Politics: getting involved.

All otolaryngologists in the United States, indeed all physicians, are affected directly and profoundly by politics. The same is true for physicians in many other countries around the world. Hopefully, the thoughts in this editorial will be applicable elsewhere, but they are directed primarily toward those of us who live and practice in the United States, the part of the world with which I am most familiar.

Over the past few decades, most otolaryngologists have observed changes in our practice environment that we regard as changes for the worse. Malpractice litigation in many states has reached troublesome, even crisis, status. In some areas, such as southeastern Pennsylvania, the costs and unpleasant atmosphere associated with an excessively litigious environment have combined with extremely poor reimbursement to create a significant disincentive for young otolaryngologists who might otherwise choose to live in such areas. In Philadelphia, for example, despite the attraction of an extremely livable and affordable city as well as the richness of an academic community with five medical schools and four otolaryngology residencies--recruiting has become difficult. Furthermore, some excellent, established otolaryngologists have chosen to leave the region.

Here and in many other cities, the practice environment is made more challenging by other factors, as well, including the intrusions of managed care companies into medical practice, increasing government involvement in patient care through "pay for performance," and other initiatives and factors that were far from the minds of most otolaryngologists when they chose to devote their lives to careers in medicine. These problems affect not only the quality of our lives and practices, but also hinder our ability to deliver first-rate care to our patients.

So, how did we end up in this mess?

In the first sentence of the previous paragraph, I noted that we have "observed changes," and I would argue that that is part of the problem. Most of us went into medicine because we wanted to take care of patients. If we had wanted to go into politics, we probably would have gone to law school. Nevertheless, the past couple of decades have taught us that we cannot afford the luxury of passivity. If we do not become actively involved in the political process, we will continue to be on the receiving end of decisions and policies that affect us and our patients--but over which we have had little or no influence. Since these decisions clearly affect patient care, I believe we have an ethical responsibility to become involved, at least for the protection and safety of our patients if not for other reasons.

We have already spent too much time on the sidelines, trusting that our altruism and dedication would be appreciated and would lead the public to protect us and our ability to practice, but this strategy has failed. For example, numerous surveys have shown that the public has a negative attitude toward physicians, even though respondents have a positive attitude toward their own physicians.

So, once again, how did we get into this mess? There are far more reasons and complexities than can be summarized in the space of an editorial. However, I suggest that there is one simplistic and obvious problem that I have never seen discussed elsewhere, and so I will raise it here: television. At the moment, physicians clearly do not enjoy public sympathy and do not hold public confidence to the extent that we deserve. Hence, we are not a potent political force. Legislators have little to gain by supporting pro-physician causes at the expense of alienating other constituencies. When did we lose our public base? It appears to me that it was when Marcus Welby, M.D., Ben Casey, and Dr. Kildare went off the air. They were the last television shows that really developed physicians' characters in depth and showed their dedication and humanity.

Whether we like it or not, a huge percentage of Americans are raised in front of television sets. They get their ideas, images, and stereotypes from the tube. They have enjoyed decades of sympathetic shows about lawyers, ranging from L.A. Law to Law & Order, but what have they had to watch that helps them appreciate, admire, and strive to emulate physicians? I suspect that if the AMA had spent our money developing pilots and lobbying for network television shows that showed physicians the way we really are, we would have the power of the public and not be in the politically challenged situation we now face. While this is only one of the causes of our current situation, I believe that it has been largely unrecognized, and its importance should not be underestimated.

Nevertheless, we need to accept our current reality and work proactively to improve it. That means getting involved. Perhaps a few of us have the talent to write some good screenplays and create a hit series about an admirable otolaryngologist, but for those of us with less writing talent, at the very least we should become involved with the political process, both monetarily and personally.

Many of us complain about the influence of trial lawyers, but it is also well known among politicians that they are lucky to get a $50 contribution from a physician, while a litigation firm is happy to write $10,000 checks to support campaigns. Campaigns cost money, and we can hardly blame politicians for paying attention to the people who help them get elected. Therefore, we need to step up to the plate and support the politicians who support us, our patients, and our beliefs.

As president of the Pennsylvania Academy of Otolaryngology--Head & Neck Surgery and as an elected Republican committeeman, I would encourage generous support, but I have been surprised at how much even a little bit of support is recognized and appreciated. Physicians' political action committees (PACs) provide state and national politicians with smaller contributions than many other PACs (because, unfortunately, we doctors have not been very generous in our contributions to the PACs). However, even at the current, meager contribution levels, politicians notice and appreciate the support, and they listen to our input. More generous support would be better, but contributions from 100% of us (even if some were minimal) would make a striking impression.

Fund-raisers held at our homes for candidates that we admire also make an impression; one needs only to call the campaign office and offer to hold one, and the candidate's staff will provide assistance. Brief, thoughtful letters to state and federal representatives are welcome and often are read, but personal meetings are clearly better. They can be arranged by appointment with our legislators' local offices; or (sometimes better) they can be facilitated by inviting legislators to speak at events for potential voters and contributors or arranged through faculty associates, county or state medical societies, or independently.

Active participation in the political process is also valuable. Although I traditionally have had little interest in politics, several years ago I decided that if I were going to continue complaining, I had better actually do something. So, I ran for committeeman. Committeeman is as grassroots as you can get, and it is a pain in the neck having to go door-to-door every two years to get signatures on the reelection petitions. However, I have learned a great deal about the political process and about my neighbors, and I have been astonished about how much attention senior politicians (even U.S. senators) pay to elected officials even at the committeeman level and even when the senator is in a different political party. Taking the trouble to participate not only educates us but also gives us credibility in the political process that far exceeds the effort we would expect for so minor a role.

The suggestions above are easily within the reach of all of us in medicine. So is one more: the ballot box. The percentage of people who vote remains embarrassingly low in our great democracy. So low, in fact, that the winners are often determined by whose supporters actually take the trouble to come out and vote. Every election has an impact on us and our patients. There is simply no excuse for any one of us to be observers in the electoral process. If we don't at least show up at the polls, we have little right to complain about what "they" do to us next.

It has never been more clear that the future of medicine and the care of our patients depend on what happens in state capitols and in Washington. It is high time for us to have our say before decisions are made, rather than complaining about policies after they are foisted upon us. No matter how busy we are and no matter what our political beliefs, we can no longer afford not to take the time to be involved in the political process.

ROBERT T. SATALOFF, MD, DMA 

Editor-in-Chief

EAR, NOSE & THROAT JOURNAL