The doctor’s trade is a narrow one. In periods of political and social stability, people need doctors only to treat their ailments. During times of disorder, society turns toward businesspeople, academics, and artists for the picture of a better world. But rarely do they consult doctors, unless during a pandemic. Doctors, it seems, have little to offer besides their instruments and pills.
It was not always this way. Physicians played important political roles early in American history. Ten percent of the signers of the Declaration of Independence were physicians. But since then, physician participation in public life has steadily declined. In the country’s first hundred years, more than 250 physicians served in Congress; in the second hundred years only 60 did. In the country’s first hundred years, 25 physicians served as governors of the 13 original states; in the second hundred years, only 4 did. The number of physicians in Congress reached a nadir in 1990—only two.
True, in nineteenth-century America, there were more physicians per capita than there are today. The sheer number of doctors at that time made physician participation in public life more likely. Things have picked up: In 2023, nineteen physicians served in Congress.
Another observation confirms the downward trend: Since the beginning of the last century, physicians in other countries have generally been more active in public life compared to their American counterparts, even among the class of revolutionaries—for example, Che Guevara in Cuba, or George Habash, founder of the Popular Front for the Liberation of Palestine. Physicians in other countries have reached the highest levels of power. Sun Yat-sen, the first president of the Republic of China, was a physician, as was Georges Clemenceau, the former prime minister of France. In the US, the only person with a medical background to reach the highest level was President William Henry Harrison, who went to medical school but never finished.
All this may seem little more than a curiosity. But the reasons for it are more than merely academic. In fact, the reasons have real life consequences for both patients and citizens. In the doctor’s office, they account for some of the mistakes physicians make. In everyday life, they account for some of the coarsening in American civil discourse. Less physician participation in public life, medical errors, and the breakdown in civil discourse—these seemingly unrelated phenomena have a connection.
The Problem of Specialization
During the nineteenth century, most doctors were generalists. Specialization took hold among American doctors during the first third of the twentieth century. By 1940, roughly a quarter of US physicians were specialists. By 2015, two-thirds of US physicians worked in specialist areas.
The decline in physician participation in American public life correlates with increasing specialization. Specialists focus almost exclusively on a body part, allowing them to work at the highest level of technical skill. But they must practice that skill constantly to avoid losing it, which chains them to their work. As a specialist myself (an anesthesiologist), I often noticed a dip in my performance after being away from work for just a few weeks, consistent with the old medical adage: “There’s nothing more dangerous than the occasional anesthesiologist.” Unlike generalists, specialists cannot easily take time off to enter public service, unless it’s a one-way trip.
Because specialists are less likely to view patients in their totality—for example, to inquire into their home situation or relationships—they grow removed from people’s everyday problems. As a result, they are less likely to develop the sort of “raised consciousness” that drives people into public life. It is no coincidence that doctors entering public service in other countries have traditionally worked in primary care. There, they learned first-hand the plight of everyday people. That primary care doctors form a larger percentage of doctors in these other countries only strengthens the point.
In a different sphere, the specialization trend has created a new class of medical errors due largely to bias. A gastroenterologist, for example, might wrongly view all lethargy as a stomach problem; a cardiologist might view it as a heart problem. Late at night, when on-call at the hospital and responsible for treating a much wider range of cases than typically seen during the day, the specialist may be unprepared to deal with an emergency that requires a general skill he or she has let atrophy. A specialty’s literature and rules for practice, somewhat unfamiliar to non-specialists, can have a harmful effect on the latter’s decision-making. When confronted with a specialty case, a non-specialist will instinctively follow the specialty’s rules to the letter, for fear of straying into utter darkness, thereby replacing considered judgment with mimicry.
In the sphere of American civil discourse, specialization fosters enmity between elites and average people. The specialists in public life are the “experts.” They have mastered the literature and rules in their respective fields. Just as medical specialists often look down on non-specialists, so do experts dismiss the uneducated, and while experts profess to love the whole of humanity in the abstract, they tend to scorn input from mere folk. The ancient arrogance of the nobly born has been replaced by another kind of arrogance, based on the pride of expertise.
