Keeping Politics Out of Patient Care: Interview With Anupam B. Jena, MD
Political differences have been found to “spill over into nonpolitical domains,” with evidence suggesting that physicians are also increasingly polarized.
Political polarization is “the defining feature of early 21st century American politics.”1 A 2014 study conducted by the Pew Research Center1 found that Republicans and Democrats are “further apart ideologically than at any point in recent history” and that this polarization “goes beyond politics” and is reflected in the personal lives and lifestyles of those on both the right and left.
These divisions between Republicans and Democrats have grown even larger since Donald Trump's first year as president, and the “magnitude of these differences dwarfs other divisions in society, along such lines as gender, race and ethnicity, religious observance or education,” according to an updated 2017 Pew Report.2
Political differences have been found to “spill over into nonpolitical domains,” with evidence suggesting that physicians are also increasingly polarized3 and that physicians' political beliefs may predict their clinical decisions.4
A 2016 study of >20,000 primary care physicians (PCPs) from 29 states, linked physician records to their political affiliation (based on a voter registration database). A sample of Democratic and Republican PCPs was then surveyed to ascertain attitudes to 9 patient vignettes that addressed particularly politicized healthcare issues (marijuana, abortion, and firearm storage).4
Democratic and Republican physicians were found to “differ substantially in their expressed concern and recommended treatment plan” regarding these issues. The researchers concluded that “physician partisan bias can lead to unwarranted variation in patient care.”
A 2018 study3 offers a different perspective. While acknowledging the significant partisan gaps that affect physicians as well as others, the findings suggest that physician political affiliation is not associated with the intensity of end-of-life care received by patients in the hospital.
The researchers used a random sample of Medicare beneficiaries (N=1,480,808) who were hospitalized between 2008-2012 with a general medical condition and died in the hospital or shortly thereafter.
They examined total inpatient spending, intensive care unit (ICU) use, intensive end-of-life treatments among patients dying in the hospital, and hospice referrals among patients discharged but at high predicted risk of 30-day mortality after discharge.
The researchers characterized physicians as Democrat (N=1523), Republican (N=768), or non-donors (N=23,627), using federal contribution data.
They found that mean end-of-life spending as well as intensive end-of-life treatments for patients who died in the hospital did not vary by physician political affiliation. Similarly, the proportion of patients discharged from the hospital to hospice also did not vary between physicians of differing political affiliations.
To shed further light on the study's implications, MPR interviewed lead author Anupam B. Jena, MD, PhD, Ruth L. Newhouse Associate Professor, Harvard Medical School, Boston, MA.
What was the focus of your inquiry?
In our study, we looked at a particular issue – end-of-life care – and focused on patients who were hospitalized to see if political affiliation of the physicians responsible for their care had anything to do with the care they actually received in the hospital. Given the findings of a previous study,4 we hypothesized that there would likely be differences based on political affiliation. We also thought that care might be more aggressive at the end of life if the patient were treated by a Republican rather than a Democrat.
Your study seemed to produce different findings from the previous study,4 which showed major differences between physicians in patient care, based on their political affiliation. Why do you think your findings differed?
The previous study was certainly interesting and novel in that it identified doctors as Republicans and Democrats, and then provided them with hypothetical vignettes to see how they might provide care in these scenarios. They found that the decisions described by Republican and Democratic respondents aligned with their respective party lines.
The limitation of that previous study is that it was survey-based. In other words, we don't know what these physicians would actually do if they were treating a real patient, rather than a hypothetical one. Our study was based on analyzing Medicare data, which reflected decision-making trends in actual situations.
Additionally, clinical decisions reflect conversations between the provider and the patient. In that type of shared decision-making, it is not only the physician's viewpoint that informs the final course of action. So it is not clear that the physician's preferences would be able to override those of the patient and/or family.
Beyond the patient and family, other people also contribute to the decision regarding end-of-life care. We tend to attribute much of the decision making to a single physician. But care in hospitals is often provided by multidisciplinary teams. Although an individual physician might be “in charge” of a team, the decision about patient care at the end of life might not have been made by a physician in insolation. Given the potential involvement of a multidisciplinary team, the potential input of the patient's primary outpatient provider, and the larger context of decision-making, such as health system characteristics, the impact of an individual physician's political preferences on end-of-life care might be diluted.
What is the take-home message of your study?
I think the message is that, at least when it comes to end-of-life care, physicians do not let political ideologies influence the type of care they provide. It seems that these physicians can separate out the issues so that their political ideology and patient care do not intersect. In other words, they may not consciously or even subconsciously impose their own view on how they care for their patients.
What are your reactions to your findings?
I thought that the results were heartening, considering the current climate. Additional research is necessary to explore whether physicians' political ideologies influence the delivery of end-of-life care in outpatient settings as well as other politically controversial areas of medicine.
- Doherty C. 7 things to know about polarization in America. Pew Research Center. June 12, 2014. Available at: http://www.pewresearch.org/fact-tank/2014/06/12/7-things-to-know-about-polarization-in-america/. Accessed: May 3, 2018.
- Pew Research Center. The Partisan Divide on Political Values Grows Even Wider. October 5, 2017. Available at: http://www.people-press.org/2017/10/05/the-partisan-divide-on-political-values-grows-even-wider/. Accessed: May 3, 2018.
- Jena AB, Olenski, Khullar D, et al. Physicians' political preferences and the delivery of end of life care in the United States: retrospective observational study. BMJ. 2018 Apr 11;361:k1161.
- Hersh ED, Goldenberg MN. Democratic and Republican physicians provide different care on politicized health issues. Proc Natl Acad Sci U S A. 2016 Oct 18;113(42):11811-11816.