09/10/2012 01:40 pm ET Updated Nov 10, 2012

Talking Politics in the Examination Room

Four years ago, as I was making rounds on the oncology floor, one of my patients with leukemia asked, out of the blue, "Hey, Doc, who you gonna vote for?" He had an Obama T-shirt by his bedside.

Chuckling politely, I asked him why he wanted to know. "I'm curious, Doc," he said. "It tells me your worldview." He said that if we agreed on who should be the next president, it would strengthen our doctor-patient relationship. I asked what would happen if we didn't agree. He said, "That would be okay."

I'm not so sure. I have strong political opinions, but I am edgy about disclosing them to my patients for several reasons. For one, I'm in an authoritative position: When I talk about antibiotics, my patients listen and usually do as I advise. As a result, they might give inappropriate weight to my political pronouncements. For another, I fear that no matter how carefully I tread in these conversations, a disagreement could leave a dead zone in our relationship; that would be damaging because doctors and patients have to work as a team.

I asked a cardiologist what he would have said to my leukemia patient. "I clearly avoid political conversations in the examination room," he said emphatically. "It raises the patients' stress level, and they're already stressed-out being in the office."

Another colleague, an orthopedic surgeon, also refuses to talk politics, but his reason was purely practical: "Who has the time to chitchat?" That's a good point. As a 2006 study showed, the average primary care visit is 17.4 minutes long and includes discussion of 6.5 topics. Often, I barely have time to spell out the potential side effects of my patients' medications. A political discussion should include more than sound bites.

These colleagues reflected what I think is the norm: medical professionals prefer to keep politics out of the examining room. At our hospital, even wearing a political button is considered unprofessional conduct. (Remember when Ronald Reagan was shot in 1981? He quipped to the doctor who was going to operate on him, "I hope you're a Republican." The doctor replied, "Today, Mr. President, we're all Republicans." That would have been less convincing from someone wearing a Carter-Mondale pin.)

Not all patients are open to political discussion. One editor told me she deeply resented it when her dentist, drill in hand, began an opinionated conversation about the Middle East, knowing full well she works for a newspaper.

One man with a heart transplant and an infection where part of his right leg had been amputated had the same reaction as my orthopedic colleague. "It's not a taboo, but I don't want to take up the doctor's time," he said. "I want him to treat my stump."

In the doctors lounge (where the TV usually broadcasts Fox News, and conversations tend to be weighted to the right) I'm more willing to talk about the election. Not every doctor would do that. One gastroenterologist I know says: "I'm a blue doctor in a red state. I don't want to anger my referral base for consults, so I just stay quiet [about politics] or avoid going to the doctors lounge."

But this must go on in every office. Employees test the waters or tiptoe around conversations when the colleague, the client or the boss has a differing political view.

However, I'm a little uncertain how I should advise patients on health issues that have political implications. Two years ago when the health reform law, the Affordable Care Act aka Obamacare, was being contested in Congress, and this spring when the Supreme court hailed it as constitutional, I was in a dilemma.

The conversation about health insurance and preexisting conditions is germane to nearly every doctor visit, yet does not happen often enough. One in five of my patients is uninsured or under-insured. Lack of adequate insurance is a proven risk factor for higher morbidity and mortality. A 2004 Health Affairs study found that lack of health insurance leads to 13,000 to 30,000 deaths annually among the near elderly (ages 54-65). Lack of insurance is no different from smoking, excessive alcohol intake or high blood pressure. Shouldn't I discuss these issues with patients?

This election year the most contentious topic is Medicare. The Democrats would make cuts of $716 billion dollars to hospitals and insurance companies while the Republicans would change Medicare to a voucher program, putting the burden of cost control on Medicare patients. Should I mention these facts to my patients?

The American Medical Association code of ethics notes: "It is natural that in fulfilling their . . political responsibilities, physicians will express their views to patients or their families. However, communications . . . about political matters must be conducted with the utmost sensitivity to patients' vulnerability and desire for privacy."

So even though the presidential candidates have different positions on many health-care issues, and even though my leukemia patient assured me that my opinion would not influence his, I don't tell patients how I'll vote.

But, I do tell my patients, when asked, how specific public policies will affect their health.