White House Physician

JAMA Review’s “The White House Physician”

The White House Physician: A History from Washington to George W. Bush

By Ludwig M. Deppisch
266 pp, $39.95
Jefferson, NC, McFarland & Company Inc, 2007
ISBN-13: 978-0-7864-2976-9

JAMA. 2008;299(18):2214-2216.

Dr Deppisch‘s charming work is a hybrid: on the one hand, it traces the history of medicine in the United States through the lens of the care of presidents; on the other, it examines the presidency as a peculiar medical entity. The book’s major axis is chronological but not rigidly so. In the first 11 chapters, Deppisch treats groups of presidents in terms of the characteristic arrangements of each period for presidential medical care. The final 4 chapters are topical—on the 25th Amendment (procedures to be used when a president becomes incapacitated), on psychiatry, on the deaths and major infirmities of vice presidents, and on the post–White House careers of recent presidential physicians. Interpolated into the biographies of presidential physicians, the problems they dealt with, and the changing institutional character of White House medicine are discussions of the waxing and waning of medical sects in the United States, the rise and transformation of the hospital, the predominance of specialization and academic medicine, and the ambiguous status of modern osteopathic medicine. The book is more than a chronicle of physicians attending presidents from the first George to the most recent; it also addresses important themes of democracy and medical ethics, though not always in a focused fashion.

Most important of these is the contingent character of the institution of presidential medicine, an evolved and evolving composite of personal preferences, customs, and formal policies. Is a president’s health a public issue or a private one? Certainly it is a more public matter than it once was, but the answer must be “a mix.” During the early years, presidents did not have regular physicians. Like other citizens, they entered the medical marketplace, summoning eminent regional or local practitioners as needed. An exception was Andrew Jackson, more in need of a bullet extractor than a suave society physician (though on a trip north he would be bled by the eminent Dr John Charles Warren of Harvard and the Massachusetts General Hospital). It does not appear that treating a president brought unique prestige, though it was an opportunity for a hefty fee (ie, 84 pounds for treatment of George Washington’s abscess in the summer of 1789).

With James Monroe’s administration, the practice of calling on the military for presidential medical care was initiated. Already, and much to the annoyance of the local civilian physicians, Washington-area military medical practitioners had begun supplementing their modest salaries by practicing among the families of the federal establishment. Presidents could avoid fees (with the exception of James Buchanan, whose estate was billed for $1000 by his military physician); as commanders-in-chief of their physicians, they also altered the balance of authority in the patient-physician relationship: “doctor’s orders” could not carry the same weight in such circumstances. Military physicians could (or could be commanded to) travel with presidents. Yet consultations with civilians and with other military physicians were frequent, if sometimes difficult, owing to ambiguity about accountability and other forms of intraprofessional conflict. Not all presidents would follow this pattern: James Garfield, for example, was attended by 2 Ohio homeopaths, one a woman, Dr Susan Edson.

With Captain Presley Rixley, USN, attending physician to both William McKinley and Theodore Roosevelt, a pattern of close friendships between presidents and their physicians became evident. Rixley came to McKinley’s notice as physician to the daughter of the Secretary of the Navy, who accompanied McKinley on an 1898 Spanish-American war inspection trip. That led to Rixley becoming the McKinleys’ family physician (though mainly to provide daily monitoring of the health of the president’s wife, Ida McKinley) and, subsequently, the Roosevelts’. The relationships that developed, notes Deppisch, were those of “pals . . . male buddies who shared stories, sports, and social intimacies” (p 69). That the same person could become a close friend of the staid and domestic McKinley and the ebullient and outdoorsy Teddy may suggest the loneliness of the presidency. The Hippocratic rules of decorum with respect to the families one serves, as well as the physician’s focus on the well-being of the patient, created an atmosphere in which presidents could recognize in their physician that rarest of creatures: someone who wanted nothing and would tell no tales. Yet this role of physician-confidante was still a public charge: “special duty” in the Navy. And, even if unsought, presidential manna did often come. In 1902, while still the president’s physician, Rixley was appointed surgeon general of the Navy and promoted from captain to rear admiral. This pattern of fast friend and fast promotion would persist into the Eisenhower administration. Dr Joel Boone, USN, taught Florence Harding to dance and went to ball games with the Coolidges; Dr Cary Grayson (who had gone from lieutenant to rear admiral) would help the widowed Woodrow Wilson remarry.

Sometimes, overseeing the well-being of the president might mean deceiving the president: Ross McIntyre worried about alerting Franklin Roosevelt to the precariousness of his hypertension in 1944, just as Grayson had kept from Woodrow Wilson full knowledge of his first wife Ellen Wilson’s condition because Wilson’s own health was too fragile to handle any more anxiety. Eisenhower, too, would be kept in the dark about details of his Crohn disease.

