Dying In A Leadership Vacuum: The NEJM Editorial in Context

By now, you’ve probably read that the editors of the New England Journal of Medicine (NEJM) published an editorial entitled “Dying In A Leadership Vacuum” that asks Americans to work together to vote out Donald Trump because of his dreadful mismanagement of Covid-19 and the subsequent deaths of more than 220,000 Americans.

To call the editorial scathing would be putting it mildly.

If you don’t have time for the entire piece, please read this closing section:

Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. But this election gives us the power to render judgment. Reasonable people will certainly disagree about the many political positions taken by candidates. But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.

By way of background, you might like to know something about what this journal and this editorial mean to physicians themselves.

First, you’ve probably heard that the NEJM is prestigious. There are literally thousands of medical journals from around the world available in English. Every medical specialty in the US alone publishes its own stack of them, and there are 135 recognized specialties in the US, with dozens of other unrecognized ones (like Chinese medicine, herbal medicine, and more).

But physicians everywhere pretty much agree that the NEJM is the gold standard of medical publications. It’s been continuously published since 1812 and in its pages appeared the first milestones in medical history. Here’s a bit more on its mission and history.

When I was in medical school and during my residency, my training hospital would order a stack of the journals every week. We’d pore over each issue and discuss not only the articles, but the letters to the editor. The mark of an excellent researcher at any medical school was that his or her work had been published in the NEJM.

According to the analytic service Journal Citation Reports, NEJM has the highest “impact factor” of any medical journal published anywhere. This means that an article appearing in its pages garners significant mainstream attention that endures throughout the ensuing decades.

In other words, the editorial asking Americans for the sake of their health and well-being to vote Trump out of office will be quoted as part of US history.

Powerful and unprecedented
The powerful editorial (which I’ll link to again here) was signed by all 34 of the journal’s editors. It condemns Trump’s handling of the pandemic, calling it dangerously incompetent and asserting that the administration has taken a crisis and turned it into a tragedy. This is the first time in its 208-year history that the NEJM has ever supported or rejected a political candidate. Only three other times has an editorial been signed by all the editors.

The NEJM editorial reminded me of a curious fact about doctors. Across the board, the medical profession is surprisingly non-political. And while physicians certainly identify as Republicans, Democrats, or Independents, it’s been regularly noted that getting them to vote can be quite a challenge.

A real question, especially in the context of this NEJM editorial is “why?”

Why do fewer than half of US doctors (48%, same as college students) show up to vote? This compared to about 75% of lawyers. Surveys among physicians report the very excuses you might expect: “no time,” “don’t keep up on political issues,” and so forth.

Shifting tides
Throughout the 20^th century, medical societies, medical schools, and hospital boards were quite conservative, almost reactionary. The AMA only allowed Social Security to pass in 1935 if all language were removed that might include health care coverage. Until the Affordable Care Act (ACA) passed in 2010, every single effort to provide health insurance for US citizens, including Medicare, had been steadfastly blocked by virtually all state and national medical societies.

Medical students in the US have traditionally been taught to believe what their elders believe, and I can say with certainty there wasn’t a single member of my University of Illinois class of 200 (90% male, 99% white) who didn’t believe that socialized medicine had something vaguely to do with Russia and the communists.

With the passage of the ACA, the AMA had a massive change of heart. Virtually all physicians today see the moral necessity of providing health care coverage for all Americans. Doctors are deeply concerned that overturning the ACA will bring back the much-loathed pre-existing condition denials for care, especially given the potential long-term health consequences for people with Covid-19.

And now in the US, with 7.72 million documented cases of Covid-19 and 214,000 deaths (according to the reliable Johns Hopkins Coronavirus Resource Center), the numbers increasing daily, suddenly politics has become central to the lives of healthcare professionals. Especially when you consider the more than 900 frontline healthcare workers whose deaths from Covid were sometimes attributable to a lack of protective equipment. Remember the nurses wearing garbage bags?

For shame. Hence the significance of the editorial in the journal we all respect the most.

Be well,
David Edelberg, MD