Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, May 10, 2007

Help: Ethical Dilemma in Real Time

A lady walked into my office yesterday (established patient, though not seen since 2003) with the following question for my staff: her gynecologist had prescribed a course of treatment involving daily injections for a period of time. She didn't want to travel the longer distance to his office just for a daily injection and she didn't want to do it herself. Would I be willing to provide her with this service?

My staff immediately assumed she was undergoing fertility treatments, so they were certain (and correct) that I'd be fine with it. However what she pulled out was a sheaf of papers describing daily injections of HCG for 40 days (except when having her period) for weight loss.

At this point I came to the front desk and started looking over her materials. (It was a good thing I did, because one look at this tall slender lady who wanted to lose weight made my staff want to slap her silly.) I asked her a few questions: the prescribing doctor was her regular gynecologist, not a "weight loss specialist" or someone I could mentally label an "altie doc." There was a long document in tiny font that appeared to be some kind of release, probably from the third party company that was supplying the drug for injection.

I've seen some of the gynecologists in my area doing stuff like this recently; tapping the vast market for weight loss services by purchasing products (usually vitamins and/or "nutraceuticals") and services from third-party companies and then re-selling them to their patients, sometimes along with office visit charges for their services. The first time I saw this I actually called the guy up. I'd known him for a long time and was wondering why he'd gotten into this. All I got was a kind of half-assed, "I dunno; it sounded good, it offers the patients a computerized analysis of their needs based on their personalized profile [right; anything using a computer has to be good]; it doesn't seem to be doing any harm, and the patients like it." I was unimpressed (and lowered my opinion of him slightly) but as long as they keep it in their own offices I don't have much say in the matter. But this is different: a patient is asking me to participate in what I believe is fraud by requesting that I give her injections of a medicaly-unindicated substance.

What do I do? She's standing right there. Yes or no?

Here's what I said: Make an appointment to come back and I will teach you how to do it yourself. She agreed and is coming in tomorrow. Afterwards I realized that there is no difference ethically between giving her the injections and teaching her to do them herself, but it gave me time to think and decide what to do when I see her.

Of course I will begin by calculating her BMI (no way it's over 30; possibly as high as 26, but this lady is NOT overweight) and finding out why she wants (or thinks she needs) to lose weight. I can then (try to) address the body image issues, possibly the mood or relationship issues that are the real problem; at least move away from injections of pregnancy hormone. (That's what HCG is, for all you non-medical readers.) Despite my admittedly formidable powers of persuasion, I don't think I'm going to get very far.

I will then try to explain that the treatment is unproven, not recommended by any competent authorizing body, has no plausible scientific mechanism of action, and like any such therapy has the potential for unforeseen harm. At this point she might ask, "Then why did my doctor prescribe it?"

Now there's a can of worms. "Don't badmouth other doctors" is an important rule in private practice for a variety of excellent reasons. Other docs may know more than I do; patients give different histories to different docs resulting in different treatment recommendations; you don't want them badmouthing you when patients give you different histories, and when you know more than other docs. I can't come out and say, "He's trying to tap into the vast market of desperation and gullibility that typifies women's culturally-induced desire to attain an unreasonable body weight." But I can tap dance around "I don't know" til the cows come home. I may convince her, but I don't think I will.

The most likely outcome of this discussion is that she says, "Thanks for your concern, but I trust my gynecologist ["more than you" is the implication] and I still want the shots." What do I do?

Some other things to factor in:
  1. Money is not an issue. I can charge her for a level 1 (probably even level 2) visit out of pocket every day and she'd likely pay it gladly. I happen to know she is very well-off.
  2. Assume litigation potential is not an issue. Of course "you never know" but I know the patient, and I have assessed the risk as negligible.
Here are the options as I see them:
  1. Refuse to give her the injections, telling her I've thought about it and can't do it in good conscience. Upside: I'm doing the right thing ethically. Downside (potential): she gets pissed and badmouthes me to friends and neighbors. (Patients aren't bound by the "don't badmouth other docs" rule.) Downside (likely): She'll find another way to get the injections, and so will still incur the "harm."
  2. Agree to give them to her, then reiterate to her at each visit the points that she doesn't need to lose weight, the treatment is unproven, etc. Upside: I may eventually convince her and she'll stop, thus lessening the "harm." Downside: She may eventually get annoyed/pissed enough to stop coming, but will probably find a way to get them somewhere else and may still badmouth me.
  3. Teach her to self-inject. Upside (marginal): I am not involved on a daily basis. Also: the patient is pleased with my service. Downside: ethically it's equivalent to giving her the injections without the continued discussions.
All input appreciated.

