Clinical Scenario
You’re seeing Frank Bell today for a follow-up visit after an initial treatment of acute rhinosinusitis. Mr. Bell is an extrovert with a tendency to express his viewpoints on a wide range of subjects. Today, he seems eager to talk about politics immediately after you greet him.
“So, Doc,” he says, “you’ve got to tell me what you think about (insert any political topic).”
“You look better today than when you came in two weeks ago, Mr. Bell,” you respond. “How are you feeling?”
“Much better. So where do you stand on this craziness? This guy (insert name of politician) is going to run our (insert city, state, country) into the ground. You agree with me, right?”
“Well …”
“You have to see what’s happening here, Doc, right?” Mr. Bell continues. “We have to all stick together against these politicians. I was telling my wife just this morning that if anyone would agree with me on these politicians, it would be you, Doc. Tell me you agree.”
You give a thoughtful pause before saying, “So, has the infection resolved satisfactorily?”
Mr. Bell shakes his head and says, “Doc, I’m not letting you get off that easy. We have to fight this political war together or we all lose.”
You sigh; it’s going to be a long day.
How do you handle the situation without making your patient upset?
Discussion
Effective, appropriate, and respectful communication with our patients is fundamental to the integrity of the patient–physician relationship. As physicians, we are responsible for creating and maintaining the proper atmosphere for bilateral communication, and for directing the conversations toward the necessary clinical goals. Indeed, it’s important for the physician to connect on a personal as well as a professional level with the patient, with the personal interactions directed toward facilitating the professional interactions. A proper greeting, inquiring about a patient’s family and/or job, discussing the weather, asking about social interactions, and so forth are neutral, but important, adjuncts to the professional relationship.
Physicians regularly discuss difficult topics with patients in the course of providing care—end-of-life decision options, sexual activities, drug and substance use, stress in marriage, and a host of other sensitive topics. We don’t shy away from these discussions because they can be difficult or potentially embarrassing; instead, we proceed tactfully and supportively so that decisions can be made and appropriate care can be given. We’re used to engaging patients in stressful and often awkward conversations in the course of our care. It’s part and parcel of what we do.
Political discussions can range from a pleasant, respectful sharing of viewpoints to an unexpected stroll through a philosophical minefield. At the least, it’s important for a physician to ask him or herself, “Is it worth the risk to discuss politics with a patient?”
There are other topics that are only tangentially related to patient care, however, or are completely dissociated from the medical topic at hand that the patient may wish to discuss. Among the most potentially risky topics is politics. Political discussions are potentially risky for a number of reasons:
- Alienation of the patient relationship due to difference of opinion;
- Possible misinterpretation of the physician’s viewpoint that could lead to a suspicion of biases;
- A patient’s sense that their opinion doesn’t matter to the physician; and
- A host of other downstream effects if the patient shares the physician’s viewpoints with others.
Political discussions can range from a pleasant, respectful sharing of viewpoints to an unexpected stroll through a philosophical minefield. At the least, it’s important for a physician to ask him or herself, “Is it worth the risk to discuss politics with a patient?”
In the article “Finding Words” in the October 2020 issue of ENTtoday, author Renée Bacher explored the topic of using appropriate words when discussing delicate or controversial topics. When faced with a politically charged question from a patient, the recommendation was to take a moment to think before responding. One patient’s political comment or question may be quite innocuous and easily answered with information, while others may involve significant emotional investment from the patient and a subsequently risky downside for the physician giving an opinion. The gist of the article’s advice, and it is good advice, is “if in doubt, demur.”
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The AMA’s Code of Ethics, Opinion 2.3.4, supports a physician’s right to free speech, including in the political arena, and indicates the appropriate venues for expressing those viewpoints. The Opinion rightfully recommends that boundaries should be placed on physicians expressing their personal political views to patients and their families, with the understanding that, because of the imbalance of power in the patient–physician relationship, patient vulnerability may be adversely affected. There’s a firm statement in the Opinion that “physicians should refrain from initiating political conversations during the clinical encounter,” and that “physicians must not allow differences with the patient or family about political matters to interfere with the delivery of professional care.” This would seem to be a clear mandate.