This method of intimidation is out of sync with the democratic spirit. A single error on the part of experts, like a single untruthfulness on the part of teachers or parents, inevitably leads to distrust and rebellion, similar to how a young person regards his surroundings with suspicion after finding the adults have lied. For example, education policy, which once seemed to average citizens like neurosurgery, and was thought to require expert management, now seems more like blowing one’s nose, which anyone can do on their own. As the education experts fail, and reading and math scores decline, parents think they can do the job just as well, and demand more say. A similar phenomenon can be observed in other public policy areas. With experts and non-experts distrusting and scorning one another, the age of conciliation in politics has given way to an invasion of fury.
The Problem of Disorder
If the problem of specialization grew out of science’s urge to subdivide disciplines, the problem of disorder grows out of science’s countervailing urge to obliterate all distinctions. Although established by science, classification systems become increasingly meaningless under the eye of science. Is a human being a variation on the amoeba, or is the amoeba a variation on the human being? Is the organic a variation on the inorganic, or the other way around? Whichever way science chooses seems arbitrary. Classes cease to exist in a hard and fast way, and instead of seeing many things, science eventually sees only one thing. Science, which began as a system for classifying things, ranging from the stars to plants to animals, eventually recognizes that its own distinctions are arbitrary, at which point it turns on itself.
In medicine, this blurring of distinctions can lead to medical error, as everyday problems are wrongly fused with medical problems. Examples abound. Some doctors mistakenly view everyday unhappiness as a medical problem best treated with drugs. Some doctors wrongly medicalize every aspect of aging, as when they view menopause as a “disease” and aggressively treat every falling lab value in older women, or shower older men with testosterone supplements. Some doctors splice the adolescent carrying just a few extra pounds into the population of the obese, and push weight loss drugs on both. These therapies for newly medicalized everyday problems come with risks that are often ignored.
In civil discourse, the problem of disorder creates a different set of difficulties. As the borders between disciplines blur, experts expand their reach beyond their original assignment. In academia, some English professors today call themselves cultural historians, while some law professors call themselves social scientists. In government, public health authorities add foreign policy and crime to their portfolio, while social service workers aggressively intervene in family life. At the other end of the spectrum, blurred borders encourage citizens to bring their private emotional trouble into public discourse. “Everything is political” is code for the new order that renounces separate compartments, neutral ground, or places to rest. Private anger and despair are unleashed on all the spheres of life, as no border exists to hold citizens back. Today, experts antagonize citizens with their power grab, citizens inject their private furies into public life, and civil discourse grows less civil.
The problem of disorder also explains some of the decline in doctors’ participation in public life. With disintegration of the line separating public from private, doctors, like many Americans, no longer must enter public life to solve public problems. Instead, they can work in nonprofits or NGOs—institutions that epitomize the collapse of the public-private divide. Today, the nonprofit sector in the US employs more people than local, state, or federal government, while wielding considerable influence on public policy. Much of American foreign policy toward Africa, for example, is shaped by NGOs.
In some ways, then, the decline in physician participation in official public life is misleading. Many doctors are involved in public life, just not in any official public way. The nonprofit Doctors Without Borders exemplifies this blurring of boundary lines, both in its work and very name.
The Problem of Fads and Ideologies
Doctors deal in tradeoffs, carefully weighing a therapy’s benefits and risks. Their work is like a carefully thought-out game of chess and demands the utmost intellectual exertion. Doctors are also cautious, steady, and prudent, virtues typically ascribed to the shopkeeper. The best doctors are people of deep understanding. When doctors bring these traits with them into public life, they help stabilize civil discourse, not unlike how lawyers in Tocqueville’s America provided society with a steady hand. But modernity is also the age of ideology, as opposed to the age of refined and thoughtful humanists, and this truth affects everyone, including doctors.