In deceiving the president, these physicians were likewise deceiving the public. Increasingly, these presidential friend-physicians would become involved in presenting a carefully orchestrated appearance of healthfulness to a public with exacting expectations for the president’s health. Serving as a presidential physician required a talent for spin-doctoring as well as other sorts of medicine. Occasionally this might mean magnifying the president’s condition, as with the resigned Richard Nixon; much more often it involved projecting an image of perpetual health. Presidents, it seemed, did not experience the aches and pains of ordinary citizens. While always closely attending to their presidents, it was important that presidential physicians not actually be seen in their company: any impression of human fragility must be avoided.

Even as presidents were choosing their own physicians—often through family contacts, and with care of spouses or other family members as their primary concerns—a military-staffed White House Medical Unit was gradually emerging. It evolved with a broadening of presidential medical responsibility. Increasingly, presidents were asking their medical staff not only to see members of their own family, sometimes including cousins, parents, and siblings, but also to treat the vice president and other cabinet members and their families as well as distinguished friends and visitors (thus, Boone treated Madame Curie and Thomas Edison); to serve aboard the presidential yacht, to accompany any of these parties on their travels, and so on. Ultimately, the White House Medical Unit would be charged with the health of the White House staff and also with the medical logistics of presidential travel; wherever the president went, there must be plans and facilities for emergency as well as routine care.

Perhaps the most remarkable form of extension was the offering of the services of the president’s physician as a sort of medical “show the fleet” gesture to foreign leaders overseas. Thus, Truman’s physician, General Wallace Harry Graham, removed an esophageal tumor from King Ibn Saud and performed hand surgery on the president of Peru (p 107). The political symbolism is plain: the gift of attention from the president’s healer is part of a tradition of regal hospitality. It may be used to recognize inclusion in an inner circle, to cement international friendship, or even as a magnanimous political gesture: in 1972, Nixon sent his physician Dr Lukasch to oversee the surgery on George Wallace following an assassination attempt on Wallace, his rival for the Republican nomination.

In odd ways, the symbolism is entangled with substance: it would be naive to assume that the person who happens to be the US president’s physician also happens to be the country’s leading expert on both esophageal and hand surgery and yet not unreasonable to assume that a president should and can command, anywhere at anytime, whatever medical miracles US medicine can offer. At least in certain circumstances, one can imagine that refusal of the offer of the president’s physician might be taken as a minor diplomatic affront. It would appear that the potlatch is 1-sided: a key function of the White House Medical Unit is to ensure that anywhere in the world, the president need not be the subject of a reciprocal gesture but rather, as far as possible, receive care by US physicians.

What about the symbolism of presidential medicine to the people of the United States? Both as an official concern (due in part to Cold War imperatives for instantaneous and competent decision making) and as a cultural matter, the president’s health is no longer simply the private business of physician and patient. The healthy president symbolizes the state of health to which every citizen should aspire; no less than Air Force One, the medical care available to the president exemplifies US technical achievement. But what is being symbolized is puzzling: one might see the president’s care, together with the military medical establishment from which much of it derives, as indicative of the excellence available in a nationalized medical system—if the president goes to Bethesda Naval Hospital, other citizens should too—yet the presidents still use the private medical sector, with George Washington University Hospital recognized as a presidential hospital.

Generally, the need to maintain a close, trusting, and private relationship between president and physician has prevented presidential physicians from directly addressing the question of what relation the medical care available to the president bears or should bear to that available to the rest of the population. Only rarely have presidents used their position as a platform for health politics, that being the responsibility of another official, the surgeon general of the Public Health Service. Yet, with Truman’s blessing, Dr Graham campaigned for national health insurance, while George H. W. Bush’s physician, Dr Burton Lee, was an outspoken critic on issues of high medical costs. Lee, however, appears to have been speaking more as a private citizen. If presidential medicine were truly private, these issues would not matter; to the degree it is public, they do.

This book raises other issues—for example, sooner or later the 25th Amendment will put medicine at the center of crises of constitutional legitimacy. Equally, it seems likely that in this age of rapidly changing possibilities for psychiatric intervention (and of standards of psychiatric health), presidential mental health will become an increasingly prominent and controversial issue.

While Deppisch is not a professional historian of medicine, he makes good use of the standard academic sources. He writes well and clearly; portraits of presidential physicians are a welcome inclusion. My concerns about this book are few and relate particularly to the 19th century. For example, Deppisch implies that presidents generally would have chosen the best-qualified practitioners, yet he underestimates the ambiguousness both of medical training and of quality of care. What the reader sees more clearly are networks within which presidents choose their physicians and how one enters those networks; whether, and how, military physicians jockeyed for an opportunity for presidential medical service is less clear.

Financial Disclosures: None reported.

Christopher Hamlin, PhD, Reviewer
University of Notre Dame
Notre Dame, Indiana

Book and Media Reviews Section Editor: John L. Zeller, MD, PhD, Contributing Editor.

White House Physician