I already know that this newsletter is going to upset many people–especially those who don’t read beyond the title. Everyone likes to believe that their political views are carefully thought out, rational opinions formed by their awareness of the world around them and a mastery of facts. In other words, they are the result of absolute free will and are therefore entirely independent of all other aspects of their lives. Anything that challenges that opinion, which is effectively a challenge to free will, and especially anything that contains the words Republican and Democrat, really upsets people. In other words, anything that even implies that our politics might be influenced by our fundamental psychological or even genetic makeup or, even worse, that our political proclivities might shape how we view the world and the decisions we make, is going to bring out the dogs of war.
But if we are honest about it, we all intuitively know that political beliefs do indeed spill over into nonpolitical domains such as consumer spending, choice of romantic partner, and job hiring. That said, what we’re going to talk about today is something quite different but nevertheless touches on the same hot buttons. A new study suggests that the political beliefs of our primary care physicians may predict their professional decisions–at least for certain health questions.1 Eitan D. Hersh, Matthew N. Goldenberg. “Democratic and Republican physicians provide different care on politicized health issues.” PNAS 2016 ; published ahead of print October 3, 2016. http://www.pnas.org/content/early/2016/09/28/1606609113 According to the study, when it comes to politicized health issues like marijuana and abortion, it turns out that a physician’s partisan identity is highly correlated with his/her treatment decisions. Because physicians regularly interact with patients on politically sensitive health issues, and because the medical profession is increasingly politicized (e.g., state governments are regulating politicized aspects of medicine), it is necessary to understand how your doctor’s political worldviews might impact their decisions, recommendations, and actions in the medical examination room when it comes to your diagnosis and treatment. That understanding should then inform not only how you filter their recommendations but also whether or not it’s in your best interest to look for a new doctor.
So, setting aside the question of free will for the moment, which really isn’t being called into question by this study, let me suggest that you read through to the end of the article as there are real lessons to be learned from the several studies we’re going to talk about–real lessons that can affect the health care you receive.
With that in mind, let’s take a look at the newly released study in question.
Republicans, Democrats, and Doctors
The co-authors of the study, Eitan Hersh, an assistant professor of political science, and Matthew N. Goldenberg, MD, an assistant professor of psychiatry, linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, thus obtaining the physicians’ political party affiliations. They then contacted 1,529 of them to participate in the study, ending up with a sample of 231 doctors–both Democratic and Republican primary care physicians–whom they then surveyed. The survey involved the physicians evaluating nine patient vignettes which they were told were recounted by patients as part of a complete physical. Three of the vignettes addressed especially politicized health issues (marijuana, abortion, and firearm storage). Specifically, the vignettes presented scenarios such as a healthy-appearing 38-year-old male patient who “acknowledges using recreational marijuana three times per week” or “who is a parent with two small children at home” and “acknowledges having several firearms at home.” And yet another fictional patient said she had two abortions in the past five years. Those vignettes were interspersed with some more neutral complaints like obesity, depression, or not wearing a motorcycle helmet.
Hersh and Goldenberg then asked the physicians to rate the seriousness of the issue presented in each vignette and how they would treat the patient. The physicians who responded did not know that the survey was about their politics. Rather, they thought it was about how they administer the patient interviews that primary-care doctors give patients before they first treat them. On the politicized health issues–and only on such issues–Democratic and Republican physicians differed substantially in their expressed concern and their recommended treatment plan. (It should be noted that the study controlled for physician demographics like age, gender, and religiosity, patient population, and geography.)
According to Hersh and Goldenberg, “The evidence suggests that doctors allow their political views to influence their professional decisions in the medical exam room. Just as patients choose physicians of a certain gender to feel more comfortable, our study suggests they may want to make a similar calculation based on their doctor’s political views.” It’s important to note that this is not an insignificant issue as physicians frequently interact with patients about politically salient health issues, such as drug use, firearm safety, and sexual behavior.
