Making the Cut

Yet another family medicine group discussion gone awry.

One of the residents in the group is in the process of opening up his own family medicine practice. He has joined a group of family physicians in a small town just outside of our larger academic centre, one of many towns in our area desperate for family doctors. Good news, right?

He came to the group for suggestions a few weeks back. He had a very definite idea of how his practice should look. He didn't just want 'the rejects from all the other family doctors in town'. In fact, he also didn't want many elderly people. Or many sick people in general. He wanted a practice composed primarily of young families. In order to do this, he intended to provide intrapartum care (so he'd deliver babies) but he wanted to know how he could go about 'screening undesirables' out of his practice.

I was reminded of a recent patient I saw in emerg. He was a middle aged man, well dressed, who presented with the chief complaint 'requesting meds'. That's never a good sign. Either the person is a drug-seeker, or they're using the emergency room inappropriately. The way we usually deal with them is based on how urgent the need is. If the person is asking for narcotics, we pull all their old charts and, if it's during a weekday, we call their family doctor to see if they're legit. They're usually not.

One guy, though, was legit. He had injured his back and shoulders quite badly in a workplace accident several years before, and according to his medical file he had significant joint and nerve damage. And no family doctor.

This is a catch-22 for those of us working in the emerg. On one hand, ER policy has us explain to the person that the emerg is not the place to come to get prescription renewals. At most we should give them a script to cover them until the next business day, then go to their family doctor for ongoing care. If they don't have a family doctor, they are instructed to go to a walk-in clinic. Problem is, several of the walk-in clinics in this town have newly-posted "We Do Not Prescribe Narcotics" signs on their front doors. They're having as much trouble with the drug-seekers as we are.

So this guy was frustrated. Understandably. He had come into the emerg for his meds 6 times in the past month. Sometimes he'd leave with a script, sometimes not. His pain wasn't well controlled. The walk-in clinics refused to prescribe him narcotics. This was actually the second time I had seen him in the past two weeks. The last time I had offered him a three day script for Percocet (which he'd been on ever since his workplace accident) and a printed list of the family doctors in town who were accepting new patients. I asked him if he had called the doctors on the list.

"I called all of them."

I was suspicious. "All of them? There were over 20 doctors on that list."

"Yup," he answered, "Nine of them weren't taking new patients anymore. Two of them were more than a 30 minute walk from a bus line. Three of them I left messages with. Of the 6 I got a hold of, I got interviews with 4 of them. Two of them screened me by phone."

"Screened you?" I asked, knowing what was coming.

"The secretary asked my medical history and what meds I was on. After I got to 'chronic pain' from my accident, the doctor suddenly wasn't taking new patients anymore."

"And the ones you interviewed with?"

"I've had 2 so far. Neither one wanted me as a patient."

Sad, but true. Doctors are at such a premium around these parts that it has become common practice for a doctor accepting new patients to interview them first. In theory, these interviews are intended to help identify any fundamental differences in medical ideology between the family doctor and potential patient. For me, a big red flag would be parents who refuse to vaccinate their children and are unable to provide a valid reason why not. But that's another post.

So here I was, fresh from my experience with the frustrated patient, listening to one of my collegues ask us how he can best filter out these 'undesireable' patients. You can see where this discussion lead. Nowhere good.

My family medicine group now officially thinks I'm an argumentative troublemaker. My collegue's view was that it would benefit the community in which he practices more for him to build a sustainable practice, one that he enjoyed and wouldn't lead to burnout. I thought that was unrealistic-- we're not going to love every patient that walks in the door, but the ones he was excluding from his practice were the ones who needed a family doctor the most.

It might be a cliche, but if you're not part of the solution... you're part of the problem.

Baa-Baa Black Sheep

In my family medicine group, I always seem to have the dissenting voice. And as those of you who are loyal blog-followers know, that voice isn't a quiet one. Recently, one of my co-residents shared a story about a friend of hers in BC who was refused a prescription for the birth control pill. Apparently this physician (not her regular family doctor but a locum while her doctor was on vacation) is Catholic, and prescribing the pill went against his values. She was asking the group if we'd ever heard of this before, and if it was legal.

Well, yes. It's legal. And many of us had heard of it, but more in the case of Plan B (aka the Morning After Pill) than the birth control pill. Quite a few physicans (and pharmacists, for that matter) have been known to refuse to prescribe or dispense the morning after pill under the premise that it aborts a fetus. For those who believe that life begins the moment that sperm meets egg (like that Eliza-bitch on The View... uh, the secret is out. I read celebrity gossip magazines at the gym.) prescribing or dispensing Plan B would be like being accessory to murder. But that's not what I want to talk about.

I know of a woman who was recently faced with a horrible choice. After receiving a high risk result on her maternal serum screen, she was faced with the very real dilemma of whether or not to undergo a second-trimester termination or continue with the pregnancy, knowing that she had a very good chance of giving birth to a baby with a severe developmental delay. She opted to have an amniocentesis, in spite of the 1% risk of miscarriage, to confirm whether or not baby actually had the chromosomal abnormality. Baby was fine. But that's not what I want to talk about either.

