INTRODUCTION
Throughout the history of the United States, physicians have been involved in the domestic political process, both directly and indirectly. Examples of indirect physician participation in politics include holding positions on school boards, serving as political advisors to local politicians, participating in advocacy work led by professional physician associations, lobbying elected officials, and donating to political campaigns. Examples of direct physician participation include running for political office both at the local and national level with the hope of being elected to Congress. Physicians’ historical role as national political leaders has roots in the assembly of the Continental Congress that coordinated the resistance to the British occupation from September 5, 1774, to October 21, 1788. Thirty-one (8.5%) members of the Continental Congress were physicians.1 Furthermore, three physicians (10.7%) were among the signers of the Declaration of Independence in 1776,2 and two physicians (5.1%) participated in the writing of the US Constitution in 1787.3
Nevertheless, the proportion of physicians in politics has declined since the eighteenth century. While in the first century of Congress (1789-1889) 252 of 5405 (4.6%) members were physicians,4 that number decreased to just 60 during the following nine decades, perhaps in part reflecting the implementation of more rigorous standards to become a physician.4,5
Between 2005-2015, the increased political prominence of healthcare issues was associated with an important relative increase in direct physician participation in Congress to 27 (3.0%) of 894 members.5 However, since 2015 the number of physician congressional members has decreased by more than a third.6
Compared to other professions, fewer physicians act as congressional members. For example, the ratio of attorneys to physicians in Congress is 40 to 1.7 Kraus and Suarez7 suggest various reasons for the decreasing physician representation in Congress. These include a lack of financial incentives to seek public office (and for some subspecialty physicians even a comparatively lower salary); busy and demanding practices preventing physicians from finding the time to adequately prepare for the election process; professional burnout and dissatisfaction discouraging physicians from civic participation as elected officials; highly focused and patient-centered medical education making it more difficult to choose alternative career paths; lack of professional tradition of seeking elected office; and fewer role models of physicians with successful records of congressional service.
While physicians face unique challenges in directly participating in politics and running for public office, they are well positioned to make important political contributions. In addition to their healthcare-related expertise, physicians enjoy high public credibility which is essential for the viability and the public approval of healthcare legislation.8 Furthermore, physicians are considered to possess important individual characteristics that may contribute to their success in politics, such as excellent time management skills, the ability to make rational decisions under pressure, and a strong propensity for teamwork and collaboration.9
This study aimed to examine the perspectives of four physicians who served as congressional members and determine their willingness to mentor physicians who may be considering joining the political sphere.
METHODS
One-on-one interviews were conducted with four retired or current physician congressional members between October 1, 2020, and March 31, 2021, via telephone or videoconferencing. The semi-structured interviews included 12 open-ended questions that were designed based on literature review and research team consensus (Supplement). Each interview explored the following topics: factors influencing the decision to enter politics, challenges faced during the transition from practicing medicine into politics, mentorship and support received during entry into politics, experience as a physician in congress, and willingness to mentor younger physicians that are planning to run for political office.
The interview responses were transcribed verbatim and anonymously. Confidentiality of the participants’ responses was ensured, and detailed personal responses were de-identified to the best of the team’s ability during the transcription process. Informed consent was obtained verbally at the commencement of each interview encounter. Consent included permission to use quotations in publications. Participants did not receive financial compensation.
The author also searched the biographical records of all interview participants in a non-partisan Congressional biographical database,10 as well as on their official government websites. Data extracted included years served, party affiliation, age, gender, marital status, ethnicity, and medical specialty. The voting history of the participants was reviewed using an independent website that tracks the status of legislation in the United States Congress.11
Institutional review board approval was not considered necessary because the data was collected using publicly available sources on elected officials.
RESULTS
Demographics and voting records
Characteristics of physician-members of Congress participating in our interview are shown in Table 1. Congressional voting records show that the four interview participants were the primary sponsors of 572 proposed legislations, out of which nine bills were enacted.
The most common three areas of sponsored legislation were related to Health (29.9%), Taxation (23.8%), and Armed Forces and National Security (9%). (Figure 1).
Deciding factors for entering politics
Our interview participants reported various reasons for entering politics, including ending the Vietnam war after witnessing first-hand its severe psychological trauma on patients, confronting the prescription opioid epidemic and drug trafficking, protecting the Second Amendment of the United States Constitution, improving the quality of our healthcare system, and improving public education.
Level of support from family, patients, and physician colleagues when entering politics
All four respondents reported excellent support from their family members and patients when deciding to run for political office. While two respondents had additional support from their physician colleagues, the other two reported a lack of support from their medical practice partners, citing concerns about reduced financial contribution to the practice and potential risks to the practice reputation.