Perhaps not too surprisingly, Republican physicians expressed more concern than their Democratic colleagues about the vignettes on marijuana use and abortion whereas the Democratic physicians were more concerned about the vignette related to firearms. Democratic doctors were less likely to discuss the health risks of marijuana or highlight its legal risks or encourage the patient to cut down their usage. On the other hand, they were more likely to urge patients not to store firearms in the home, whereas the Republican physicians were much more likely to discuss the health and legal risks of marijuana and to advise the patient to cut back. They also were twice as likely as Democrats to discourage patients from having more abortions in the future and 35 percent more likely to discuss mental health in connection with abortions. Interestingly, Republican physicians were also significantly more likely to ask their patients if they were storing their firearms safely, though Democrats were more likely to urge them simply not to have them in the home. It should be noted that research shows that counseling by doctors can help promote safe gun storage.2 Albright TL, Burge SK. “Improving firearm storage habits: impact of brief office counseling by family physicians.” J Am Board Fam Pract. 2003 Jan-Feb;16(1):40-6. http://www.ncbi.nlm.nih.gov/pubmed/12583649 On the other hand, studies show that a majority of doctors choose not to go there.3 Butkus R, Weissman A. “Internists’ attitudes toward prevention of firearm injury.” Ann Intern Med. 2014 Jun 17;160(12):821-7. http://www.ncbi.nlm.nih.gov/pubmed/24722784 Again, physicians of both parties similarly rated the vignettes on non-political issues like depression, alcohol abuse, obesity, and not wearing a motorcycle helmet.
Effect of “Republican” on seriousness of issue. (PNAS)
The study concluded that physician partisan bias can lead to unwarranted variation in patient care. Thus, awareness of how a physician’s political attitudes might affect patient care is important to both physicians and patients alike. As Goldenberg noted, “Given the politicization of certain health issues affecting countless patients, it is imperative that physicians consider how their political views may affect their professional judgments. The evidence calls for heightened awareness among physicians and more training concerning our biases in how we address politically salient health issues.” As the authors write in the study, “To be clear, we cannot say with any certainty what the root cause of partisan differences in treatment is. However, regardless of the underlying mechanism that affects physician judgment, the evidence suggests a clear effect from the patient’s perspective.”
In summary, “Just as a patient may seek out a physician of a certain gender to feel more comfortable, the evidence suggests that a patient may need to make the same calculation regarding political ideology.” Of course, a Republican or Democratic doctor would likely live in an area where the majority of his or her patients were of the same party. Still, if a contentious health issue is discussed during an appointment, it might be the provider’s political beliefs talking, rather than their medical training. In certain cases, according to the study’s authors, it might be worth getting a second opinion–perhaps a few towns over.
That said, although I would tend to agree with the study’s observations, I’m not sure I agree with their recommendation, at least as stated. But before we go there, let’s take a look at the elephant in the room. (And yes, the pun was deliberate.)
The Elephant in the Room
Hersh said he hopes the study will open up a dialogue about how political bias affects medical decision-making and make practitioners more aware of ways in which their personal beliefs might affect the care they give patients. Depending on the study’s response, he says, he might even consider making his data on physician names and party affiliations public. This would be important because until the political data can be effectively linked to actual outcomes, the true extent of how politics affect physicians’ decisions won’t be clear. Unfortunately, he is likely to encounter resistance, especially among the large number of doctors who don’t think that their political views inform their practice decisions. As Rep. Phil Roe (R-Tenn.), a retired obstetrician-gynecologist who co-chairs the GOP Doctors Caucus,4 http://doctorscaucus.roe.house.gov/ told the Washington Post, “I never once treated a Republican or Democrat cancer in my life. When a patient walked into my office, I didn’t know if they were a Republican or a Democrat, and I honestly didn’t care.”5 Erin Blakemore. “Democratic and Republican doctors treat patients differently.” Washington Post. October 3, 2016. (Accessed 8 Oct 2016.) http://www.washingtonpost.com/news/to-your-health/wp/2016/10/03/want-to-know-how-your-physician-will-treat-you-ask-if-they-vote-democrat-or-republican/ Roe went on to tell the Post that he hopes patients will seek out the best care available regardless of their doctor’s political affiliation. “Party affiliation should have nothing to do with patient care.”
And he is correct. Party affiliation should have nothing to do with patient care. Unfortunately, his pronouncements on the study have nothing to do with the study’s actual conclusions. They are a red herring. In fact, the study has nothing to do with Republican or Democratic cancer. All the study is saying is that certain mindsets that are frequently, but not exclusively, associated with party affiliation do have an effect on physician decision making.