Her appointment is tomorrow.


At Thu May 10, 08:18:00 AM, Blogger A Kipp said...

I'm just a lowly medical student, and so haven't had any personal experience with these kind of difficulties, but I have a pretty good philosophy background. Just looking at the ethics, I'd say you're pretty well obligated to go for option #1.

Bottom line is that you shouldn't be a part of something you don't believe in. People are going to do stupid things to themselves, but you're not obligated to help them with that. All you can do is explain your reasons and beliefs, and leave the decision in their hands.

As for the possibility of bad-mouthing you to other people, I think the possible damage is pretty minimal. You are uncomfortable doing something that you believe is medically ill-advised, which means you're smart and willing to stand by your beliefs. If she tried badmouthing you to friends and family, and she ends up explaining the story, I think she'll look a lot more foolish than you.

At Thu May 10, 09:51:00 AM, Blogger DDx:dx said...

Pretty common problem actually, from my recollection. Runs all the way from this(extreme case) to, "Will you phone in antibiotics for my kid with a runny nose? Your PARTNER, Dr. Smith will for me all the time!"
The medical student's comment that the bad mouthing won't hurt is niavete reflecting the thought that this guild provides a service, it's not just a popularity contest.(Like the gyn has decided). It does come down to being principled. This lady has decided what she wants. If you don't think it's "healthy" you shouldn't get on board. That was the compass I tried to use, health. Didn't always work, I admit

At Thu May 10, 10:20:00 AM, Anonymous Anonymous said...

This may sound way out in left field, but these are the same sorts of questions that I've heard others ask at the pharmacy when we sell clean needles to addicts. ("Why are we facilitating their habit?")

The answer is because it's the lesser of two evils. By providing inexpensive, clean needles, we are (hopefully) slowing the spread of nasties like HIV. Because let's face it, they're going to get their fix with or without a clean needle. The lesser of two evils is to make clean needles available affordably.

Bearing this in mind, if you see her every day, you may be able to make a dent in her self-image problems. Your powers of persuasion are indeed formidable; you've got a strong personality that bends everything around it. Bring your gifts to bear as much as you can during this time. The other upside is that you know the injection is being done safely and in a controlled environment. If you achieve any degree of success in helping her (injections notwithstanding) then you will have done more good than taking the easy and potentially professionally damaging, short-sighted route of refusing them.

She'll still get them regardless, why not some informal counseling while it's being done?

At Thu May 10, 10:23:00 AM, Anonymous Anonymous said...

Oh and by "short-sighted" I mean that while your moral objections may be quieted, you won't have helped this woman in the slightest.

At Thu May 10, 10:28:00 AM, Anonymous Anonymous said...

The answer to the question, "Why did my doctor prescribe it?" is easy. "You will have to ask him why he prescribed it. I can't speak for someone else. And while you are at it, ask him to provide you with scientific evidence from refereed medical journals that supports the use of HCG in weight loss."

You can't really let worries about what the patient might think or say about you, because you acted ethically, goad you into doing something unethical. While it sounds possible that she may "bad mouth" you, it is also possible that if you take a principled stand, she may reconsider an unproven therapy with unknown dangers.

At Thu May 10, 11:00:00 AM, Blogger Detail Muse said...

Isn’t this a personal integrity issue? -- a desire to help mixed with a need to please. The Dino I see in this blog is outraged by fraud. Yet he’s considering participating “ what I believe is fraud”?

A difficulty in saying No is wonderful territory for private exploration. Forget the temporary distraction of whether the patient’s BMI is 25 or 27.

Where’s the patient’s responsibility in this? She apparently doesn’t want to do the lifestyle work (diet, exercise, counseling) to lose weight ... and doesn’t want to drive to the gynecologist to get the supposed quick-fix shots ... and doesn’t want to give the injections herself. Um, even if you weren’t uncomfortable with the therapy, why are you taking on all her work? How will she become a motivated partner in her therapy?

If she isn’t a litigation risk, why do you suspect she’s a bad-mouthing risk? You mention it several times, so why encourage a further doctor-patient relationship with her at all, especially with this therapy? You'll be leaking your doubts and negative energy all over the place every time you see her. (BTW, the people she talks to will know her and will know how to evaluate what she says; those who know you will do the same.)