Challenges encountered during the transition from medicine to politics
All four respondents reported that despite their extensive medical training and experience, they lacked the political knowledge and skills necessary for adequately running a political campaign. Specifically, they did not know much about fundraising, grassroots organization, advertising, communications and social media, polling and research, legal requirements, and campaign debating.
Mentorship received when entering politics
All four respondents reported knowing little about politics initially, and that mentoring was a highly important aspect in their decision to enter the field. However, only three out of our four participants received any form of mentoring when first entering the political world, either from elected local officials or former congresspeople. The mentorship was informal and there were no physician mentors. One physician participated in the Candidate Workshop of the bipartisan political action committee of the American Medical Association prior to running for public office.
Ability to continue practicing medicine while serving in Congress
All four participants reported missing their work during their time in Congress, specifically interacting with patients and the rewarding experience of helping patients deal with their health issues. They also believe that, if possible (depending on the medical specialty), it is important to maintain a clinical practice to retain relevance and credibility as a physician member of Congress. Our respondents indicate that the biggest obstacle in continuing to practice medicine is the US House of Representatives’ rule prohibiting members from receiving compensation for working in order to avoid possible conflicts of interest.12 Another notable challenge is that of reconciling a developing political career with the importance of providing safe patient care continuity. Nevertheless, after obtaining approval from the Committee on Ethics of the US House of Representatives, two respondents (a Family Medicine physician and a Urologist) managed to continue practicing medicine in the Washington D.C. area, with all earnings from their clinical work ultimately donated to charity.
Experience as a physician serving in Congress
All four respondents reported that as physician members they felt very respected in Congress, not only for their noble profession but also for being good listeners and promoting teamwork. They collaborated and created alliances with other physicians in Congress to promote healthcare legislation. One of our respondents was a founding member and co-chairman of the GOP Doctors Caucus in 2009.
Post-Congressional careers
Three out of four respondents have retired from Congress. One returned to practicing medicine full-time, the second is an author and political mentor, and the third began part-time work as a healthcare lobbyist with plans to ultimately return to medicine. The one respondent who is currently in Congress plans to return to medicine after retiring from politics.
Advice for current physicians that are contemplating entering politics
All four physician Congressmen that participated in our interview strongly encouraged physicians to become involved in politics in order to have an impact on important issues in our society. However, they all recommend starting with clearly defining one’s goals for entering politics. One of the respondents suggested to “consider if the goals can be accomplished without necessarily running for office. A lot can be accomplished by getting to know your local politicians and see if they can embrace your ideas”.
Secondly, all respondents recommend getting input from family members about the decision to enter politics. Running for office takes a toll on the entire family with new challenges including reduced income, relocating to Washington D.C. with or without immediate family members, and placing yourself and the family in the public eye. Because anticipating public scrutiny is a crucial step, retired physician-Congressman Jim McDermott highlighted the importance of passing what he calls “the kitchen chair test”. This consists of sitting in a chair facing a corner in the kitchen with closed eyes and thinking of an embarrassing moment. He goes on to say that “you should be comfortable with that information becoming public and being on the news” before deciding to enter politics.
Once physicians have decided to enter politics, our respondents strongly recommend doing it gradually, beginning with involvement at the local level. This allows them to learn new political skills and also helps determine if political involvement is ultimately the right fit. One participant recommended attending the Candidate Workshop of the bipartisan political action committee of the American Medical Association prior to running for public office in order to learn how to prepare for an electoral campaign.
While in Congress, our respondents recommend that physicians avoid being single-issue lawmakers and focus not only on healthcare but also on other issues facing our nation. Because members of Congress have different political viewpoints, our respondents emphasize the importance of treating everyone with respect despite differences in opinion and political affiliation. As physician-Congressman Greg Murphy suggests, “physicians are very educated and high achievers, but they should not consider themselves infallible and come across as arrogant”.
Our respondents consider mentoring to be very important throughout all stages of the political career of physicians involved in politics. Importantly, all four physician members of Congress that participated in our interview are willing to mentor other physicians who are contemplating entering politics.
DISCUSSION
Currently, physicians make up a proportionally small part of Congress with only 17 current members (4 senators, 13 representatives) out of a total of 535 members (100 senators and 435 representatives).13 Our study aimed to understand the perspective of some of these physicians, their motivation to pursue a career in politics, and advice they may have for other doctors wishing to enter this field.
While the motivation for pursuing politics varied between our respondents, common themes included medicine and healthcare. It follows that approximately one-third of their sponsored legislation was related to health. While this is a natural role for physicians to fill in Congress, our respondents warned against being single-issue lawmakers. Physicians have experiences and talents beyond just medicine that can be utilized in a lawmaking setting.
