Correspondence

More on the President's Checkup

N Engl J Med 1995; 333:1645-1646December 14, 1995

Article

To the Editor:

Dr. Rubenfeld (July 27 issue)1 portrays President Bill Clinton's recent physical examination2 as “routine screening for a healthy 48-year-old man” and therefore inappropriate in its complexity. He believes that this bad example is likely to enhance a sense of entitlement that already makes more health care seem better, especially when other people's money is being spent.

Although the President may be viewed as a moral leader, he may also be seen as a man whose actions affect all Americans. Physical health certainly has an important bearing on the ability to perform wisely. The question then arises: Should ordinary rules apply to everyone, no matter what that person's responsibilities and authority to affect others?

Former presidential physician Burton Lee thought so. Treating George Bush “like an ordinary patient, not like a VIP,” he omitted thyroid-function testing from Bush's periodic physical examination (guidelines of the American College of Physicians advise against thyroid screening in the absence of suggestive symptoms).3 Shortly after his physical, Bush ordered the United States into the Gulf War, against the advice of his senior advisors. Only then did the onset of atrial fibrillation herald the presence of underlying hyperthyroidism.

Since hyperthyroidism may promote impulsiveness, New York Times physician-columnist Lawrence Altman wondered editorially whether what is cost effective for an ordinary patient is similarly so for a president.3 Indeed, would earlier detection have altered presidential policy? The question has received surprisingly little attention from the medical community, even though the incremental cost of thyroid screening is small and testing is commonplace in everyday practice.

All of medicine involves the calculation of odds. But is the margin of tolerance for error the same for everyone? Intellectually, I have my doubts about the elaborateness of Clinton's physical, but given the experience with his predecessor, I do think the presidency warrants a higher standard than guidelines intended for general use.

Philip R. Alper, M.D.
1838 El Camino Real, Burlingame, CA 94010

3 References

1. 1

   Rubenfeld GD. Another truly presidential checkup. N Engl J Med 1995;333:260-261
   Full Text | Web of Science | Medline

2. 2

   Altman LK. Clinton is a few pounds heavier but in fine health, doctor says. New York Times. March 25, 1995:8.
   

3. 3

   Altman LK. President's thyroid: questions of mood. New York Times. May 21, 1991:B5.
   

Author/Editor Response

Dr. Rubenfeld replies:

To the Editor: My letter did not address whether the chief executive's responsibilities justify a higher standard of health care than that accorded the average 48-year-old man.

Citing evidence and expert opinion,1 I questioned what Dr. Alper apparently accepts implicitly. Does a presidential checkup with extensive laboratory testing and specialist consultation necessarily constitute a “higher standard” of general medical care for healthy adults?

Choosing an optimal screening strategy involves weighing a complex set of variables that include the prevalence of disease, the accuracy of tests, the ability to treat discovered ailments effectively, and the implications of false positive results. Although a patient's profession may dictate vigilance for specific diseases, anecdotes about recently missed cases or perceived VIP status should not play a part in health care decision making. Demonstrating that the President's biochemical and physiologic profiles lie in the normal range may have some political merit. I submit, however, that these have little to do with making the President, or his decisions, healthier.

This intensive level of routine care sends a clear, and probably erroneous, message to the American public about what constitutes optimal medical practice. If Mr. Clinton's responsibilities justify the alleged benefits of a presidential checkup, what about members of Congress, the clergy, physicians, or my mother in New Jersey?

President Clinton recognized the important part evidence-based guidelines can play in improving the quality and efficiency of health care.2 It is interesting to note that Patient Clinton and his physicians choose to practice otherwise.

Gordon D. Rubenfeld, M.D.
University of Washington, Seattle, WA 98195

2 References

1. 1

   Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions: report of the U.S. Preventive Services Task Force. Baltimore: Williams & Wilkins, 1989.
   

2. 2

   President Clinton's Health Care Reform Proposal and Health Security Act. Medicare and Medicaid guide. Report #773. Chicago: Commerce Clearing House, 1993:833-8.