When this woman was weighing her options, she learned that a second trimester termination, regardless of the indication for it, wasn't available in her hometown. She doesn't exactly live in a rural area-- her town has a population of over 100k people, but she would have had to travel 3 hours to another centre. The reason that this procedure isn't available is because too many nurses had opted out of it. They found it "wrong". Even in the case of a severely deformed or damaged fetus that would be unlikely to survive more than a few hours after birth, these nurses have decided that it is wrong to abort a fetus after 12 weeks gestation and have been given the option to absent themselves from this aspect of their work. Once a critical number of nurses decided not to assist in this procedure, the hospital eventually was forced to stop offering this service altogether. So now this incredibly difficult and emotionally devastating process has to be done while she stays in a hotel in a strange city, away from her support system.

No one uses second trimester abortions as birth control. They are difficult procedures, both emotionally and physically. And like any termination (in my opinion, anyway) it isn't easy to perform. I've never taken any termination I've attended lightly, even the ones done at 10 weeks where the fetus is barely distinguishable from the other products of conception. But is it really ethical to take the choice away from women simply because nurses don't want to participate?

The other family medicine residents believed that it was perfectly within any health professional's rights to refuse to participate in a treatment or procedure that they find morally objectionable. I was, once again, the outlier. I believe that if our refusal to participate in said treatment compromises a patient's access to it (such as the case of the woman in need of the termination, less so for the woman requesting the birth control pill) that it then becomes immoral to abstain from providing it.

As health care providers, sometimes we have to put our personal feelings and judgements aside for the benefit of our patients. Am I judging the 16-year-old who is pregnant with her second child? Sure I am. But I'll treat her threatened miscarriage the same as the 29-year-old married woman who had been trying to conceive for 5 years. And the alcoholic who cracked his head on the sidewalk outside of the pub? He'll get the same suture job as the child who fell off her bike. Because even if I'm secretly thinking that the person I'm treating is a waste of oxygen, no one will ever know I'm thinking it.

So to these nurses who refuse to participate in second trimester abortions? You became a nurse. You chose obsterics and gynecology. You don't get to pick and choose the parts of your job that you enjoy and refuse to do the ones you don't. If that were the case, I'd spend my time in emerg treating actual illness and not the drug-seekers, the addicts and the drunks. Sure, second trimester abortions aren't pleasent. Neither are the early abortions, for that matter. But for women to have a choice, someone has to do it. And if we as health care providers keep passing the buck on the grounds of moral objection, that freedom of choice is in real danger.

Paternalism in Medicine

Today I had academic day, which is my only chance to sit around and compare notes with other residents. We frequently discuss cases, particularly ones that had a counselling/psychological/touchy-feely component that we were unsure about how to approach.

The case brought to the group today by one of my fellow residents was the story of a 19-year-old who came to see her seeking the birth control pill. Might have been straightforward, but she was also asking for a refill of Imitrex, a migraine medication. The birth control pill raises a woman's risk of blood clots, which will make her more likely to have a stroke. Have a certain kind of migraine (with aura, where you get visual and/or neurologic signs that preceed the headache) also raises the risk of stroke. To be taking both together raises your risk of stroke by more than either one alone.

The bottom line is that the Society of Obstetrics and Gynecologists of Canada says that migraines with aura are an 'absolute contraindication' to prescribing the birth control pill. So the group was saying that she shouldn't have prescribed the pill (she didn't in the end, but her preceptor ended up caving and giving it to her). I was the lone voice of dissention.

Don't get me wrong, I'm not in a big hurry to prescribe drugs with harmful interactions, but I wasn't sure if it was right to outright refuse the girl her prescription. I was of the opinion that if you are able to appreciate the consequences of your actions, you should be able to make the decision for yourself. For example, if I were to explain that the risk of stroke for a 20 year old woman on the birth control pill is 1 in 1000, and the risk of stroke for the same woman if she gets migraines with aura is 2 in 1000, but if you put the two together your risk of stroke goes up to 8 in 1000. (fictional statistics for emphasis)

Well, if that woman decides that the benefits of taking the birth control pill outweigh the 6 in 1000 risk of stroke, who is to say that it isn't her right to say so? The group shot me down-- lawsuits are stressful, it's ABSOLUTELY contraindicated (thanks, I got that the first time), her reasons for going on the pill were frivolous (who are we to judge her reasons?)...

I stood firm. She was an adult. If she understood the risks, I didn't see why we couldn't leave the decision in her hands. All appropriately documented, of course, to cover my ass in the event that she DID stroke out and I end up being sued.

So now my group probably thinks I'm negligent. I'll likely be voted 'most likely to be sued first' at our next dinner party.

This medicine stuff is complicated.