Political Polarization Has Hit Medicine, Too
As our national struggle to cope with the coronavirus fractured along partisan lines, we may have hoped that at least medicine remained above the fray, offering unfailingly consistent advice that, while not perfect, was at least driven by the best understanding of the science, and not tainted in some way by partisan affections.
This hope—both idealistic and naïve—was damaged by the astonishing response of many medical leaders in response to the protests that emerged in response to the despicable murder of George Floyd in Minnesota.
As Thomas Chatterton Williams wrote in early June in the Guardian,
[I]n the time it takes to upload a black square to your Instagram profile, those of us who move in progressive circles now find ourselves under significant moral pressure to understand that social distancing is an issue of mere secondary importance.
This feels like gaslighting. Less than two weeks ago, the enlightened position in both Europe and America was to exercise nothing less than extreme caution…. Two weeks ago we shamed people for being in the street; today we shame them for not being in the street.
Health leaders played a central role in legitimizing this “whiplash-inducing messaging,” as Williams memorably describes it. A letter signed by over 1,200 health professionals offered medical cover to the protesters, explaining, “[W]e do not condemn these gatherings as risky for COVID-19 transmission. We support them as vital to the national public health.”
As one epidemiologist who attended the protests subsequently confessed to the New York Times, “I certainly condemned the anti-lockdown protests at the time, and I’m not condemning the protests now, and I struggle with that. I have a hard time articulating why that is okay.”
We should be disappointed by this response, and concerned by the “hemorrhaged credibility and authority”—in Williams’ words—that health experts squandered. But perhaps we shouldn’t have been surprised. An evolving body of academic research suggests that medicine as a whole is becoming increasingly progressive, particularly the very people—academic specialists in areas like infectious disease and public health—we’re most likely to look to for advice in times like this.
In 2014, Adam Bonica, a young professor of political science at Stanford, published a paper, “Mapping the Ideological Marketplace” in the American Journal of Political Science that introduced an attractive new way of quantifying political ideology at scale.
The methodology leverages the relatively recent public availability of detailed information about campaign contributions, which Bonica, as a graduate student at New York University, had assembled into a massive dataset that at the time contained over 103 million records, detailing contributions made between 1979 and 2012. (It has continued to expand with each election cycle.)
The idea is to distill donor political preference into a relatively simple number, reflecting the fraction of political contributions an individual donor makes to candidates of one party or the other, or to political action committees (PAC) conspicuously affiliated with one party or another. To be counted, donors must contribute to at least two recipients.
One benefit of this approach is the detailed information about donors included in the database—their zip code, for example, as well as their occupation and employer.
This approach proved tremendously powerful. His data demonstrated a profound liberal skew among academics (the most progressive), the entertainment industry, print journalists, and a category called “online computer services,” which encompasses technology companies such as Google, Oracle, and Facebook. Skewing right: mining, building and construction, agriculture, and oil, gas, and coal (the most conservative). Lawyers and the pharmaceutical industry emerged with a bimodal pattern skewing slightly left, while real estate and banking and finance also revealed a bimodal distribution, but tilted slightly to the right.
Bonica and several colleagues immediately used this approach to analyze several occupations in greater detail, including law and, of particular interest, medicine.
A remarkable paper, also published in 2014 analyzed the political contributions of a range of medical (and surgical) specialties, and found staggering differences. Surgeons and surgical subspecialists tended to contribute to Republicans, while pediatricians and pediatric subspecialists, as well as psychiatrists and infectious disease doctors, were most likely to contribute to Democrats. Orthopedic surgeons were the most conservative, by this measure, while pediatric infectious disease specialists were the most liberal. The authors demonstrated a remarkably close relationship between physician income and political preference, with the relatively lower-paying specialties favoring Democrats, and the more affluent specialties leaning Republican.
The authors noted that traditionally, doctors had been regarded as a right-leaning profession. And Bonica’s data confirm that in the early 1990s, physicians as a whole did, in fact, contribute slightly more to Republicans than Democrats, and thus were slightly more conservative than the average of all donors.
By 2012, however, physicians as a group had become more liberal, and now lined up squarely with the average of all donors.
The analysis of physicians also revealed that women were far more liberal than men; doctors who worked for non-profit organizations (like universities) were far more liberal than doctors working in a for-profit environment; and, pediatricians were far more liberal than surgeons—a split that appeared to be widening over time.
By 2012, surgeons contributed 48 percent more to Republicans than did pediatricians—a degree of polarization exceeding, as the authors point out, the 39 percent difference in the 2012 presidential vote between “red” Wyoming and “blue” Vermont.
An follow-up paper, published in 2019, demonstrated that recent medical school graduates—especially women, but men as well (though to a slightly smaller degree) skew much more to the left than their older colleagues, a progressive shift the authors argue is likely to continue, and over time, shift the political balance of the profession as a whole, since “[f]ew physicians change the partisanship of their contributions with age, although there is some tendency to moderation of both extremes.”
