Talking politics in the exam room [PODCAST]

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“The medical profession now understands that social determinants of health are probably the most important driver of a patient’s overall health, and these determinants are largely the result of political decisions. Clearly, we have a professional responsibility to teach our patients the science underlying their health issues. Don’t we also have a professional obligation to ensure that our patients understand the health ramifications of their political choices? If that is the case, do we not have a professional obligation to initiate a conversation about the political issues which impact our patients’ health?

If we fail to breach the taboo of ‘talking politics’ in the exam room, are we not shirking our professional responsibilities to our patients and society?”

Hayward Zwerling is an endocrinologist who blogs at I Have an Idea.

He shares his story and discusses his KevinMD article, “Talking politics in the exam room.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Hayward Zwerling. He’s an endocrinologist, and he wrote the KevinMD article “Talking politics in the exam room.” Hayward, welcome to the show.

Hayward Zwerling: Well, thank you very much for having me here, Kevin. I think this is an important topic, and I’m glad to get a chance to discuss it.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Hayward Zwerling: Yeah. So originally, I was planning on staying in academics and was planning on doing protein structure-function relationships. After my fellowship and a year of that, I decided, OK, this is not the right path for me, and ultimately I moved into private practice, and I have been in private practice for almost 30 years, a little more than 30 years. In the process, I created an electronic medical record program called ComChart EMR, which I sold for about 15 years, and I’m in the process of shutting it down now because the market has changed.

In the last, I don’t know, two or three years, I’ve been doing a fair amount of blogging as a mode of therapy to deal with the angst we all are having. This article sort of arose out of a couple of clinical encounters and was a way of sort of organizing my ideas.

Kevin Pho: All right, so let’s talk about that article, “Talking politics in the exam room.” As you know, we live in a very polarized environment currently, and politics inevitably seeps into the exam rooms. We’re both bloggers, and in health care blogs as well, politics is not something you get away from. So for those who haven’t read your article, can you just walk my audience through it and maybe share the story of why you decided to write it?

Hayward Zwerling: Yeah, definitely. The way it started was that everybody is having an increasing number of encounters where people come in, patients come in, with misinformation, or factually incorrect information, which has an adverse impact on their health. And of course, in today’s universe, facts seem to be optional. One can get to choose their set of facts. But as a physician grounded in science, there is a set of facts that I believe the data supports. Over the course of several years, or at least over the last year, occasionally either patients would bring up this information and say, “What do you think about coronavirus?” or it was obvious that a patient’s misunderstanding of the situation was going to have an adverse impact on their health.

There have been many patients with whom this has evolved. Some will outright ask me, “You know, who are you going to vote for, and why?” There was one patient who came in wearing a Make America Great Again hat who didn’t want to wear a mask in the exam room, and in our office, everybody’s got to wear a mask, so the conversation was really forced. And there are others who will say to me, who will come in. The one this article is actually mostly based on came in and said something like, “Well, you know, no, my friends all support Trump. All the news says this coronavirus stuff is fake. You know, what do you think?”

This was coming from a patient, who is the focus of the article, who has type 1 diabetes and a prior history of substance abuse and is clearly at very high risk. He really wanted to know what the facts were, and he was a bit apologetic presenting the coronavirus as non-factual. But his response was, “But, you know, every time the news says something about coronavirus being a real problem, they’re just trying to hurt Donald Trump.” And so we had a conversation about it, and it led me to this article. How does one deal with this, when we all have been trained to avoid these political conversations in the exam room?

At the same time, what has happened in the last five or 10 years is that we’ve learned that these social determinants of health, and what goes on outside the exam, are as big or a bigger influence on our patients’ health than the patient’s genetics and individual background. I’m a firm believer that physicians, besides taking care of the patient in front of them, have a role in society to improve everybody’s health. I was trying to talk through in my own mind what is the right way to deal with this problem, recognizing that it is a taboo, but on the other hand, it conflicts with my professional obligation to take care of the patient in front of me and the wider society, to try to prevent disease. So that’s really how the article came to be.

At the end of the article, I sort of argue, or try to lead the reader to the conclusion, that I’m not sure what the right thing to do is. There are some patients with whom there’s no point in having a conversation, and I found I have to pick and choose when I should do it and when I shouldn’t do it. It’s not a matter of trying to say to people, “This is what you need to believe, and this is how you need to vote.” The criticisms on the KevinMD website, the comments, were basically assuming that’s what I was doing, and it’s not. What I’m trying to do is, like we do with every other disease, like we do when we talk to patients about cigarettes or seat belts or motorcycle helmets, we try to present them with the facts as best as the science understands it and then let them make a decision incorporating that information with their own set of values. You know, the person who wants to ride a motorcycle without a helmet: I think it’s the wrong thing to do, but that’s their set of values, and I’m not going to say what they need to do. But I think they need the facts so they can make the right decision that’s in their best self-interest.

