared her values and concerns was eye opening for Dr. Shah. “I met the most wonderful human beings for whom this cause was both professional and personal. I realized what it means to be an ally: You support those who are directly impacted by oppression, through acknowledgement, listening, empathizing, and, if it feels right, in speaking up, signing a petition, or coming out to march alongside them,” she said.

Months before the GENECIS clinic closure, the American Medical Association (AMA) had taken a public stand on the issue of healthcare services for transgender children, and had written a letter urging governors to oppose state legislation that would prohibit medically necessary gender transition-related care for minor patients. Certainly, the AMA and other professional groups can be extremely effective as mouthpieces for physicians; why, then, it is necessary for individual physicians to announce a position? “Physicians are human and layered with the effects of their life journey—how they were raised, their cultural heritage, their personal experiences,” said Dr. Wei. “It’s simply a human right to express our unique, individual opinions and thoughts.”

She added, however, that these thoughts should be delivered in a nonpartisan manner and without a “morally righteous” tone. “When the science is available, even if imperfect, we need to provide key information on what we know will protect public health,” Dr. Wei said. “But we can’t bridge our immense divide unless we can start having open conversations while maintaining mutual respect.”

When passions rise, restraint can go out the window, added Dr. Holland. “In general, everyone needs to tread a little more lightly,” he said. “Tolerance isn’t what it used to be. But you know the old saying: ‘If you’re not at the table you’re going to be on the menu.’ It really does behoove us as physicians to be involved in the political process.”

Assessing and Mitigating Risk

Before enlisting the support of the greater public, Dr. Shah advocates for speaking out within hospitals and institutions, medical communities, and societies to support or oppose a point of view, or to protest a change. “After all, the goal of our hospitals is to serve our communities, so when the needs of the community are emphasized and brought forward by the community itself, that is where the impact can be made,” she said, adding that this includes talking to colleagues and writing to the people in charge, so they can hear how changes are affecting physicians. “Good leaders want to have their finger on the pulse, and the response you receive will reveal the values and goals of the institution, so you’ll know whether it aligns with yours,” Dr. Shah said. “Regardless, all dialogue should start in our clinical settings where we are being affected by policies.”

Physicians who broadcast their opinions less discriminately can become subject to professional risk, said Emily A. Johnson, JD, a Chicago-based healthcare attorney who served as a senior consultant with a national health management consulting company before joining the legal firm of McDonald Hopkins. She urges physicians who choose to make a political statement to “first consider how the statement may impact their employment, their fellow partners or coworkers, their patients, and the physician’s own general reputation. If the benefits of speaking outweigh these risks, then the provider may proceed with caution and should keep in mind the ethical guidance issued by the American Medical Association.” She added that it’s always best to consult with an attorney when in doubt.

Johnson encourages physicians to scour their contracts before stepping on that soapbox. “Sometimes there are restrictions on who has the authority to speak on behalf of a hospital,” she said. “More commonly, though, there is language prohibiting a provider from portraying the hospital, medical school, or healthcare organization in an unfavorable light. Additionally, hospitals and health systems might have language in their bylaws prohibiting speaking on behalf of the hospital without the hospital’s approval or speaking in a manner that casts a negative light on the hospital.” Setting aside the contractual issues, however, it is legal for a physician to express an opinion, she says.

The venue and context in which a statement is made matters. “Statements to patients, on social media, or to medical journalists are generally higher risk, whereas a statement made at a conference—but not as an official conference speaker—may carry less risk,” said Johnson.

Dr. Holland avoids bringing up politics while practicing in the clinic or when representing his employer, Ascension Providence Hospital in Waco, Texas. “But they’ve given me leeway if I’m speaking on behalf of the Texas Medical Association,” he added.

Physicians who use social media to get a point across should exercise caution on these platforms, as should anyone. Dr. Holland maintains a robust Twitter account in which he freely expresses his thoughts on issues. “I’ve always been politically active and was so even before I went to medical school,” he said, admitting to having been quoted and “gone viral in ways that perhaps I shouldn’t have.” His advice: “Never post anything the first time you think about it.”

Dr. Wei knows of several physicians who have been targeted via social media. She is willing to take a risk for what she believes in—but not online. “I rarely post about controversial topics on my personal or professional social media accounts,” she said. “Most institutions have marketing personnel that monitor social media. Physicians must make sure that whatever they post is disclosed as not representing their organization.”

The good news is, at a time when the art of “agreeing to disagree” appears all but lost, physician activists have an opportunity to show the public how to engage and work cooperatively with others who may hold an opposing point of view. “Our job is not simply to spout opinions,” said Dr. Holland. “We need to choose our battles carefully, to be selective about what we say in public, in print, and in the media, and then be respectful no matter what.”

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Linda Kossoff is a freelance medical writer based in California.