White House doctors: The president's shadow
(CNN) -- Whether the president is overseas, on the campaign trail or aboard Air Force One, a White House doctor is close at hand in case of a minor mishap -- or a catastrophic event.
"The doctor is always within a few feet away, so you essentially shadow the president," says Dr. E. Connie Mariano, a White House physician from 1992 to 2001.
Mariano ran the White House medical unit under President Clinton, overseeing five military doctors, five nurses, five physician assistants, three medics and three administrators.
With an office inside the White House and staff that travels with the president, the medical unit -- much like the Secret Service -- aims to protect the chief executive, whether by guarding his or her day-to-day health or performing emergency surgery.
The unit is also charged with providing comprehensive medical care to members of the president's immediate family, as well as the vice president and his family. Emergency care also is available for the more than 1.5 million visitors, including international dignitaries, who annually come to 1600 Pennsylvania Avenue.
The White House medical office is much like a typical doctor's office, Mariano says, except for the prestigious address. It has private examination rooms, basic medications and a crash cart for emergency resuscitation.
"It's like a mini urgent-care center," Mariano says.
Even the president's plane, Air Force One, has emergency medical equipment, including an operating table and operating room lights that typically are stored in compartments but can be installed in the center of the plane.
There is no standard selection process to become a White House medical staff member, although Dr. Lawrence Mohr -- physician to Ronald Reagan and George H.W. Bush -- told CNN that asking for the job is a good way not to get it.
Presidents have often selected their personal physician. George Washington's doctor while he was in office and afterward was Dr. James Craig, a friend of the family. In the past two decades, all new White House doctors have come from the military.
"The medical unit has evolved through time," Mariano says, but has "become more formalized in the last 15 to 20 years."
The nerve center for White House medical care since President Hoover is an office next to the Map Room and across from the elevator that the president takes to get to the West Wing from his residence upstairs.
"It's beautifully situated because it is right across the elevator, so the president or first family can just walk across," says Mariano.
"We would greet him every day as he got off the elevator," adds Dr. John Hutton, a physician to President Reagan.
Robert Gilbert, a political science professor at Northeastern University in Boston, Massachusetts, said he believes the medical unit's location plays a big role in keeping the president healthy.
"The medical personnel's office is located where the president walks past it on his way to and from the Oval Office," said Gilbert, who has written several books on presidents and illness. "So they see the president. They see if he looks well. They see if he seems tired, or looks tired."
The ripple effect
President Reagan, with the first lady, makes an appearance inside the hospital four days after the attempted assassination.
The pressure on the White House medical unit to keep the president healthy is high in part for political reasons. News of an ailment affecting a president could have ripple effects on world diplomacy, public policy and the economy.
"[Presidents] are constantly in the light of public day. They are constantly being examined," says Jerrold Post, director of the political psychology program at George Washington University. "Every word they say is being scrutinized both by domestic supporters and political adversaries, national and international rivals. So there is never really a letting down."
News of President Eisenhower's heart attack on a Saturday in 1955 caused the Dow Jones index to drop 6.5 percent the following Monday.
President Reagan's uncertain health after the attempt on his life in 1981 prompted steps to prevent a similar reaction. Directors of the New York Stock Exchange shut down trading, and the Treasury Department announced plans to buy back dollars to maintain the stability of U.S. currency overseas.
"The job of the president is immensely difficult because he is under the constant glare of the public spotlight," Post says.
The 25th Amendment
But what happens if a president is mentally or physically unable to perform the job?
After suffering a stroke in 1957, President Eisenhower pushed for a way under the Constitution to transfer power temporarily to the vice president. In 1967, the 25th Amendment was ratified, outlining the succession of power in the White House and authorizing the vice president to assume the duties of the office if the president is incapacitated.
The definition of "incapacitated" is not concrete, though, and decisions to invoke the amendment have been debated by Cabinet members, presidential advisers and the medical staff.
Invoking the amendment could put the White House doctors in a particularly unpleasant situation.
"To whom is the physician responsible?" Post says. "Is he responsible to the suffering human being that he is treating? To the occupant of the role? Or to the American public? And can he simultaneously be responsible to all three?"
When President Bush underwent a colonoscopy in 2002, he temporarily transferred power to Dick Cheney.
Moreover, historians and the media have scrutinized the decisions of presidential doctors and others dealing with sick or recovering presidents.
Some historians, for example, criticize the Reagan administration for not invoking the amendment when Reagan was shot and recuperating from debilitating surgery.
"I think the 25th Amendment should have been invoked," Gilbert says. "There was a period of 10 to 15 hours where Ronald Reagan could not have responded to a crisis. He was out of communication. He was under anesthesia for three hours, then he was in the recovery room."
When President George H.W. Bush succeeded Reagan, he established elaborate -- and classified -- contingency plans covering medical emergencies but never needed them. President Clinton planned to invoke the 25th Amendment if an operation to repair a torn quadriceps tendon had required general anesthesia, but it didn't.
President George W. Bush made history June 29, 2002, when he underwent a routine colonoscopy and invoked the 25th Amendment. The procedure required the commander in chief to be anesthetized for a few hours.
Before the procedure, Bush signed letters to House Speaker Dennis Hastert and Sen. Robert Byrd of West Virginia, transferring presidential authority to Vice President Dick Cheney under the 25th Amendment. Bush resumed power a few hours later.
Asked at the time about the decision to transfer power, Bush said, "I did so because we're at war, and I just want to be super-cautious."
Care and advice from the White House medical unit can influence a president's often-agonizing decision, Mariano says.
These doctors have the power to influence the president's life -- and thus, the nation as a whole.
"This is a patient like no other," she says. "Their decisions affect millions of lives."