Kevin Pho: Let’s go back to that patient that you talked about in the case, who thought that the coronavirus was an attack on President Trump. Now, where was that patient getting his or her information from?

Hayward Zwerling: Well, he only had one source. It was Fox News and his peers, and their one source was Fox News. We all know that over the last year, Fox has presented, a charitable word would be, a skewed image, but it’s really much more malicious than that. They presented the facts in a way which is factually inaccurate to advance a political agenda, without regard to the health care consequences to society. I think he probably knew that he was getting a slanted view. I’m not 100 percent sure, but he did acknowledge that was his only source of information.

When I come upon a patient like that, the way I try to deal with it with them is, rather than saying, “Well, my facts are right and your facts are wrong,” I try to lay it out and say, “Look, information is very complicated, and the best way for you to get the facts is to listen to multiple news sources.” And I proceed to say that I read multiple newspapers and multiple websites that span from Fox News to MSNBC and everything in between, and I encourage them to do that, and then I try to teach them to take all the information and come to a conclusion of what is reality, as opposed to just Fox News or just MSNBC or whatever website they were going to.

Kevin Pho: And in your experience, especially over the last few months, how has the response been from patients that you had to push back on a little bit?

Hayward Zwerling: Well, I try not to push back, and I don’t want to make it confrontational, because if it gets confrontational, it’s not going to be productive for them. I’m trying to say, “This is what the science tells me, and if you do X, Y, and Z, this is going to be the consequences to your community and your health. And if you decide X, Y, and Z fits your priorities in life, that’s fine.” You know, if you think that ignoring the virus is the best way to go forward, as long as you understand that’s not what the science says.

So I try to avoid confrontation. And there are some patients where it’s obvious, as soon as I bring it up, that there’s just no point in going forward. But I try to be respectful, and I try not to say, “This is what you should do.” I try to say, “If you get into an accident on a motorcycle while you’re on the highway and you’re not wearing a helmet, your chances of being injured are far higher. If you’re going to smoke cigarettes, your chances of an adverse outcome are far higher.” And then they have to decide what to do. So it’s not a matter of telling them what to do. It’s just trying to connect the dots of what will happen if they choose path A versus path B.

Kevin Pho: And if a patient asks you a blatant political question, like, “Who are you going to vote for?” how do you respond?

Hayward Zwerling: So that did come up. And my response for the one patient was, and I think I put this up on the blog in response to the comments, one woman had asked me that, and I just said, “I believe in science.” And she stopped right there, because she knew what I was saying. But she came back later in the conversation and asked me who I was going to vote for and why. And ultimately, we had it, and I responded, and I told her why, and I asked her what she was going to do and why. And she said, “Well, I’m going to vote for the president because he had a great economy. If it wasn’t for coronavirus, it would still be a great economy, and it’s not his fault.”

And I tried to show her how, in other countries around the world, if the president had chosen to follow the lead of the scientific and public health community, there would be tens or hundreds of thousands fewer people dead, and the economy would be further along. I tried to show that there are examples where a different choice would have had a better outcome. But I just sort of tried to play that: These are the facts of what happened elsewhere, not saying you’re making the wrong choice.

I understand it’s a fraught situation, but I also think we have an obligation to our patients, so that they have the information to make the best decision that’s consistent with their values. And if they’re only getting their information from one source, they don’t have the whole story, any more than anybody who gets their information from only one medical article. We all know that medicine is complicated, and it takes multiple studies to prove most points. Politics and science are exactly the same way.

Kevin Pho: Now, if a patient has a sharp political disagreement with you, how does that affect the doctor-patient relationship?

Hayward Zwerling: If that’s the case, I try to avoid politics at all costs, because it’s not going to help me take care of the patients. I then abandon this idea that I need them to understand the bigger ramifications of their political things in terms of the health of their community and family, and I just focus narrowly on them. So I’ll avoid that, and sometimes I’ll say, “You know, we really shouldn’t be talking politics, because it’s not going to accomplish anything,” and my first priority is to that patient. So I’ll push it aside and try to move on.

Usually, if I do that, they don’t keep pushing back and saying, “I want to talk politics, I want to talk politics,” although there have been some. And there have been some where we’ve agreed, “OK, we’re going to disagree, but let’s just move on.” And sometimes it is pleasant. If they keep coming back to me, I know I made the right decision. If they disappear, I know I made the wrong decision. But that’s not usually the case.

