AMA Journal of Ethics^®

The 109th Congress comprises an impressive variety of people. Between the House of Representatives and the Senate there are 82 women, 43 African Americans (only 1 in the Senate, however), 28 Hispanics, and 141 with records of military service.¹ Overwhelmingly, most of those serving in the federal legislature have had previous careers as state legislators, congressional staffers, or public servants.¹ There is also a small but outstanding group of Congress members who share a past different from all others: these 17 legislators have medical degrees. As physicians, these men and women have the ability to understand the bedside issues of health and health care better than their congressional peers, and they can more easily grasp the interconnectedness that these intimate situations have with politics and policy making. In their roles as elected officials, these physicians possess a unique body of knowledge, and this knowledge and subsequent power can be exploited or manipulated, or it can be used for good ends. This article will look at 4 physician-congressmen—2 in the House and 2 in the Senate—to examine the degree to which each identifies himself as a physician in his political role, understand how the medical background of each may have influenced his decisions to introduce or support specific legislation, and assess how successfully each manages his dual role.

Some history about physicians in the legislature will establish a context for this discussion. Since the first Congress, there have been a total of 47 Senators who have studied medicine, 10 of whom did not practice (6 of those 10 studied both law and medicine and chose careers in law.)² Despite this strong history, there were no doctors serving between 1935 and 1959, and there was a gap again between 1969 and 1995. A 2004 article in the Journal of the American Medical Association entitled "Is There a Doctor in the House…or the Senate?" observes that, unfortunately, "as the political salience and economic impact of health care in the United States have increased, physicians have taken a smaller role as congressional members."³ Authors Kraus and Suarez offer several hypotheses for this trend including financial concerns—most physicians today are making as much money (if not more) practicing medicine as they would as US Congress members—and the decline in numbers of physicians in the US relative to members of other professions, particularly attorneys who top the list of professions of legislators. One of the most fascinating reasons that the authors suggest for the decline of physicians in politics is that there has been a "general decrease in professional morale among physicians, precipitated by an increased workload, changes in practice driven by managed care and biotechnology, lower reimbursements, and increasing expectations from health care consumers."³ Kraus and Suarez believe that the current demands and stress of medical practice leave many feeling that civic participation is unnecessary or too difficult to manage along with their other obligations.³ Physicians may have faded in number, but today there are 2 powerful, outspoken physicians in the Senate. Those men are Dr. Bill Frist, R-Tennessee, and Dr. Tom Coburn, R-Oklahoma. In the House of Representatives, while there are more than 2 doctors, I will take as examples Drs Phil Gingrey, R-Georgia, and Joe Schwarz, R-Michigan.

Identity as a Physician-Politician

These physicians do not have expertise in the same medical specialties, and they serve different constituencies; nevertheless there are similarities among the 4. All are Republicans, all were practicing medicine when they were elected to the Congress (and some still are), and each has used his medical knowledge while serving his respective branch of the legislature. But how each man goes about this is different. Three of the 4 draw their identities as much from their medical professions as from their political careers.

This year Representative Phil Gingrey has combined his medical knowledge and his political reach to call the attention of Georgia citizens to important facts and information about the "bird flu," the need to spend health care dollars (specifically Medicare dollars) more effectively, and the role of preventive medicine in Medicare, all through newspaper op-eds. In 3 separate publications Gingrey prefaces his writings with the phrase "as a physician" before he continues to make his medical as well as his political point.^4,5,6 A review of his most recent articles indicates that Gingrey does not take strict partisan positions, but he does call upon his role as a physician to add weight to arguments that carry political consequences.

Similarly, Senator Bill Frist has emphasized his role as a physician-congressman in a variety of political ways. He has relied upon his training to assess the threat of cholera, malaria, and typhoid in Southeast Asia following the 2004 tsunami; in 2001 he wrote a book entitled When Every Minute Counts: What You Need to Know About Bioterrorism from the Senate's Only Doctor.⁷ Frist also employed analogies of healing and diagnostic skills in his 1994 campaign.⁷ Clearly Senator Frist is proud to be a physician when he declares, "Every morning I get up, I see a physician…. I spent 20 years, every day, getting up and looking at that mirror and seeing a heart surgeon."⁷ Like Gingrey, Frist makes little-to-no effort to separate the physician from the politician.

This willingness to combine medical training and expertise with politics is seen, perhaps most strikingly, in Senator Tom Coburn. Senator Coburn has sponsored a lecture/slide show on a current public health topic for congressional staffers and Congress members annually since he began in Washington politics in the 1990s. In 2005 he premiered a slide show entitled "Revenge of the STDs" to a roomful of mostly speechless colleagues.⁸ Like Representative Gingrey, Senator Coburn has pushed the issue of preventive medicine and the need to limit frivolous or excessive medical lawsuits.⁹ Coburn has been an outspoken advocate of the pro-life movement and has called upon his expertise as a physician who has delivered more than 4000 babies to oppose expansion of stem cell research and abortion.

