The President’s Doctor the Ultimate Concierge Medicine

Concierge medicine is all about preventive healthcare, proactive medicine, and treating illness before it even becomes a problem. In our everyday lives this kind of care helps us to be more productive, more attentive to family needs, and much healthier. Getting sick just isn’t an option for us anymore, when work and family has to come first. Now imagine how important it is to stay healthy and productive when you’re the President of the United States.

The New York Times published an interesting article this morning reviewing a new book, “The White House Doctor: My Patients Were Presidents – a Memoir” by Dr. Connie Mariano, and how concierge medicine and preventive care is so crucial in the White House.

The Rigors of Treating the Patient in Chief

By LAWRENCE K. ALTMAN, M.D.

(The New York Times)

WASHINGTON — No patient gets closer medical attention than the President of the United States. Wherever he goes, a doctor, nurse or paramedic trails a few footsteps behind, ready for any medical need. It is the ultimate in concierge medicine.
WHITE HOUSE DAYS Dr. Connie Mariano, right, at a news conference on President Clinton’s knee surgery in 1997. With her are Mike McCurry and Dr. Marlene DeMaio.

PRESIDENT AND PATIENT Bill Clinton and Dr. Connie Mariano left the White House together in 1994 for Mr. Clinton’s annual physical in Bethesda, MD.

For the president’s doctor, it is a little different. The job of White House physician combines professional responsibility with the glamour and trappings of proximity to history. The White House medical office is only a few steps from the Oval Office, and the doctor has automatic access to the president’s living quarters.

A medical staff member stays overnight in the White House. When the president travels, the doctor rides in a limousine near the head of the motorcade. Jet lag and stress make the job one of near-constant fatigue, shadowed by dread of assassination attempts.

Now a recent holder of the job, Dr. Connie Mariano, has written an account of her nine-year tenure under three presidents, Bill Clinton and both George Bushes. The book, “The White House Doctor: My Patients Were Presidents — a Memoir” (Thomas Dunne Books), is one of just a handful of autobiographical accounts by presidential physicians.

Dr. Mariano’s story is an inspiring one. The daughter of a Navy steward, she was the first Filipino-American of either sex to rise to rear admiral, and the first woman in the military to become the White House physician. But her account gives scant attention to some important points and passes over others.

For example, the 25th Amendment deals with succession when a president becomes disabled or incapacitated. Dr. Mariano does mention that to avoid invoking the amendment, Mr. Clinton received spinal rather than general anesthesia when he needed surgery to repair a torn quadriceps tendon. But she has little more to say about the amendment, which is central to any serious discussion of presidential health.

Asked about that in an interview, Dr. Mariano replied: “There was a lot I didn’t put in the book because the publisher said it wasn’t of interest to the general public. They said this isn’t a scholarly thing — it’s a memoir.”

Since the Civil War, the White House medical staff has been drawn largely from the military. The doctors are from a variety of specialties and are chosen by the president. One reason is that few civilian doctors can afford to suddenly abandon a practice for four years. Also, Dr. Mariano said in the interview, because the medical staff members are first responders in the field, “White House medicine was like practicing battlefield medicine.”

The White House medical unit — Dr. Mariano supervised a staff of 24 — also cares for the vice president and his family, for White House staff members in some cases and even for guests at state functions. But if the president or his family members need attention, everyone else is pushed aside, even if seriously ill or injured.

Chiefly for safety reasons, White House medical staff members are instructed to work as invisibly as possible, and the challenges range widely. Staff members plan the president’s annual physical, rescue guests choking on hors d’oeuvres at White House functions, help foreign leaders seek care in the United States or elsewhere, and plan emergency care should the president need it while traveling.

White House military doctors are outranked by their patient, who is the commander in chief, potentially creating conflicts in the patient-doctor relationship. Whenever her boss, the president, insisted on pushing the envelope, Dr. Mariano said, “visions of court-martial danced in my head.”

In 1997, she did yield to Mr. Clinton’s demand that he fly to Helsinki, Finland, to meet with the Russian president, Boris N. Yeltsin, four days after the quadriceps operation. (He needed crutches for support.) But when Mr. Clinton had “the stomach flu” and wanted to continue working, she put her foot down, telling him she would have to tell his wife, Hillary Rodham Clinton. “O.K., I’ll listen to you,” he replied, and backed off.