Political ideologies didn’t really exist prior to modernity; the lack of efficient communication and the low level of popular participation in politics made conflicts more individualized during that older era, rather than struggles with a strong theoretical foundation. Ideology, by contrast, is a tool for dreamers in the modern era to conceptualize the future on behalf of thousands of people. Alongside ideologies are fads. These consist of momentary lapses in sanity in which great numbers of people latch onto a fashion, a lifestyle, or an idea, and make it an integral part of their lives—until everyone realizes how ridiculous it is. The fad’s believers are “mad” for their fad, just as ideologues are fanatical about their ideology.
The strength of ideologies and fads in the US helps to explain why physician involvement in public life has declined. Medical practice was often what drew doctors toward political involvement, as doctors worked with patients, learned about their problems, and plunged into politics to help solve them, bringing their virtues and thoughtful disposition cultivated during years of practice along with them. Today, those few American physicians who enter public life are less likely to do so organically. Rather than gradually widen their field of vision from the patients they see in primary care to the larger community, they often go into politics because they have absorbed an ideology in college, or embraced an ideology learned through magazines or social media. It should not surprise that the majority of doctors in the 2023 Congress were not primary care doctors but specialists, and with a strong ideological bent—for example, Senator Rand Paul, is both an ophthalmologist and a libertarian. Only a particular kind of doctor gives up medical practice to follow ideology into politics, which means fewer doctors entering public life.
Ideologies and fads need not always be political. In scientific form, they plague medicine and prejudice doctors, causing medical error. Typically, they take the form of buzzwords—for example, “biogenic amines,” “endorphins,” “neurotransmitters,” “BMI,” “fat-free,” “sugar-free,” “wellness,” and so on. Simple yet powerful, the buzzwords resonate with the public at large, while luring doctors, who are equally susceptible to their influence, into making bad clinical decisions.
An example is a doctor who prescribes a weight loss drug to a patient with a BMI of 28, although the patient’s BMI is high merely because he or she is a healthy muscular athlete. The term “BMI” (body mass index) has become sloganistic shorthand for the ideological movement to fight obesity. (“MAHA,” or Make America Healthy Again, is another catchword in that movement.) The term itself has become dogma; people obsess over their BMI numbers; they worry if their BMI is over 25 and panic if it’s close to 30. Some doctors obsess over it too, and let the number guide their therapies even when all other indicators suggest a healthy patient. Doctors often think these buzzwords summarize the best and latest in science, when, in fact, they do nothing more than reflect people’s hopes and aspirations for a better life. Hopes and aspirations are not science.
On the political level, ideologies and fads harden civil discourse. The buzzwords become a rallying cry. An army of believers is created, followed by a dogma that helps to promote the movement. The great and vehement conflicts that plague American civil discourse today, steeped in unreasonableness and intolerance, are more often than not the result of certain ideologies attached to buzzwords rather than due to any inherent human propensity to bloodthirstiness. An ideology or fad lets loose the will to violence and the drive to attack. Fanaticism takes over and concludes that only what it thinks is acceptable and must be forced upon the whole country. It splits America into friends or foes, heroes or criminals, believers or heretics. Since it recognizes no other system than its own and no other truth than its own, it makes civil discourse impossible.
A Call for the Medical Humanities
Exposing doctors to the liberal arts has become a popular method for making doctors better doctors. The method, called medical humanities, is valuable. The liberal arts show doctors gaps in their reasoning—for example, the blind spots in the scientific method. They also expose doctors to new ways of thinking about algorithms, patient psychology, the definition of the good life, and their own role going forward in an age of artificial intelligence.
But the liberal arts can also help doctors from another angle. By probing the roots of our crisis in civil discourse, doctors can become better citizens, and, like all good citizens, help lower the temperature in our politics. In the process, as they learn the underlying reasons for that crisis, they also discover how those same reasons underlie some of the mistakes they make in medical practice. By learning how to become better citizens, they also learn how to become better doctors.
This learning experience goes both ways, I should add. By grasping the reasons underlying some of their medical mistakes, doctors learn how they, as citizens, along with millions of other citizens, have pushed civil discourse into a rut. They learn how the problem of specialization, the problem of disorder, and the problem of ideologies and fads cast a long shadow over much of American life, and not just over their medical practice.