GUEST EDITORIAL MEDICINE: AN APT PREPARATION FOR PUBLIC OFFICE MichaelL.Riordan,MD Medicine is a social science. and politics is nothing else but medi- cine on a larger scale. -Rudolf Virchow' Virchow was right-so why aren't there more physicians in American public office? A recent artlcle2 tells us that not only has the representation of physicians among our nation's governors. legislators. and executive officers been very modest but also that representation has markedly ,. slipped as the Republic has moved through her first and second cen- turies. Of course, politically inactive doctors have easy explanations for this phenomenon: "Medical training doesn't leave room for that sort of thing ... "Medicine is a jealous mistress." "Ifl'd wanted to go into politics I would have gone to law school." What a shame. Many of the skills. mental processes. and ex- periences afforded by medical training are well suited to public policymaking. A look at medical school itself reveals several fea- tures that make it good prepara- tion for serving In public office. First: The medical student is taught to obtain, analyze. judge. and integrate several types of in- formation: the patient's history and symptoms. the physical exVOL 76/NO 5/0CTOBER 1984/POSTGRADUATE MEDICINE amination findings. and a host of laboratory data-chemistries. radiologic studies. microscopy. etc. A strategy for therapy is then decided upon, ideally based on an understanding of the cause of a patient's problems. with several considerations weighed simulta- neously: What discomfort. risk. or inconvenience accompanies the therapy. and how do such short- comings compare with the bene__,J fits? What net change in the pa- tient's "quality of life" will result? What is the cost of therapy to the patient and to social support sys- tems? What are the psychologic and social consequences of treat- ing or not treating? A striking analogy exists be- tween this process and that re- quired of. say, a governor deciding how to remedy a state's declining agricultural productivity. After continued 13 GUEST EDITORIAL CONTINUED Michael L. Riordan Dr Riordan received his MD in May 1984 from The Johns Hop- kins University School of Medi- cine, Baltimore, and holds a master's degree from The Johns Hopkins University School of Advanced International Studies. He now works in the biotechnol- ogy field for Arthur D. Little, Inc, Cambridge, Massachusetts. analyzing several possible causes of the decline, he or she must choose a therapeutic policy. per- haps a restructuring of the agri- cultural loan program, keeping In mind the Interrelated effects of such a decision upon farmers' lives and livelihoods. rural com- munities, agriculture-related businesses, political alliances. state revenues, future productivi- ty, and a multitude of other fac- tors. Treating the body, therefore. Is much like treating the body pol- itic. Second: Medical training shows one first-hand the effects of poverty. One measure of a so- ciety's progress Is the condition of Its poorest members. and govern- ment policy Is often directed to- ward ameliorating the plight of 14 socioeconomically depressed seg- ments of the population. Thus. the policymaker should be well acquainted with the impover- ished among his or her constitu- ency. A large part of the patient population at most teaching hos- pitals Is Indigent, and In fact many of the older teaching hospitals were first established to treat the poor. More than a quarter of the university medical centers In the United States "sit squarely in the midst of the largest. most trou- bled decaying Inner cities. ":J The great majority of medical students have extensive contact with poor patients on the "public floors" during medicine. surgery. or ob/gyn rotations, In walk-In clinics. and In the emergency room. Granted. some of the stucontin ued VOL 76/NO 5/0CTOBER 1984/POSTGRADUATE MEDICINE GUEST EDITORIAL CONTINUED dents may in the end be revolted by the clinical manifestations of poverty, but at least they see and deal with the chronic alcoholic from the nearby slum: they take care of the demented grandmother abandoned on the street: they help treat, in the emergency room, the attempted suicides, the heroin addict with gunshot wounds, and the laid-off warehouseman scalded by an enraged spouse. Poverty is in many ways directly reflected by the types of disease the student encounters in this economically depressed patient population. In the recent recession. for example, greater numbers of tuberculosis cases. more poisonings from lead-based paints, and an increase in infant mortality have already been noted in urban areas. Thus, the medical student is in a unique position to observe the consequences of poverty. It is a position that responsible presidents, senators, and representatives should envy. Third: The medical student must actively confront more and more issues that formerly were regarded as purely social problems but which are now being "medicalized": drug addiction, alcoholism, certain criminal and violent behaviors, marital difficulties, child abuse, sexual-Identity problems, mental and physical disabilities, and even gambling.4 Not only are societal ills being 16 medicalized: so, too, are corporate ills, as occupational health litigation on, for example, asbestosis or black lung continues to burgeon and the fate of sued corporations hangs upon the radiologist's viewing panel. Fourth: Medical training does, indeed, teach one about the "real world." There Is a common misperception that the medical student's immersion in studies and in the hospital prevents him or her from experiencing the workings of business and the economy at large, therefore crippling him or her as an effective policymaker in America, since "America's business Is business." For better or for worse, however, medicine itself is big business. The industry of medicine and health care now accounts for 12% of the gross national product. Medical school teaches the student, In detail. the fundamentals upon which that entire "medical-industrial complex" is built and around which It continues to grow.