■ Physicians who treat the president are always on call and prepared for the worst. They travel the world and practice medicine in the White House. They train for emergencies with Secret Service agents and ride in a "decoy" limo. They steer clear of the "kill zone" that surrounds the president and carry a stocked medical bag. Chief physicians to U.S. presidents have a unique place in medicine. They head up a team of physicians, nurses and physician assistants, forming the White House Medical Unit. Together, they treat the president, vice president and many others at 1600 Pennsylvania Ave. "When the president is sick, it's not his problem. It's ours," said retired Navy Rear Adm. E. Connie Mariano, MD, an internist and chief physician to President Bill Clinton. MU and is acting as chief physician. American Medical News spoke with former chief physicians. Here are some of their recollections. Tales of a "trench" doctor Sitting across from Dr. Mariano during her job interview was Burton Lee III, MD, President George H.W. Bush's chief physician. Dressed in her Navy uniform, Dr. Mariano didn't know what to make of him. He seemed grumpy and shouted, "Why do you want this job?" she remembered. "What can you do here?" "You see these bars on my sleeve?" she asked. "Well, the longer I'm in the Navy, the more stripes they put on my sleeve and the more they stick me behind a desk. I'm not a desk doctor. I'm a trench doctor." It was the right answer. Dr. Mariano got the job as a White House physician and eventually replaced Dr. Lee as chief physician to the president when Clinton defeated Bush. She was just the second female to hold the position -- Janet Travell, MD, was President John F. Kennedy's chief physician. Dr. Mariano worked in the White House from 1992 to 2001, for Clinton and parts of both Bush administrations. To ensure proper medical care, she instituted a 24-hour coverage mandate for the president and vice president. "I started with the first President Bush in 1992, and when the president was in for the night, everybody would go home. I'd think, 'Wait a minute, what if he falls down the stairs? What if he has chest pain?' " She also hired the first emergency physician. "We needed primary care gatekeeper docs who are very good with acute medicine and practicing in the field," said Dr. Mariano, 53, who now runs her own concierge practice in Scottsdale, Ariz. "So we had myself as an internist, a handful of family practice guys, and at least one was in emergency medicine." Dr. Mariano went along on all of Clinton's foreign trips and vacations, and most of his domestic travel. She saw a lot of golf from a cart and watched Clinton jog as she rode inside a trailing ambulance. "We're pretty invisible," Dr. Mariano said. "You're part of what they call the secure package -- you're along with the Secret Service and military aides. You're part of a handful of people who are close to the president at all times." Sometimes they're reluctant patients, as was first lady Hillary Clinton -- who once wanted Dr. Mariano to wait until a Monday to look at a leg that had swollen on the weekend. The doctor insisted on checking her right away, and it turned out to be a blood clot. "You worry like any doctor, but it's magnified. A lot of times I would call a local internist and say, 'I'm not going to tell you who [my patient] is, but let me run something by you.' You always have to make sure it's the standard of care." The flip side is that presidential physicians experience things others in their profession never see. For instance, Dr. Mariano drew President Clinton's blood for the DNA test that linked him to Monica Lewinsky. "We had a lot of controversy. But basically, your whole life focuses on the president and his family. You're really their family doctor. To this day I still keep in touch with the Clintons. They remain friends." Ground-floor view This wasn't the scenario Dr. Burton Lee had pictured when he became President George H.W. Bush's chief physician in 1989. At the end of a marathon foreign tour, Bush got the flu and threw up while sitting next to Japanese Prime Minister Kiichi Miyazawa at a VIP dinner in Tokyo. The president collapsed with Miyazawa cradling his head and first lady Barbara Bush holding a napkin over his mouth. The room was in shock. "I could see it happening from almost 100 feet away," said Dr. Lee, who had advised Bush not to attend because of the illness. "I could see the color change in his face and get pale and green and gray. I said, 'Uh-oh.' " He tried going around the table, but Bush passed out. With the Secret Service swarming and others blocking him, there was only one path left. "I got down on my hands and knees and started going under the table. I went between people's legs, and damned if I didn't end up right on top of him under the head table." Bush regained consciousness after a vasovagal reaction. He was fine, aside from embarrassment. Dr. Lee couldn't say the same for himself. "I knew I was going to get some sort of crazy thing in four years, but this was above and beyond where I thought I was going to go. I felt terribly sorry, but it worked out. He became better friends with the prime minister of Japan, and they remained friends for a long time." Dr. Lee is a longtime friend of the Bush family, which got him the job. Once at the White House, he quickly learned that being a presidential physician involves more than treating the president. "In that White House medical office, you take care of all the people who go through the White House, which is well over 1,000 a day. Most people don't realize that." Many tourists have a common medical problem. "They'd keep these people standing outside in the sun for three or four hours at a time, so sometimes they'd pass out. When I got there, the medical staff was putting the paddles on them, shocking them. I'd say, 'Look, maybe one out of 1,000 of these people have cardiac arrests. What most of them need is a glass of orange juice and a doughnut.' " Dr. Lee enjoyed his time at the White House. But the frustration of not being able to advise Bush on health care policy -- something he says he had been promised -- still riles him. "Would I do it over again?" asked Dr. Lee, 78, a highly regarded oncologist who gave up a 30-year practice in New York and is now retired in Florida. "I'd have to say that I should not have done it. I gave up much too much. But I did do it, and you can't complain about being in the White House. It's a huge honor, and George Bush ran a very upscale White House." Opportunity of a lifetime Retired Army Gen. John E. Hutton, MD, came to the White House in January 1985 as assistant physician for President Ronald Reagan. He wasn't there for the first term, when Reagan was shot in a 1981 assassination attempt. Dr. Hutton worked as Reagan's senior White House physician from 1987 to 1989. The doctor and Reagan formed