In medicine, there are Core Competencies laid out by the Accreditation Council for Graduate Medical Education (ACGME) that are the foundation of medical training.14 Of these six competencies, only two specifically relate to medicine: Patient Care/Procedural Skills and Medical Knowledge. The other four are skills possessed by physicians that translate to any field: Practice-Based Learning and Improvement, Interpersonal and Communication Skills, and Professionalism.
Practice-Based Learning and Improvement, the skill of continually incorporating new knowledge and research into day-to-day practice, prepares physicians to take on new tasks and adapt to new fields such as lawmaking. This correlates with our respondents’ advice to avoid becoming single-issue lawmakers. Physicians have the ability to synthesize data from research and experience and to apply it to new situations, uniquely positioning us to serve in government positions that require specialized expertise.
Physicians are additionally trained to develop useful interpersonal and communication skills, as well as to maintain an ongoing attitude of professionalism. Highly ingrained in the job of a physician is the ability to engage with other people in respectful manners and to develop relationships that encourage vulnerability and understanding.15 A legislator must also engage with other politicians and their constituents.16 These communications are best executed by individuals who are deft in creating comfortable and welcoming environments, such as physicians.
Regardless of the expertise that physicians bring to the table as politicians, our respondents point out the importance of mentorship when entering politics. Currently, through the American Medical Association (AMA), there is a bipartisan political action committee (PAC) through which physicians are supported in the process of being elected to the U.S. Congress. The mission of the American Medical Political Action Committee (AMPAC) is to support new and existing physician candidates who will work as medical allies in the Capitol by prioritizing Medicare payment reform, medical liability reform, and expansion of healthcare for all.
Aside from mentorship, the APMAC provides political education both through the Candidate workshop and the Campaign School. The Candidate workshop is designed to help physicians transition from clinical practice to campaigning and even congressional office. The workshop is led by political experts who previously held office in the Democratic and Republican parties. They provide firsthand advice about politics and the sacrifices needed to run a successful campaign. They also give insight into how to tailor your campaign from when to make the decision to run, the appropriate medical advertising avenues, the role of your family, and how to handle crises. The Campaign School provides high-quality training through a simulated campaign that is applied to exercises related to voting, social media, and public speaking, among others. Physicians’ spouses are even encouraged to attend education forums, highlighting insight into how a political career impacts the entire family. Lastly, one can learn about the field through volunteering opportunities provided by the APMAC.17
There indeed exists a community from which physician politicians can glean mentorship and education. For example, “Doctors in Politics” is a society comprised of members who fill several roles. These include individuals who are simply interested in learning about available opportunities through newsletters and events, ambassadors who recruit prospective candidates, and national advisory council members who provide sponsorship to the organization. As a political action committee, “Doctors in Politics” supports and encourages doctors who advocate for a more patient-centered healthcare system to run for Congress. They highlight those who are currently running and reportedly plan to source and support 50 doctors to run for Congress in 2022.18 There are additional communities for women physicians, including those who stand for democratic principles.19
A critique of this study, and of physicians in Congress in general, is the lack of diversity. Our study group consisted of four white men, therefore providing a limited perspective on the process of entering politics and the challenges that may be experienced. The primary barriers acknowledged by our respondents were related to lack of experience in politics and family concerns. It is difficult to know from our limited study if physicians from different backgrounds would experience unique difficulties not previously mentioned.
When considering the challenges presented to Donna M. Christensen, the first female and black physician in Congress, it is worth noting their similarity to those reported by our interviewees. As a Family Medicine physician from St. Croix, she felt she could not perform her duties as a clinician while serving in the House of Representatives. It was a difficult decision to part ways with practicing medicine to pursue a career in Congress. Luckily, she had the support of her patients and community, as well as prior political experience as a former Democratic National Committeewoman. While she had no formal political training, she felt that the skills gained through her medical training, namely decision-making ability, caring for patients, and building a differential to arrive at a diagnosis, served her well as a politician. Like many of our participants, Dr. Christensen does not plan on remaining in Congress indefinitely. However, she continues to emphasize that, as physicians, we share a unique skillset uniquely positioned to shape the future of politics as it surrounds healthcare.20
Despite this limited scope, we hope that our review on physicians as lawmakers encourages physicians to engage in politics and to make an impact beyond the one-to-one physician-patient relationship.
CONCLUSIONS
Our study suggests that, while there are many unique challenges for doctors entering politics, physicians who have been elected and have served in public office are willing to mentor others who may be considering joining the political world. Through a high level of public trust, healthcare expertise, and other distinguishing factors, physicians are well positioned to play an important role in the political life of our nation and help tackle the challenges that our society faces.
ACKNOWLEDGMENTS
The authors thank Elis A. Kristo for his technical assistance in coordinating the interviews with the physicians in congress and analyzing the biographical records and voting history of the interview participants from a Congressional database.
DISCLOSURE
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.