~ Can other paths of preparation for public office cla1m an intimate acqua1ntance with such a large chunk of the nation's economy? Fifth: Medical school deals with "human factors." Numerous authors have decried the deficiencies of many public leaders In the understanding of these factors that should be inherent to governing. Some of those authors emphasize how unfortunate It is that "statesmen are rarely trained In psychiatry, psychology, or anthropology and have no special cla1ms to any acquired skill in evaluating individual behavior and personality. "6 Medical school provides an unparalleled view of human behavior-Its frailties and its astounding potential. The physician and medical student are brought into the confidence of their patients and are granted insight into the emotional travails of the unfortunate businessman stricken by amyotrophic lateral sclerosis or into the steadfastness of the mother confronting chemotherapy for cancer. Not only does the medical student formally study psychiatry and behavior, he or she also has, in each patient, a personality case study, and each one of them enriches the understanding of human thoughts and actions. Sir Arthur Conan Doyle, the physician who created Sherlock Holmes, had this in mind when he stated that "medical training (is] a most valuable possession for a man, even if he [does] not afterwards engage in practice. After a medical education all work In life, If done In the right spirit, [becomes] far more easy. "7 The human insights abounding in medical education also prompted the author William Somerset Maugham, who studied medicine, to assert, "I do not know a better continued VOL 76/NO 5/0CTOBER 1984/POSTGRADUATE MEDICINE GUEST EDITORIAL CONTINUED training for a writer than to spend some years in the medical profes- sion. "8 Sixth: Throughout many of the clinical clerkships, the medical student must work in the hospital for long hours, often under stress and without sleep. While on call the student must maintain com- posure in the face of demanding patients, a lengthy scut list, and an impending case presentation to the chief of medicine the next morning. He or she must also be level-headed in an emergency (even though it may have abrupt- ly roused him or her from sleep) and carefully, deliberately assist the resident in, say, performing cardiac compressions and defi- brillation during a cardiac arrest. There is an obvious parallel between this experience and the performance demanded of a gov- ernment leader in a time of crisis, in which instead of one life, many lives may be at stake: The leader must think clearly and act deci- sively, under stress, perhaps without sleep. Indeed, the public leader in a crisis can take direc- tion from the admonition of Osler' to medical students: they must maintain "imperturbabil- ity," a "coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril .... " In conclusion, it is difficult to accept the fact that there are so 18 few medically trained people lead- ing our political and governmen- tal institutions, when their schooling is so appropriate for these roles. In history we find several examples of medical peo- ple who served eminently as lead- ers and statespersons: Jean Paul Marat, one of the four leaders of the French Revolution; Sun Yat- sen, the father of modem China; Prime Minister Georges Clemen- ceau, the "Tiger of France" who led his country during World War I and was the chief author of the Treaty of Versailles. Today in America, to the society's detri- ment, there are but a few who apply their enormously valuable medical education to the intense- ly challenging and important tasks of political and governmen- tal leadership. There should be more. RM Referenca 1. Quoted In Ackerknec:ht EH. Rudolf Vir<:how: doctor. statesman. anthropolq!tst. Madlsln. WI: Univ Wisconsin Press. 1953:46 2. Juneeon MG. Physicians and Amertcan pollUcal leadmlhlp. JAMA 1983:249('7):929-30 3. Kogen DE, Blendon RJ. The academic medical center. a stn,ssed Amertcan lnstltutlon. N E11!!1 J Med 1978:298( 17):940 4. Fm RC. The medlcallzatlon and demedlcallzatlon of American society. Daedalus 1977: I 06( I ):9-22 5. Reiman AS. The new medlcal-lndustr1al complex. N Engl J Med 1980:303( I 7):963-70 !Exposttlon on growth and emergence of a **new** medlcal-lndustr1al complex I 6. L'Etanjl H. F'tt to lead? London: Heinemann. 1981: 185 7. Doyle AC. Introductory addn,ss on 'Toe Romance of Med!ctne:* (Abstr) lancet I 910::2l0ct 8): I 066 8. Maqbam WS. The summing up. London: Heine- mann. I 938:45 9. Oeler w. Aequanlmltas. Presented as Vala'.llctory Addnss. Unlvmilty of Pennsylvania. Philadelphia: I 889 May! VOL 76/NO 5/0CTOBER 1984/POSTGRADUATE MEDICINE