a strong bond. Dr. Hutton, 77, was an honorary pallbearer for Reagan's funeral in 2004 and still keeps tabs on 87-year-old Nancy Reagan. As senior physician, he didn't have any emergencies but assisted with some surgical procedures, including removing a cancerous tumor from the president's colon. Reagan kept everyone at ease, even telling a joke to the anesthesiologist. "He could find something humorous in just about any situation," Dr. Hutton said. Reagan was good at making people comfortable, he said. The first time he went to the Reagans' California ranch, the president was in the doctor's cabin. "He smiled, reached up and grabbed my hand. Then I noticed he had a big hole in his dungarees, and there was blood all around it. He was out with his chain saw and he had cut his thigh. If he'd gone another inch, he might have hit a big artery, but it was a glancing blow." Dr. Hutton treated it like a war wound, which he had ample practice treating as chief of surgery at a combat hospital in Vietnam. Before long, Reagan was back to clearing trails for horseback riding. Reagan demonstrated his sense of humor the day Nancy Reagan informed him of the tumor in his colon. "She put her arms around him and said, 'Now, Ronnie, the doctors have found something in there, and it's so big that they can't get it out through the [scope]. So they think we ought to get that taken care of tomorrow morning,' " said Dr. Hutton, a professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, Md. Reagan said, " 'Does this mean the bad news is that I can't eat supper tonight?' That completely put us all at ease. He was just so compliant and considerate. It was a pleasure working for him." BACK TO TOP ADDITIONAL INFORMATION Presidential physicians always thinking ahead Accompanying a president across the globe sounds appealing. But for the president's medical unit, it comes with a hefty challenge -- establishing medical emergency plans at each destination. "Every trip that the president took had a medical contingency plan developed to deal with any emergency that would take place," said Lawrence Mohr, MD, a retired Army internist who served as a White House physician for Presidents Ronald Reagan, George H.W. Bush and Bill Clinton. "This includes coordination with local hospitals, as well as local surgeons, to provide emergency care or critical care." Several weeks before a trip, a nurse or physician's assistant from the unit is dispatched to scout the best places to handle medical emergencies. "My nurses did a lot of the advances," said Burton Lee III, MD, who was Bush's chief physician. "That entailed plotting out where the president is going and what the fastest route to a hospital is. They have to pick a hospital and make sure everybody is on call at that time." Dr. Mohr said each presidential physician should carry a list of top specialists. Retired Army Gen. John E. Hutton, MD, remembers having such a list when he was Reagan's chief physician for the last half of the president's second term. "Down in New Orleans, we had a very fine trauma surgeon whom we'd always line up," Dr. Hutton said. "In fact, he slept in the hospital so that if anything happened he would be Johnny on the spot. We never had any problems, but we were always ready." The constant preparation for disaster was not only a job requirement but a challenge for retired Navy Rear Adm. E. Connie Mariano, MD, Clinton's chief physician. "It's predictably unpredictable. It's a wonderful way to test your medical skills. You really learn a lot of in-the-field medicine. You're pretty much on your own, but it's exciting. It's an amazing way to practice medicine." Presidential medicine has come a long way Samuel Bard, MD, was, in essence, the first U.S. presidential physician. Dr. Bard was considered the top doctor in New York in the late 1780s, when that city was the U.S. capital. When President George Washington was in his first year in office he went to Dr. Bard with an abscess on his thigh. Dr. Bard and his father, also a physician, incised the boil, thus offering the first known medical treatment to a U.S. president. "Samuel Bard was maybe the preeminent physician in New York, even though he wasn't active in support of the revolution," said Ludwig M. Deppisch, MD, a pathologist, historian and author of The White House Physician: A History from Washington to George W. Bush. "But he was the best, and George Washington took the best." Over the years, the position of presidential physician has evolved from a side job for top civilian doctors to an appointed position in the president's official delegation. President Andrew Johnson, in 1865, broke the chain of using civilian doctors and started the tradition of choosing presidential physicians from the military. "Military physicians were available, you didn't have to pay them and the president could boss them around," Dr. Deppisch said. "So that became the norm." There have been exceptions. Presidents Ronald Reagan and George H.W. Bush both appointed civilians to run the White House Medical Unit and serve as their chief physicians, while military doctors assisted. But the job of top doctor shifted back to military physicians under President Bill Clinton and President George W. Bush. The WHMU was officially created in 1945 and is staffed by six physicians -- usually two each from the Army, Navy and Air Force. There is also a team of nurses and physician assistants. Through the decades, the practice of caring for the president and vice president has evolved into the year-round, 24-hour preventive care approach that it follows today. Three events changed the way physicians attend to presidents, said retired Navy Rear Adm. E. Connie Mariano, MD, Clinton's chief physician for both terms: the assassination of President John F. Kennedy, the attempted assassination of Reagan and the election of Clinton. "It wasn't until Kennedy's assassination when they realized, 'Oh, we need to work closely with [the] Secret Service,' " Dr. Mariano said. The Reagan assassination attempt highlighted the need to identify the best trauma center for a Washington, D.C., emergency. "When [Clinton] became president, we went from an older president, who pretty much followed a schedule, to a younger, unpredictable guy who traveled everywhere," Dr. Mariano said. "So we said, 'We need 24-hour coverage and we need to do more emergency medicine.' " That wasn't the standard of care for President James Garfield, who was shot in 1881, six months into his first term. Garfield died 81 days later. "That was before antisepsis and before x-rays, so nobody knew the track of the bullet," Dr. Deppisch said. "[His doctors] all stuck their unwashed, dirty fingers into the wound multiple times. He got an infection and probably died of sepsis. [The assassin's] initial defense was, 'I may have shot the president, but it was his physicians who killed him.' " Source