Kevin Pho: Have patients left your practice because of a political disagreement in the exam room?

Hayward Zwerling: It’s hard to know, honestly. I remember there was one person with whom the issue of guns had come up, and I tried to engage about the importance of having locks on the guns at home and having the guns locked up and so forth, and I never saw that patient again. I don’t know if it was just because they thought I was a bad doctor, or they didn’t want to hear my comments about gun safety, or that they just got what they needed and moved on. I’m in the role of a consultant, so with some of these patients, I just give an opinion and that’s it. But there are others, the diabetics who I’ve been following for 30 years.

So I assume that there are some who have left, and I just don’t know the reason, and I assume there are others who come back if they want to hear more. I have to do what I think is right as a professional, which is to take care of the patient and take care of my community. And there are going to be people who are going to be unhappy with that. I understand that, but my job isn’t to make everybody happy. My job is to fulfill my goal in life, which is to try to help the health of my community and neighbors and society as a whole.

Kevin Pho: We’re talking to Hayward Zwerling. He is an endocrinologist, and he wrote the KevinMD article “Talking politics in the exam room.” Hayward, I think that you diagnosed one of the problems of hyperpolarization accurately, in that there is one side that gets one source of facts and another that gets another source of facts. Now, when educating patients about evaluating the news and information that they read, how do you approach that, and what kind of advice can you share with other clinicians in terms of how to educate patients to critically evaluate what they read, especially online?

Hayward Zwerling: I’m a big advocate of giving patients information and giving them reliable sources, and the source that I use most is MedlinePlus.gov. Now, that’s a National Institutes of Health, National Library of Medicine source. There’s no pharmaceutical advertising. And I can say to patients, and I frequently do, I’ll bring them around to the computer, I’ll show them how to get online, and I’ll show them how they can search any topic they want, with literally thousands of links to other reliable sources. Or I’ll pick out professional organizations.

I try to steer them away, and try to explain to them, “Don’t just type in hyperthyroidism and see what people wrote about it or the treatment, because you’re going to get an anecdotal experience.” And I try to explain to them how, in medicine, every physician has had an experience where we prescribed a drug the first time and a bad outcome happened, and we decided we’re never going to use that drug, even though we know that the data is that the drug is safe, on average, for the vast majority of people. And so I try to explain that anecdotes aren’t a useful way to make a decision, and that’s why it’s important that they visit reliable websites such as MedlinePlus.gov.

Kevin Pho: And in a majority of cases, are your patients pretty accepting of going to, say, a .gov website? Do you have any people who are suspicious of .gov websites because they are under the auspices of the government?

Hayward Zwerling: That hasn’t really been an issue. You know, most of the patients, in my experience, will get it either from anecdotes, or they like WebMD, and I’m cautious about WebMD just because of the advertising, and I don’t really know what their algorithms do in the background. I also will refer them to UpToDate in medicine, which has a nice portal for patients, which is reliable. I’m not sure if it’s useful for the patients, but they seem to like the information. And sometimes they’ll email me and say, “You know, where can I get more stuff on this?” I try to give them honest information, which is uninfluenced by the pharmaceutical industry, by all the influences which would skew what the reality they see actually is.

Kevin Pho: Well, hyperpolarization, if anything, is probably not going to get better, and in fact may get worse in the coming year or so. So I would ask you, what’s your number one tip that you can share with clinicians in terms of navigating the hyperpolarization that can creep up in the exam room?

Hayward Zwerling: My suggestion would be to first try to encourage patients to visit multiple websites. Don’t go in with the sentiment and say, “That website you’re looking at is wrong.” Go in and say, “Look, you know, information is complicated. If you look at multiple sources, you’re more likely to find out what the reality is.” And then the second one is to be respectful. It doesn’t accomplish anything to get into a shouting match with anybody. So be respectful, and try to teach them how they can learn what is reality beyond just their immediate bubble. And I try to follow those rules myself.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Hayward Zwerling: I think the medical community really needs to have a conversation about this topic of talking politics with patients in the exam room. You know, recently the New England Journal came out with an editorial, “Dying in a leadership vacuum,” basically arguing that the public should vote Trump out of office because his policies caused many more deaths. And they have a very nice quote in it: “Truth is neither liberal nor conservative.” I think we need to stay with the science and help people understand how to connect the dots from the science to the policy to what happens in their community, and let the chips fall where they may, but just be honest about it.

Kevin Pho: Hayward, thank you so much for your time and insight, and thanks again for being on the show.

Hayward Zwerling: Thank you for having me.

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