(Data supporting this conclusion are unfortunately not presented by the authors, and it’s thus difficult to exclude the obvious alternative possibility, that political affiliations tend to drift from more liberal to more conservative over time, the so-called Burke paradox.)
Even so, it’s hardly implausible for the authors to speculate that,
The liberal activism of recent medical school graduates, both as campaign contributors and as petition signers, suggests that political advocacy by physicians could occupy a still more significant space within medicine. They may also become educators and models for future physicians.
Bonica and colleagues have seen the future of American medicine, and it’s bright blue.
The liberal evolution of the profession delights some physicians advocating for social change. One such champion, former New England Journal of Medicine editor Dr. Arnold Relman, took comfort from these data. In his last published writing before he passed away at the age of 91, Relman penned a commentary accompanying Bonica’s 2014 paper, expressing hope “that female physicians will expand the social outlook of the profession, encourage it to become more liberal in its political views, and persuade it to consider how to replace the ACA with a better system.”
The potential impact of an ideological shift among physicians is highlighted by a 2016 study by a pair of Yale researchers which compared how doctors who are registered Democrats responded to a set of clinical vignettes, compared to doctors who are registered Republicans.
They learned that while all physicians responded similarly to vignettes around apolitical topics involving alcohol, obesity, and helmet use, the two groups reacted quite differently to cases involving marijuana, firearms, and abortion.
“Democratic physicians rated the firearms vignette as more concerning, and Republic physicians rated the marijuana and abortion vignettes as more concerning,” the authors report, noting the size of these differences “are quite large, and they only appear on the politically salient vignettes.”
The two groups of physicians had divergent views not only on the seriousness of the issues raised by the vignettes, but also in how they might approach the situations. In the case of firearms in a house with young children, for instance, Republican doctors might focus their counseling on safe storage, while Democratic doctors are more likely to encourage the patient not to store firearms.
Similarly, the authors write, Republican physicians “are more likely to discuss the health risks of marijuana, urge the patient to cut down, and discuss legal risks. Republicans are more likely to discuss the mental health aspects of abortion and to encourage the patient not to have more abortions.”
In some ways, this is simply the application to medicine of Miles’ Law—“where you stand depends on where you sit.” Of course it does, though these findings run counter to the idea of medicine operating on a pure scientific plane, dispensing science-driven truth uncontaminated by personal ideology.
Just-released findings about physicians by Bonica and his colleagues are in some ways both the least surprising and the most concerning. Echoing the “Big Sort” thesis of Bill Bishop, the researchers discovered that physicians tend to self-assort, moving to regions and workplaces where their political ideologies are more closely aligned with their neighbors and colleagues.
Which means that Republican-leaning doctors are more likely to practice in areas and organizations with other Republican-leaning doctors, while Democratic physicians tend to work and live with fellow Democrats.
These results suggest that the self-affirming political echo chambers so common in online communities are also a fact of life for physicians. Doctors who practice in academic centers, generally in left-skewing communities, and researchers who publish in journals dominated by these academics, may be unwittingly immersed in an environment that reaffirms and even accentuates their generally progressive beliefs and norms. Similarly, physicians practicing in more conservative settings, in more right-leaning (often more rural) communities might find equivalent affirmation from their peers, and find themselves inevitably pushed further right.
One implication of these patterns, as University of Chicago health policy researcher Harold Pollack pointed out in a YouTube interview with Bonica about this study, is that it’s increasingly difficult for patients in rural areas to get adequate health services like mental health and social work (which both skew considerably left on the contribution metric, as apparently do epidemiologists and other public health professionals).
Many of these health service providers, Pollack points out, lack the “cultural competency” to serve effectively the needs of conservative, rural areas. This problem is getting worse, he observes, as data from Bonica and others suggest that each new cohort of health providers are more liberal than the previous cohort. “Who will provide care?” he asks.
If we believe in the value and virtue of viewpoint diversity, then we must be concerned by this increased polarization of medicine, even as we can perhaps make more sense of the underlying dynamics we see playing out before us.
To the extent the media turns to leading academic experts and instinctively valorizes their advice, it would be irresponsible not to worry about the possibility of implicit ideological bias inevitably resulting from statistically left-leaning journalists from left-leaning communities reporting the views of left-leaning academic physicians generally from these same urban centers. Failing to recognize such biases would be concerning enough, but when we deny them, and insist instead that physicians are merely vessels of objective scientific truth, we enter dangerous territory.
It is critical to benefit from the best medical science has to offer—including important, life-saving advice like social distancing, wearing masks, and basing therapeutic choices, such as whether or not to take hydroxychloroquine, on the results of randomized clinical trials, not hearsay and wishful thinking.
Trust will be essential if an effective vaccine is developed and needs to be widely adopted.
But physicians will only earn and merit such trust if, as we rush headlong to recognize, acknowledge, and remediate privilege, we also come to terms with our intrinsic ideological biases, recognize the many ways in which our personal and professional environments may reinforce these divisions, and work actively to empathetically understand, rather than contemptuously dismiss, a broader range of ideological viewpoints.