We have the right to be political actors -- doctors are citizens too -- but we risk harming the default credibility that comes with the profession if we don't choose our battles carefully
Doctors are in the cross-hairs of the nation's politics more than ever. We're all being asked to achieve more with less. We must cope with nightmare scenarios precipitated by cracks in the social and healthcare infrastructure so often these days that medical schools insist students become effective patient advocates as well as healers. Practicing good medicine necessitates navigating a minefield of competing interests. Doctors are increasingly tempted to just walk out, to lay down the pen, or to use their power in ways that subvert the system. As I wrote earlier this year, a group of Wisconsin doctors, all dedicated patient advocates, carried out a plan they hatched in the latter category.
The American Medical Association publishes a montly journal of medical ethics called Virtual Mentor. Virtual Mentor's October issue explores how doctors should behave "after hours." In light of the Wisconsin debacle, Virtual Mentor asked me to explore the question of what doctors should and shouldn't do in the field of political protest. While we're by no means clerics, physicians really have no off-hours when we're engaged in public acts. It's the nature of the job. That's the idea I've attempted to elaborate in my piece, which is also posted below.
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The United States began with acts of civil disobedience. What dwindling moral footing the nation holds in the world today stems in large part from its beating back an axis of fascist and totalitarian regimes 65 years ago, followed two decades later by its now hallowed civil rights protests that tore away a layer of domestic injustice. Yet because this great tradition exists does not mean that physicians are free to fully engage in it. Our profession is a civil construct, an invention created by a patchwork of state and federal laws. When we engage in acts of civil disobedience we must realize that we challenge the government and the society which grants us our right to practice medicine. Whether a physician fancies herself a member of the Green Party or the Tea Party, she must obey our government's rules, and be extremely diligent in those increasingly rare instances when she feels herself compelled not to do so.
Whatever you say in public will be interpreted through the lens of your connection to the profession.
When we do not choose our battles carefully, disaster can ensue, for the profession as a whole and for ourselves very personally. In February 2011 the Wisconsin state capitol was convulsed by massive protests staged by government employees, most notably its public school teachers, who were outraged over the governor's push to revoke certain collective bargaining rights, including their power to negotiate for better health insurance. Members of the University of Wisconsin's Department of Family Medicine, including both residents and attendings, felt compassion for the educators' cause, and wanted to participate in the display, but rather than symbolically protest in the streets alongside the teachers, they decided to perform an act of civil disobedience: The doctors wrote out fake sick notes for the teachers, many of whom were falsely using illness as an excuse to attend the protests, and risked firing by doing so.
The execution of this particular act of civil disobedience was telling -- and typical of the problems physicians face when they venture into public protest. When made public, civil disobedience is in fact a media act: Reporting is the primary venue through which communication of meaning occurs. Engagement with the fourth estate is a skill for which most physicians will find themselves ill-prepared. While in the midst of writing their excuses, the Wisconsin family medicine doctors appeared caught off-guard when peppered with questions by everyone from the Associated Press to freelance videographers. Associate Professor Lou Sanner implausibly claimed his prescriptions were for "stress" that he diagnosed only after forming an adequate doctor-patient relationship in the midst of all the hustle and bustle. Another doctor said she was writing the excuses to support the teachers' mental health. The messages and the acts didn't mesh. It doesn't take an M.D. to know these doctors were playing the system in service of ulterior motives, and not a single reporter present missed the red flags of incredulity.
While acknowledging the motivations of the physicians concerned as generally wholesome, the Wisconsin Medical Society had no choice but to condemn these public acts as violating a sacred trust between society and doctors. Referencing Dr. Sanner's comments in particular, the society stated that the patient-physician relationship is a cornerstone of high-quality health care, and that "important elements of that relationship, such as conducting proper medical evaluations of patients, should not be taken lightly." The Wisconsin Medical Society understood what the protesting physicians did not: The high regard with which the public holds the medical profession is not a given. It can be lowered.
Why is the medical profession respected? Why is it intrinsically meaningful when doctors have something to say? What is that added meaning? Understanding the answers to these questions is essential to gaining an accurate sense of the boundaries of our behaviors within social and political spheres, including public protest. Public regard for the medical profession is the residuum of daily patient-physician encounters, especially in those times when a patient trusts in our integrity, is soothed by our knowledge, and accepts our honest, calm, and methodical approach when we reach our individual professional limitations.
The Wisconsin doctors' actions threatened this standing, and the profession is punishing them for their breach. To date, the University of Wisconsin School of Medicine has privately censured at least 12 of the doctors they employ, and the Wisconsin Medical Examining Board may take further action when it reviews the results of formal investigations into eight of the physicians undertaken by the state's Department of Safety and Professional Services. The doctors' best defense may be the fact that we cannot practice good medicine without taking into account social factors beyond a diagnosis; I would not condemn the considered decision of a fellow physician made in the privacy of her own clinic room, who decided to grant a single work excuse for a preponderance of social needs. Our social welfare and our health are inextricably linked. But the same transaction, carried out in public view, time and again, without any plausible doctor-physician relationship necessary to make such a determination, deserves no such collegial deference. Indeed I criticized the Wisconsin doctors before a national audience on the website of The Atlantic magazine.
We have the right to be political actors in this country; doctors are citizens too, but we must understand that the profession is itself a legal construct created for the purpose of improving public well-being. There are other ways to maintain the collective health than by authorizing a single profession with all the rights and privileges physicians still enjoy in today's health care system. We will see our profession erode away through the democratic process if we undermine its standing. The quickest way to that end is abusing the public's understanding of the physician narrative. The physician narrative is the default credibility we are given by doing nothing more than entering the profession -- it is that collection of concepts, generally positive, that people think they know about us the moment they learn that we are doctors. We trade on it to do our jobs. We also trade on it in when we advocate for any issue we believe in.
Understand that public protests are a general venue open to all, but doctors can never expect to be nameless faces in the crowd.
With a medical degree comes the fact that whatever we have to say in the domain of public discourse will be interpreted through the lens of your connection to the medical profession. This truth applies to medical students as well. In my early 20s I took my tendency to speak my mind to a new level when I started evangelizing my personal spiritual views on a website I designed about philosophy and religion. While in medical school I decided to try my hand at sparking local discussion groups about my ideas around the country, beginning with a group in my own city. While my activities had nothing to do with my chosen career, my medical identity, such as it was, proved too powerful a narrative for journalists to resist. Headlines like "Medical student prescribes a religion," which appeared in the San Diego Union-Tribune, reflected how little control I had over my own message. I desperately wanted to create a movement that stood on its own, but just as interesting to the people who wrote about my work was the fact that the man at the center was about to be a doctor. My career path made a rather eccentric extracurricular activity seem less fringe, more legitimate, and more worthy of the continued attention of the reporters who kept on writing for the three years my little escapade lasted.