In the American Academy of Otolaryngology–Head and Neck Surgery and Foundation’s Code of Ethics, the section pertinent to this discussion invokes “character issues” of physicians:
“Patients and society at large place a high level of trust in physicians. Physicians are held to the highest moral standards in the community. This level of trust is based on an assumption that the physician maintains a high degree of personal integrity and adheres to a professional code of ethics. Physicians are expected to be truthful and honest. Otolaryngologists should conduct themselves morally and ethically so as to merit the confidence placed in them. Anything that detracts from the ability of an otolaryngologist to conduct himself or herself in such a fashion should be avoided.”
Why does this section apply to the issue of political discussions with patients? Perhaps the applicability lies in the moral and ethical standards to which we must hold ourselves, so that we must earn respect from the patient through our deeds and words sufficiently that they will place their health and lives in our hands. As otolaryngologists, we carry great responsibility for providing thoughtful, dedicated, and scientifically based medical and surgical care for our patients. Any distraction from the patient’s respect for our moral and ethical character might diminish their trust in our judgment. Is there truth to the old saw that it’s important to be friendly with a patient, but difficult to be friends? Friendliness is very important, but maintaining a professional relationship is fundamental and required.
There are so many issues in our country that are upsetting to patients, causing them anger and anxiety, especially now—the pandemic, vaccinations, masks and social distancing, financial difficulties, difficulty seeing physicians in person, and politics, just to name a few. It’s understandable that patients might wish to discuss issues of concern with their physicians, including issues with political under/overtones. Some patients obviously have very strong thoughts on certain political issues and may seek their physicians’ perspectives. A few may try to impose their viewpoints on their physician, which could result in the hijacking of the clinical appointment. Depending on the intent of the patient’s desire to discuss politics, the physician must quickly perform a risk/benefit assessment and respond in the most appropriate manner.
Friendliness is very important, but maintaining a professional relationship is fundamental and required.
In Great Britain, healthcare policy is national politics. An individual physician’s role in health policy is basically to understand it, to explain it to patients, and to advocate for patients. If patients ask for or require explanation of health benefits and regulations, this assistance can be given to them.
To some extent, the United States may be evolving in the same way. During the current pandemic, physicians have needed to spend substantial time helping patients understand the difficulties of providing and receiving healthcare within the constraints imposed. It isn’t inappropriate to take time to explain the importance of public health policies under effect (mask wearing and social distancing) and to discuss the risks and benefits of vaccinations given a patient’s particular health status. If patients wish to debate the politics of healthcare policies, however, a venue other than the examination room is more appropriate. Above all, the patient’s health issues are paramount, and with limited time allotted for evaluation, discussion, and treatment during a visit, discussing politics is rarely worth the distraction.
My wife, an experienced senior physician with a geriatric population in the majority, has the knack of moving past controversial topics. She has developed some very effective skills to respectfully deflect or contain a patient’s interest in talking politics. Her responses before moving on to the history and examination include:
- “Yes, our country is certainly facing a lot of challenges, but we’ll make it through just fine.”
- “Just stay informed and know the science.”
- “We have to stick together during this time of trouble and uncertainty.”
Each of us must develop the mechanisms to cope effectively and respectfully with political issues in the examination room. In my opinion, physicians shouldn’t impose our political views on patients. A political discussion with patients fulfills no ethical requirement or responsibility and could, in fact, be an ethical breach of duty.
In the clinical scenario, the physician is faced with a patient who seems determined, although friendly in his efforts, to engage in a political discussion. The physician needs to respectfully deflect and redirect the conversation to the matters at hand, namely the patient’s health issues. Using my wife’s successful model, it might be appropriate to counter with, “I can see this is a topic of interest to you, but here today my main focus is on you and your health, so let’s move ahead with the examination to see how you’re doing.” Moving the focus back to the patient will hopefully demonstrate that his health is more important to you than the health of the political climate.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.
Politics and the Workplace
Talking politics can also be disruptive to a positive, harmonious work environment, creating division between employees and isolating individuals with unpopular beliefs. These suggestions can help you keep politics out of your practice:
- Set a good example by avoiding political or other controversial topics during working hours, even if you share the same beliefs as those being expressed by your co-workers.
- Stay engaged with the conversations happening in your practice or facility by actively listening.
- Don’t make jokes about controversial topics, and gently but firmly let others know that these types of jokes are not acceptable at your practice.
- If you hear a political conversation, politely but firmly remind employees that these discussions belong outside the workplace. Don’t wait to intervene until the conversation becomes aggressive, disrespectful, or threatening, or if a confrontation goes from verbal to physical.