In fact, other research has shown that this is even more ingrained than you might think–that there is frequently a genetic factor to political leanings. A study, conducted by researchers out of the University of California, San Diego and Harvard University, identified a particular gene that seems to predispose certain people to a more “liberal” outlook.6 Jaime E. Settle, Christopher T. Dawes, Nicholas A. Christakis, James H. Fowler. “Friendships Moderate an Association between a Dopamine Gene Variant and Political Ideology.” The Journal of Politics. Volume 72, Number 4 | October 2010. http://www.journals.uchicago.edu/doi/abs/10.1017/S0022381610000617 (We will talk more about what a “liberal” outlook actually means in a moment.) Data from more than 2,500 volunteers in the National Longitudinal Study of Adolescent Health was analyzed to compare people with the R7 variant of the DRD4 gene.7 http://en.wikipedia.org/wiki/Dopamine_receptor_D4 Keep in mind that a person’s political bent has always been assumed to be a product of their environment and social background, not their genes. And while environment and background certainly have a large impact on each person’s beliefs, this study strongly indicates there is something going on behind the scenes in our DNA that influences us right down to our core values. Research has established that approximately 38% of us possess the R7 variant of the DRD4 gene. And please keep in mind that scientists hasten to add that neither version of the gene is better than the other — if one were superior, natural selection most likely would have eliminated the inferior form.
Now let’s talk about what we mean by “liberal,” at least as far as this study is concerned. In fact, “liberal” in this case does not refer to which candidate you vote for but, rather, refers to a penchant for novelty seeking behavior. Earlier studies have determined a link between the R7 variant and novelty-seeking behavior. People with the variant may be more likely to try new experiences and take some risks. In other words, the study is saying that those who are more likely to be comfortable pushing boundaries and trying new things can be defined as liberal. And those who don’t, who like to play it safe, can be defined as conservative. And again, neither is superior when it comes to genetic survival. On the one hand, playing it safe could have certainly been advantageous to prehistoric man if wild animals were about. But being willing to try new things and push out into new territory would have been advantageous if food supplies were strained in your familiar environment. Each tendency can be advantageous depending on the circumstances.
In any case, now researchers are applying the new findings to this information and suggesting that when people with the R7 gene variant have also had an active social network, they may be more likely to seek out their friends’ opinions on political subjects and be open to a wider range of lifestyles, creating a more liberal position politically. And that’s the tie-in to politics. However, having the variant does not guarantee a final resting point on the political spectrum. For example, if either the variant form of the gene is not there or the adolescent years were not socially popular ones, then the person can fall anywhere on the political spectrum. The findings were the same across age, gender, ethnicity, and background differences. The bottom line is that we’re only talking about tendencies here. There are indeed conservative Democrats and liberal Republicans (I believe they’re called RINO’s…). Again, we’re not really talking about politics. We’re talking about a fundamental, psychological way of viewing the world that merely gives people a predilection to end up in one party or another–not a guarantee.
In fact, more than half a century of research in genetics, neuroscience, and psychology has demonstrated that human behaviors, including social and political attitudes, are influenced by genetic and neurobiological factors. However, these findings have not been widely accepted or incorporated into the dominant paradigms that explain the underlying causes of political ideology. This has been attributed in part to measurement and sample limitations, as well the relative absence of molecular genetic studies.
In addition, there’s the 2012 study that combined evidence from over 12,000 twins pairs, ascertained from nine different studies conducted in five democracies with the data from three genome-wide association studies on political ideology.8 Hatemi PK, Medland SE, Klemmensen R, et al. “Genetic Influences on Political Ideologies: Twin Analyses of 19 Measures of Political Ideologies from Five Democracies and Genome-Wide Findings from Three Populations.” Behavior Genetics. 2014;44(3):282-294. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038932/ In other words, it was not a small study. It concluded that political ideology constitutes a fundamental aspect of one’s genetically informed psychological disposition.
So what does this mean for doctors? Well, let’s return to Rep. Roe’s statement: “When a patient walked into my office, I didn’t know if they were a Republican or a Democrat, and I honestly didn’t care.” We should now be able to see that this statement is irrelevant. We’re not actually talking about party affiliation. We’re talking about genetically informed psychological dispositions that can inform how doctors choose to treat certain conditions–not that they differentiate between Republican and Democratic patients. And yes, people of certain dispositions tend to gravitate to certain political parties that support that disposition–but again, that’s only a tendency, not a certainty. In any case, those same psychological dispositions tend to lean doctors towards conclusions and treatments in line with that disposition.