On the other hand, when Dr. Mariano wanted to hospitalize Mrs. Clinton for a blood clot and phlebitis in her leg during the 1998 midterm election campaign, the first lady refused, saying she was too busy. So Dr. Mariano and other experts agreed to treat her as an outpatient with a new blood-thinning drug.

Apparently no other such encounters occurred in Dr. Mariano’s tenure. But what if one had?

“I’d resign, leaving it to journalists and others to reason why,” Dr. Mariano said in the interview, repeating what she told me when she was in the White House. Other White House doctors have made similar pledges. But would a White House doctor, used to the trappings, actually resign if confronted with a situation in which a president hid a serious ailment from the public or distorted its importance?

In the past, as with Woodrow Wilson’s stroke, White House doctors have misrepresented the severity of a president’s illness.

Even when the president feels fine, fear lurks among the medical and security detail, whose members develop an attitude so fatalistic that Rich Miller, the senior Secret Service agent to the first President Bush, told Dr. Mariano, “It’s not a matter of if the president gets killed — it’s a matter of when.”

While Vice President Al Gore was recuperating from surgery to repair a torn Achilles tendon, he lost his footing and fell to his knees as he ascended the steps of a church. Mr. Gore’s metal crutches landed with a loud clang. Secret Service agents, fearing Mr. Gore had been shot, drew their weapons and raced forward.

White House medical staff members are taught to stay out of the “kill zone,” what agents call the area around the president, where a bystander could be killed by a stray bullet. Staff members often wear civilian clothes because those in military uniforms are more likely targets, particularly on presidential road trips. As Dr. Mariano said, “You can’t treat the president if you are dead.”

In preparing for a medical emergency on domestic and foreign trips, an advance White House team routinely surveys the city and its surroundings, assesses the medical facilities and meets with selected host physicians. “While my Secret Service comrades look out for bullets and bombs,” Dr. Mariano writes, “I look for bugs and bad environmental conditions.”

White House doctors have erred. Air Force One carries antibiotics and other drugs, as well as several pints of blood reserved for the president and first lady. In 1994, when Mr. Clinton was planning a foreign trip, Dr. Mariano wrote, Dr. Bob Ramsey, an Army colonel and a blood specialist in the White House medical unit, gave doctors at the host hospitals the wrong blood type for the president, a potentially fatal medical error, and Dr. Ramsey was fired.

Then there are acts of medical heroism that go unrecognized. At the first President Bush’s final Christmas party before he left office, Dr. Mariano stood near a man who wheezed and grabbed his throat. Recognizing that he was choking, she delivered thrusts to his abdomen in a Heimlich maneuver, forcing him to cough up a piece of shrimp. She never learned the man’s name, and she said he did not thank her.

A trip to Ireland in 1995 was interrupted by a call from a psychiatrist in Washington, warning that his client, a young administration staff member, was threatening to commit suicide at Dublin Castle over a breakup with her boyfriend.

Dr. Mariano called the psychiatrist back, and members of Mr. Clinton’s entourage scoured Dublin. (The woman was not in her hotel room, but her pill bottles were nearly full.) Dr. Mariano writes that she feared a suicide would overshadow Mr. Clinton’s good-will visit and produce all sorts of rumors and conspiracy theories. In the end the woman was found in a bar, and Dr. Mariano sent her back to Washington with a nurse.

To counter any impression that the job is a glamorous one, Dr. Mariano paints a vivid picture of how exhausted she and her colleagues became. The doctor lugs a heavy medical bag. Jet lag is a way of life. Medical staff members avoid sleeping pills. On one trip, her duty lasted 50 straight hours.

If doctors in training are limited to 80-hour workweeks and military medical workers to 18-hour shifts, why should fatigued White House medical staff members be exempt? Dr. Mariano said she imposed “an edict that you don’t travel longer than 24 hours without relief.” Further, on foreign trips, she worked out a rotation schedule to allow the doctor on the flight to go to a hotel to sleep while a member of the advance team took over.

Dr. Mariano was not exempt from the toll of the job. She fell victim to “good doc, bad patient” syndrome, she said, when she delayed seeking care for a neck problem that caused numbness in her arm. And her marriage became a casualty, when her husband became a virtual White House widower. (They divorced, and she has since remarried.)

Dr. Mariano, now 55, has retired from the Navy, and she is in private practice in Scottsdale, Ariz.

What kind of practice? Concierge medicine, of course.

See full article at: http://www.nytimes.com/2010/11/16/health/views/16docs.html?_r=1&pagewanted=all
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