The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Wednesday, March 22, 2006

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.

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Anonymous Anonymous said...

Doesn't the health risk of pregnancy dwarf the risks of the pill, even if you have migraines?

6:48 AM

Anonymous Anonymous said...

One of the neurologists here made the point that 85% of women get pregnant over the course of a year of regular unprotected sex.
Compared to the small risk of having a stroke if you are a migraine sufferer on BC pills it doesn't seem that unreasonable for the girl to decide to take BC pills assuming that she knows the risk.

And also to top it off if you are pregnant (increased risk of blood clots) and a migraine sufferer than your risk of having a stroke is also higher than the average pregnant non-migraine person.

Sorry I don't remember the exact numbers for this though...

10:57 AM

Anonymous Anonymous said...

Not to worry, I'll defend you!

Cousin Kate :)

1:15 PM

Anonymous michelle said...

it's funny how different providers approach things. i am a migraine sufferer (w/the aura and the numbness and all that fun stuff) and my old gyn would not hear of me going on the pill at all. after a few years, i had switched gyns and she said it was no problem. i asked my neurologist what he thought and he seemed to think it wasn't a big problem either (he said the hormones are so low so it didn't pose that much of a higher risk) but i take baby asa everyday to be on the safe side. but i do agree with you that contraindications are there for a reason and we have to be acknowledge that.

8:28 PM

Blogger Nikki said...

I agree with you. It really bugs me when we go around defending our actions because they're "the best thing for the patient," when the truth is that we are choosing that course because it is the least likely to result in legal action.

The "best thing" isn't always the lowest-risk choice.

9:18 PM

Blogger VitaminKMD said...

Dr Couz has seen me through a migraine or two...

For me, the birth control pill made them dramatically worse. A gyne then recommended that I NOT take the pill, and explained my stroking out risk. I'm with you couz, it was my decision to use BCP or not. She was only responsible for counselling me as far as I was concerned.

Perhaps my only proviso is that when the gyne recommended against the pill, she then listed my other birth control options (depo, lower dose estrogen pill, the IUD...)that didn't up my stroke risk so I could have my cake and eat it to.

Heh. 'eat'.

10:56 AM

Anonymous Shamu said...

I think you were 100% right. As long as the patient really and truly understood the risks (and, crucially, the physician was able to *prove* that these were explained to her, in order to cover her ass should it ever be necessary in this litigious world), then the patient should be allowed to make the decision.

Good girl. I'd want you as my doctor.

7:18 PM

Anonymous Shamu said...

And also... "her reasons for going on the pill were frivolous"? What were her reasons? Birth control? Isn't that the point of the pill? Jeebus.

7:20 PM

Blogger mrbunsrocks said...

Interesting. I agree with you couz. If a patient is giving informed consent and are well-versed on potential risks of it.

And besides - reasons being frivolous? Pshaw.

3:56 PM

Anonymous Anonymous said...

I don't think I can agree with you wholly although I understand your point. It would be incredibly difficult for a doctor to prove even on the balance of probabilities that the patient fully understood the risks, and opening yourself up to a malpractice lawsuit just doesn't seem wise.

1:39 PM

Blogger docsubramax said...

we are not GOD.

we are only here to help the patient, as long as he/she knows waht he/she is doing, to achieve the best that is possible in his/her health. the odds are just mathematics.

what are the odds that one will get knocked down by a car while crossing the road? the road transport department always puts up such statistics - but does that want to make you advice your patient not to cross the road again. we just tell them to be careful, right?

10:26 PM

Blogger Mama Mia said...

I think you make an excellent point. Thank you for understanding that people can make informed choices that work for them even if they aren't 'best' for them.

5:40 PM

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