But What Does the Mean to Me?
At this point, let’s just throw politics completely out the window, which should simplify the discussion and remove the emotional heat from it. Let’s just acknowledge that different doctors will vary in:
- What treatment options they recommend in certain situations
- Where they fall on the risk vs safety continuum
Now things become much simpler, which allows us to establish some physician selection guidelines.
When it comes to surgery, there are essentially two kinds: standard and cutting edge, high risk.
- For standard surgical procedures, you probably want a conservative doctor who follows the safest protocols available. When it comes to routine surgery, you don’t want a risk taker.
- For more cutting edge or experimental surgeries, you probably want a surgeon who is comfortable playing in unfamiliar territory. If the surgical technique involved is not routine, you want a doctor who thrives when playing outside their comfort zone.
And by all means, check out your surgeon’s rating for the particular procedure you’re looking to have them perform. Why in the world would you choose a doctor to operate on you who isn’t very good at performing the operation and tends to leave lots of bodies on the operating table? And for that matter, be sure and check out the safety score for the hospital where your surgeon is going to be performing the procedure. They provide your doctor’s support team.
Primary Care Treatment
On the other hand, when it comes to general medical diagnosis and treatment, you probably want a doctor who lines up with your view of health and nutrition.
- If you’re into herbs and alternative health, find a doctor who is friendly (or at least not hostile) to those protocols. Why would you want to put yourself in a position where you’re constantly fighting with your doctor about the medications he/she prescribes or the supplements you want to take?
- If you’re a strong believer in the virtues of toeing the medical line, then track down the most medically astute doctor you can find–regardless of their opinion of alternative health.
- If you smoke marijuana or use birth control, find a doctor who doesn’t fight you about it or look askance at your lifestyle.
- If you don’t believe in antidepressants or any other class of pharmaceutical drugs, then don’t go to a doctor who refuses to explore alternative treatments–even alternative medical treatments–with you.
- And, as with surgeons, even when selecting a primary care physician, it’s a good idea to check out how the doctors you’re looking at rate with previous patients.
The bottom line is that when medical skill is the priority, find the most skillful doctor you can find–regardless of political outlook. When looking for a primary care physician who will work with you on an ongoing basis, find a doctor of like mind and similar disposition. And if you find that you are with the wrong doctor, don’t hesitate to change physicians. Remember, it’s your life, not your doctor’s.
References [ + ]
|1.||↑||Eitan D. Hersh, Matthew N. Goldenberg. “Democratic and Republican physicians provide different care on politicized health issues.” PNAS 2016 ; published ahead of print October 3, 2016. http://www.pnas.org/content/early/2016/09/28/1606609113|
|2.||↑||Albright TL, Burge SK. “Improving firearm storage habits: impact of brief office counseling by family physicians.” J Am Board Fam Pract. 2003 Jan-Feb;16(1):40-6. http://www.ncbi.nlm.nih.gov/pubmed/12583649|
|3.||↑||Butkus R, Weissman A. “Internists’ attitudes toward prevention of firearm injury.” Ann Intern Med. 2014 Jun 17;160(12):821-7. http://www.ncbi.nlm.nih.gov/pubmed/24722784|
|5.||↑||Erin Blakemore. “Democratic and Republican doctors treat patients differently.” Washington Post. October 3, 2016. (Accessed 8 Oct 2016.) http://www.washingtonpost.com/news/to-your-health/wp/2016/10/03/want-to-know-how-your-physician-will-treat-you-ask-if-they-vote-democrat-or-republican/|
|6.||↑||Jaime E. Settle, Christopher T. Dawes, Nicholas A. Christakis, James H. Fowler. “Friendships Moderate an Association between a Dopamine Gene Variant and Political Ideology.” The Journal of Politics. Volume 72, Number 4 | October 2010. http://www.journals.uchicago.edu/doi/abs/10.1017/S0022381610000617|
|8.||↑||Hatemi PK, Medland SE, Klemmensen R, et al. “Genetic Influences on Political Ideologies: Twin Analyses of 19 Measures of Political Ideologies from Five Democracies and Genome-Wide Findings from Three Populations.” Behavior Genetics. 2014;44(3):282-294. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038932/|