Representative Joe Schwarz stands alone in this group of 4 as a more seasoned politician who does not explicitly see being a physician as an inseparable part of his political identity. Before going to Washington he served in the state legislature where, as the only physician, he was called upon frequently as a medical expert. Today he does not highlight his medical background nearly as much as his role as an education advocate who wants to ensure that the Congress is "keeping the avenues of scientific and medical research open to our young people."¹⁰

Introducing and Supporting Legislation

Although these congressmen must personally decide how to vote on a proposed bill, they must also, as representatives of constituencies, take into consideration how those who elected them want them to vote. Each of the profiled men is active in health care issues, and a look at their records shows how their medical backgrounds influence their decisions about medically related topics.

Gingrey has a record of supporting legislation to prevent the spending of Medicare monies on certain drugs. He writes, "As a physician and a Member of Congress, I support…introduced legislation in the U.S. House to prevent federal dollars from being spent on drugs for sexual dysfunctions. I am a proud co-sponsor of this legislation."⁴ Gingrey also introduced a medical reform bill—HR 5, also known as the HEALTH Act—which passed in the House in July. The goal of the bill was to "discourage[s] baseless lawsuits by limiting the incentives for filing meritless claims, including placing limits on non-economic and punitive damages."¹¹ Recently, Gingrey also sponsored health care bills for Hurricane Katrina victims. It is clear that Gingrey's health care background has influenced the themes of his bills and that he has succeeded in bringing his first career as a physician to bear on his new one as a representative.

As the majority leader in the Senate, Bill Frist serves as the chief spokesperson for the Republican senators, and he manages the legislative and executive business of the Senate.¹² It is in this capacity that he works very closely with the Bush administration; yet there are times when Frist abandons his coordinator role and speaks more passionately and personally about current bills in the Senate. Two recent examples occurred in the debates about Terri Schiavo and the stem cell legislation. During the Schiavo debates Frist began "speaking more as a physician than as a United States Senator" and wanted to "really speak to my involvement as a physician and—and as a Senator as leader in the United States Senate in what has been a fascinating course of events…."¹³ Many of his subsequent comments angered his fellow doctors to the point where 31 of his former medical school classmates sent him a letter accusing him of improperly using his medical degree.¹⁴ This speech left little doubt that Frist was willing to leverage his knowledge as a doctor to achieve a political end. During the stem cell debate, to the surprise of some, Frist broke from the Bush administration and decided to support fewer restrictions on embryonic stem cell research by declaring:

I'm a physician. My profession is healing. I've devoted my life to attending to the needs of the sick and suffering and to promoting health and well being. For the past several years, I've temporarily set aside the profession of medicine to participate in public policy with a continued commitment to heal….stem cells offer hope for treatment that other lines of research cannot offer.¹⁵

Despite having one of the most consistently conservative records, Frist has recently shown a willingness to allow his medical judgment to guide some of his most controversial votes—even when they seem to be atypical of his voting trends.

Back in the House, Representative Schwarz has a voting record that demonstrates his interest in both medicine and education. Recently, he has co-sponsored HR 1227, the Genetic Information Non Discrimination Act which "expand[s] the prohibition against discrimination by group health plans and health insurers in the group and individual markets on the basis of genetic information."¹⁶ Schwarz also co-sponsored HR 4166, the Family Asthma Act that would allow the "National Institutes of Health to improve asthma management and increase our knowledge of the environmental and genetic links to asthma. It also increases funding to the Centers for Disease Control to increase the CDC's educational efforts with state, local and nonprofit partners…."¹⁶ Representative Schwarz supported the Stem Cell Research Enhancement Act and Gingrey's HEALTH Act.

Senator Coburn's legislative record also prominently features health care bills. In June of 2005 he introduced the Parent's Right to Know Act that "mandate[s] that parents be notified five business days before contraceptive drugs and prescription devices are distributed to their minor child by Title X clinics."¹⁷ Coburn said that he decided to introduce this legislation because "as a practicing family physician, and as a member of Congress, I have seen first-hand the painful consequences associated with our federal policy…."¹⁷ Coburn also explicitly declared that he was at odds with Senator Frist in regards to stem cell research and wrote that "at the dawn of what will likely be the biotech century, advocating taxpayer-funded destructive experimentation on human embryos that will be ‘thrown away anyway' would set us on a dangerous course."^18,19 As a counter to the Stem Cell Research Enhancement Act, Senator Coburn introduced the Respect for Life Pluripotent Stem Cell Act of 2005.

Managing the Dual Role

It is never easy to work multiple jobs, let alone juggle a political career with the responsibilities and privileges that come with a medical career and, for some, limited medical practice. These 4 men have worked hard to maintain integrity in both of their professions, and they have met this challenge with mixed results.

Representative Gingrey is founder and co-chair of the Medical and Dental Doctors in Congress Caucus. He has chosen to remain active in health care beyond policy and practice and has volunteered his medical skills to help in the event of a Capitol-area emergency. In November 2005 "Gingrey was briefed on the location and operation of emergency medical equipment, so he can quickly assist others in the case of an emergency."²⁰ Gingrey spent part of his summer traveling throughout Georgia to hold town hall-style meetings to explain and promote the Medicare Part D program. One doesn't often see Representative Gingrey in the national media spotlight, but it seems that he has worked hard to keep political pressures from overwhelming his medical judgments.

