With presidential elections just weeks away, many physicians are finding themselves involved in political discussions—with each other and, perhaps, with patients. However, in the current political climate, physicians may decide to keep a wide berth around any form of political discussion with patients.

In the facility where I work, the administration has asked that employees refrain from making politically charged comments in public areas. There is certainly nothing wrong with that approach. However, if done appropriately, talking politics with patients can be safe, beneficial, and edifying for the patient, the physician, and ultimately even society as a whole.

Political opinions are practical extensions of an individual's world view, which is deeply connected to the idea of what it means to be human. Both the nature of government and a citizen's sense of duty to follow its laws mean that politics has profound consequences for our lives, both personally and professionally. Politics, by directing those laws and policies, also has profound consequences for our patients and our ability to care for them. For these reasons, political discussions can get personal very quickly—and that can be problematic.

Ethical considerations
Although the AAOS does provide opportunities for patients to become involved in advocacy issues, it does not yet provide specific guidelines on how to approach political discussions with patients. As orthopaedic surgeons, we can draw inferences from other guidelines and basic bioethical principles. For example, the AAOS Guide to Professionalism and Ethics in the Practice of Orthopedic Surgery, 2015, includes the following statements:

• The orthopaedic profession exists for the primary purpose of caring for the patient. The physician-patient relationship is the central focus of all ethical concerns.
• The medical profession requires physicians to subordinate their own interests in favor of the patient's best interests and to hold themselves to high ethical and moral standards.
• The orthopaedic surgeon has a responsibility not only to the individual patient, to colleagues, and to orthopaedic surgeons-in-training, but also to society as a whole.
• The orthopaedic surgeon also has a responsibility to seek changes in legal requirements that are contrary to the best interest of the patient.

The first two principles indicate that physicians should take a patient-first approach to any conversation with patients, especially political conversations. That patient-first standard can be used to judge questions, statements, and topics. The patient-first standard can also be used to initiate political conversations—specifically advocacy conversations—with our patients.

The next two principles indicate that orthopaedic surgeons have a duty to advocate for their patients. Although the most obvious application of these principles lies in advocating to policy makers about legislation that affects our patients, it also can apply to educating our patients about the policies and policy makers that will affect them.

Our patients benefit from our insights into the workings of our complicated healthcare delivery system. In the setting of the physician-patient relationship, sharing insights on the impact of certain policies and laws is within the realm of our responsibility. We must keep in mind, however, that some patients may not want to be distracted by policy discussions, and that even discussions undertaken with the best of intentions may go awry.

Other considerations
We can consider three conditions in determining whether a particle for political discussion is warranted. The first condition is solicited or unsolicited—whether the patient has asked for the doctor's opinion. A second condition is how closely the topic is related to the health of the patient and the physician's role in that care. The last condition looks at whether statements are specific or general. For example, a specific statement would be referencing meaningful use criteria in healthcare regulations; a nonspecific statement might be a derogatory remark about one political party or another.

The ideal political discussion between a physician and a patient is solicited, directly related, and specific. For example, your patient asks you about the impact of a candidate's policy on that patient's ability to access your services. Political discussions to avoid are unsolicited, unrelated, and general, such as comments about a candidate's stance on immigration.

Regardless of the circumstances, physicians should consider the following before undertaking any political discussion:

• Will the patient benefit from what you are intending to communicate?
• Is the topic one that directly affects patient welfare, patients' ability to access your services, or your ability to provide services that benefit patients?
• Do you have personal experience with the issue, and can you bring that experience to bear on the discussion?
• Can you clarify an issue that seems self-serving on the surface, for example, the way that physician compensation affects practice solvency and therefore patient access?

As physicians, we should be cautious when engaging with patients who initiate political discussions outside of our realm of expertise, outside of the duties of the physician-patient relationship, and outside the duties to society and the profession. But we can also be proactive in speaking about issues that directly affect our patients and our practices. When engaging with patients, we should be sure to also solicit the patients' opinion. We must avoid condescension toward opinions or beliefs that differ from our own.

Ryan Eggers, MD, MA, has a master's degree in bioethics and currently serves on the AAOS Ethics Committee.

Engaging Patients in Politics
Fred C. Redfern, MD

In 2012, I organized a symposium on grassroots advocacy at the National Orthopaedic Leadership Conference. (See "Taking Advocacy to the Grassroots," AAOS Now, June 2012.) At that time, I shared experiences about how I engaged patients to pass a tort reform ballot initiative in Nevada and encouraged patients to send letters to their representatives and senators to pass Medicare reform.

Being able to engage patients on issues that directly affect their access to and quality of care is an important skill for all physicians to develop. I have found that if you have a good relationship with patients, they are receptive to being educated about a political initiative that will benefit them. Once they understand the issue and understand your request for their action, most patients are glad to act and become involved in the initiative.

One way to help patients spread the word is to provide them with a one-page information sheet at the end of their office visit. Stephen Eckrich, MD, of South Dakota, and his colleagues recently utilized this method to pass a "Patient Choice" ballot initiative in that state. There is no stronger grassroots method than a widespread campaign by doctors to engage patients in a call to action.

Talking to patients about supporting a specific candidate, however, is more delicate. As a solo practitioner, I have the freedom to engage patients in appropriate political discussions. Other practice settings will require policies to be established. I have put campaign brochures on display in the office, but I don't discuss the candidate with patients unless they approach me. When they do, I bring the discussion back around to the patient by saying the candidate supports policies that will improve their quality and access to care. 

Hearing from thousands of constituents makes a bigger impression on a politician than contact from one doctor. For example, the Affordable Care Act (ACA) has generated significant political discussions with my patients. Many have benefitted by gaining access to insurance, but getting access to care can still be difficult with limited networks. Escalating premiums and high-deductible plans have created financial burdens. If, and when, a bill gets introduced to repair or replace the ACA, many patients will be eager to share their personal stories with their congressional representatives.

Occasionally, we as physicians are fortunate to have a patient who is very involved in politics or is even a politician. Joan and Curtis Patrick have been my patients for years, and have authored two books on President Reagan. They have arranged for me to attend private dinners and special fundraisers for candidates. It is very difficult to keep their office visits to 15 minutes because we love to talk politics! According to the Patricks, "It is very important to discuss with our doctor the impact current political changes will have on us. Doctors are one of the few remaining professionals who are universally trusted."

Fred C. Redfern, MD, is past chair of the AAOS Board of Councilors and served on the AAOS Board of Directors. He can be reached at redfern.fred@gmail.com