Politics and Medicine is a Bad Idea
Two recent academic articles on policy issues made me Stop and Think about what Medicine and Science is for.
The two most important US medical journals have recently published editorials on policy matters. This worries me.
Before I tell you about these editorials, I should set out two givens.
The first is that the longer I practice medicine, the more I appreciate the job. Helping people through illness provides great meaning. It also takes serious attention to lifelong learning.
The other given is that the use of evidence to guide practice is one of the core skills of a modern clinician. Though evidence is not the only factor in a decision, it is a vital one.
Doctors, therefore depend on scientists, journal editors and peer-reviewers to perform and judge evidence that we translate at the bedside. Patients depend on clinicians knowing this evidence.
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The Journal of the American Medical Association has published an article titled:
Reducing the Risks of Nuclear War—The Role of Health Professionals.
The 18 authors, all of whom are editors-in-chief of major medical journals, tell us that there is great danger from nuclear war. They urge health professionals to inform their members about the threat and to join the International Physicians for the Prevention of Nuclear War (IPPNW).
The New England Journal of Medicine published this week an editorial titled:
Reducing Health Care’s Climate Impact — Mission Critical or Extra Credit?
The two authors, one a pulmonary/critical care specialist and the other a psychiatrist, write to lament the fact that the Joint Commission has eased their requirements on hospitals to curb their impact on climate.
They write that “health professionals are staring down the barrel of the climate crisis…”
They admit that health care workers are overburdened and demoralized by the increasingly complex system. (Of course, one of the many causes of this stress are rent-seeking hospital accreditation companies like Joint Commission.)
But the authors then write this:
We believe that by aligning our profession’s quality metrics with the values of environmental stewardship and health equity, we can improve morale and restore faith in the hospital accreditation process.
Beyond the utter nonsense that a hospital’s stewardship of the environment could affect the morale of its workers, what worries me about this move into policy is that it’s way out of our lane.
As private citizens, we can and should have ideas on policy. But our medical training provides us no expertise on policy.
The classic example is the matter of mass shootings and gun violence. We obviously have a problem with gun violence in this country. It’s awful.
Whenever this happens, you often see specialists in trauma opine on policy fixes. It’s as if fixing the injured gives special policy knowledge. It doesn’t.
Consider for instance two trauma surgeons: one practices in New York City and rides a bike to work and pursues yoga and meditation as hobbies. The other practices in Alaska, drives a truck, and hunts big game as a hobby. These two clinicians may have disparate views on guns.
The threat of nuclear war is real. Health professionals have no substantial role to play in policy solutions. In my two decades of work as a doctor, I have never once helped a patient by discussing nuclear policy.
Environment stewardship, too, is important. But doctors and nurses, now mostly employees of major hospital systems, have little role in a hospital’s stewardship of the environment.
You might now think, come on Mandrola, who cares? Let medical people go on about whatever they want.
My rebuttal is that that would be fine if all was well in Medicine. But all is not well.
There are many downsides when healthcare professionals overstep our expertise.
Spending time on things that have no bearing on learning and practicing the craft of medicine or public health distracts people from their actual job. People who get sick depend on their clinician to be trained in health and disease, not climate or nuclear policy. There is only so much time. Why not spend it on being better at helping sick people.
Public health people may push back. They might say nuclear issues are public health matters. But again, I would ask, what exactly did you learn in public health school that translates into negotiating with world leaders? I know that Bernard Lown did it, but that is an exception—a one off.
Public health people might also claim climate change as their issue. I get it. Except, what expertise does your MPH give you in geothermal science? Or the negative externalities of different solutions?
Another downside of these forays into policy is the possibility of reducing trust—which is already at a low level. Climate, gun, and nuclear issues are inherently political. Taking a stand on a political matter is fine for persons, but it is not fine for clinicians or scientists.
Of all the institutions in healthcare that must be neutral it is journals. This is where the evidence that drives decisions comes from.
If a journal displays even a perception of bias, then people could lose trust in anything that it publishes.
I’ve spent the last decade reviewing evidence in journals. I often see flawed methods, oversized conclusions and spin. In almost all cases, the direction of bias is obvious.
So I’d make the same argument to journal editors that I would make to medical schools: you have a really important job. It is the judging of science. Focus on that. Make scientists provide their data. Check their data. Stop letting authors make causal claims from non-random comparison studies.
If you want to reduce misinformation, look inward. There is work to do. If a study’s limitations are so substantial that it precludes reliable interpretation, don’t publish it—even if the conclusions agree with your policy ideas.
Scientists and clinicians have important meaningful jobs. We harm our ability to succeed when we delve into matters of policy. It distracts and sows distrust.
We should remain like a neutral judge. Always. The people can decide the best policy.