Senator Frist has recently found himself in medical and political hot water. Following the Terri Schiavo floor speech, his medical judgment was called into question by fellow physicians and the media alike. Earlier this year, while discussing the importance of abstinence-only education, Frist was asked on ABC's "This Week" if AIDS could be contracted through tears or sweat and he answered, "I don't know" but later conceded that "it would be very hard."⁷ According to the Centers for Disease Control and Prevention, "contact with saliva, tears or sweat has never been shown to result in transmission of HIV."⁷ But Frist's willingness to openly break from the White House position by supporting the Stem Cell Research Enhancement Act has demonstrated that his medical judgments can trump loyalty to the administration when necessary. Some have also criticized Senator Frist for trying to be both a doctor and a powerful politician by saying, "He should stop being a doctor and be a politician. He can't have it both ways."⁷ As Frist's political power and star continue to rise in Washington, his ability to stick stubbornly to traditionally conservative ideals may come increasingly into conflict with his scientific and medical knowledge, and, as he weighs a run for the Presidency, his ability to balance medicine with politics will be severely tested.

Representative Schwarz has been able to balance being a physician and a politician with apparent ease. He has had the fortune of representing a district that is surrounded by institutions of higher learning that often support his educational and occasionally controversial medical initiatives. Much like Representative Gingrey, Schwarz has stayed away from the national media spotlight. Within his own district, his long record as state senator, a member of the city commission, and mayor has allowed his constituents to come to know his positions, both medical and political.

Finally, Senator Coburn has had perhaps the most volatile experience trying to balance his physician and politician selves. In 1998, while in the House of Representatives, Coburn threatened to leave office because of the ethics rules that severely limit a congressman’s ability to practice medicine and do not allow physician-congressmen to make a profit from their practices.²¹ At the time, Coburn stated that "If I can only practice medicine or only be in Congress, I'll practice medicine."²¹

Coburn has also appealed to his medical skills to form unconventional and, at times, inflammatory points of view, and those have been expressed on influential shows such as "Meet the Press." During his Senate race in 2004 Coburn stated that he believed that doctors who performed abortions should face the death penalty. Consider this exchange with Tim Russert on October 3, 2004:

Coburn: Tim…as a doctor that's delivered 3,500 babies, cared for every complication of pregnancy you can imagine and have seen the procreation and creation at it's earliest states, you know, I believe when we take innocent life intentionally…we are violating moral law.

Russert: But you think the death penalty would be an appropriate penalty in that situation.

Coburn: If somebody intentionally takes life at any stage throughout the country, except to save a life, and that's innocent life, I think we have to use the law that's on the books to respond to that. I sure do.²²

In November of 2005, Coburn stated that he relied upon his training as a physician to ascertain whether people testifying before Congress were telling the truth. During the John Roberts Supreme Court hearing he told Mr. Roberts, "I've tried to use my medical skills of observation of body language to ascertain your uncomfortableness and ill at ease [sic] with questions and responses. I will tell you that I am very pleased both in my observational capabilities as a physician to know that your answers have been honest and forthright."²³ When asked by Tim Russert whether there were other times when his skills as a physician helped him to determine someone's honesty during Senate proceedings, Coburn answered, "Yeah. And then what you do is you go…and see where the problem is and all of a sudden you find, wait, this isn't truthful."²³ Taken at face value, Coburn's comments can lead one to question whether his dual allegiance may cause him to make judgments that cast a doubt over the plausibility of mixing medicine and politics.

Conclusion

Physicians and politicians hold special places in the American occupational landscape. These are 2 of the most influential positions one can hold, and it is rare today for a person to hold both esteemed positions in a lifetime. Physicians are entrusted with the life and the health of individuals and the greater population. They are told intimate truths by their patients; they have the ability to cure and heal and, likewise, they have the ability to harm and kill. Because of this extremely sensitive and powerful role, physicians are widely trusted and held in highest esteem. In return, they are expected to remain educated and up-to-date on innovations, to use science and direct evidence to come to their conclusions, and to hold themselves above political posturing.

Politicians, specifically legislators, make laws and debate the important issues of the land. Because they are elected by local constituents, politicians often are compelled to vote with "the party." A politician holds his or her job only as long as the voter is happy with his or her record, and awareness of this fact leads many politicians to make judgments they might not otherwise have made. Therefore, when politicians combine their objective, medical judgments with the necessarily subjective political obligations, the result can be a record that reflects a collision of science, professional obligations, public opinion, and party unity.

This piece has looked at 4 men who find themselves at the junction between politics and medicine. Each has chosen a unique approach to his role and each has managed his political position differently. But there is one common thread: medicine is never far from the consciousness of each, and each is astutely aware that he holds an unparalleled place of influence in this country.