A gynecologist who administers unproven alternative therapies is an “altie doc.” If it looks like a duck... But though we suspect (project?), we don’t know what the gynecologist’s motivations are.

Imagine choosing each of your options (1, 2, 3): how do you feel? look at yourself in the mirror. Look at your office staff in the mirror. I feel anxious with #2 and 3, relief with #1. If you choose #2 or 3, get ready for tomorrow’s appointment.

If you choose #1, telephone the patient today and save yourselves from a frustrating (i.e. wasted time) appointment tomorrow. Perhaps tell her you feel uncomfortable getting in the middle of another doctor’s relationship with a patient, and suggest she see her gynecologist to learn how to inject. The End. (I’ve considered her potential arguments to this and none of them sway me, they actually reaffirm.) Any questions from the patient about the HCG or the gynecologist’s practices are simply and non-judgmentally referred: “You’ll need to ask Dr. X.” If you must, you could admit that you don’t use/aren’t familiar with that therapy, especially in someone of her normal weight, and so aren’t of much help in her context. Overall, less talk is probably best.

The truth, no tap dancing.

At Thu May 10, 11:09:00 AM, Anonymous Anonymous said...

I think you ought to avoid it. Once you get started on something like this, word may get out and you will have other patients wanting the same thing. Your willingness to help can be misinterpreted as tacit agreement with therapy.

At Thu May 10, 12:20:00 PM, Blogger JBean said...

Greetings from Healthcare Chaplaincy Land!
I really admire your values and conviction. I agree with your bottom line - no injections and no teaching for this purpose.
What I would offer is a new mode of communication - deriving much of its inspiration from Marshall Rosenberg's "Non-Violent Communication." Docs and healthcare personnel are trained in approaches that supposedly protect us from liability. My experience has been that more personalized, non-judgmental, real-human-being interactions lay the best clinical foundations. They also serve as our best insurance against bad-mouthing of any kind.

In this vein, I would follow your own gut instinct - beginning by asking gentle (open-ended, non-didactic) questions about the pt's why's. Help her to articulate the deeper motivations behind the request and then offer appropriate outside referrals and resources.

I would veer away from medicalized prescriptive tone, any judgment of pt. or any questioning of GYN.

Here's what I would say next, approximately:

"Sarah, or Gertrude, or Whoever, I'm glad that you brought this dilemma here. I've thought about you and your request a lot these last 24 hours. I really appreciate our work together over the past X years and look forward to many more. (Personalize, add positive detail here....)
I wish I could honor your request. I'd love to make you happy and offer you the convenience. But I can't. I can imagine this might be frustrating news, and I'm sorry to disappoint you. Would you like to know why I have to say "no"?
(Assuming she says yes)
The treatment proposed hasn't been medically substantiated, and we don't know the risks of this particular use and method of administration. But, Sarah, more importantly, more relevant to you and me, I haven't seen evidence of a clinical problem to be solved. When I create a treatment plan for a patient, I first assess a medical need or problem, then develop goals for healing, then prescribe appropriate treatments. In your case, I can't see or document a medical need. Your weight falls squarely within the healthy range for a woman of your age. Am I missing something here?
I can imagine this might be frustrating. (Pause) I do support your goals of fitness and well-being. It's just that what I'm hearing and seeing from you doesn't jibe in my own conscience with the proposed intervention. How does it feel to hear all this?
I'm sorry to disappoint you, Sarah. I want you to know that I'll be here for you now and in the future with medical issues that arise. And I understand if you're frustrated by this response. Is there any other way I might be able to support you?"
Good luck, My Dear!!

At Thu May 10, 12:57:00 PM, Blogger Pseudo_Doctor said...

no real imput here considering I'm a lowly medical student as well but I would go with since you feel there is something up about this situation I wouldnt give her the injections. Interesting topic though glad you brough it to the forefront...

At Thu May 10, 01:30:00 PM, Blogger Dreaming again said...

Ok, I'm chiming in from a patient perspective her.

A patient with an eating disorder that is not so under control right now.

If she is not overweight ... then why is she wanting what is a rather drastic approach? There is some disordered thinking at best. If not an actual disorder.

She may not be anorexic, but she may have ED-NOS or bulimia. She may be a former anorexic trying desperately to get back to the anorexic state. She may just be trying to get to the anorexic state.

It is said, with in eating disorder circles, by those of us suffering from eating disorders, that we have the 'acceptable' addiction.

While doctors, pastors, therapists, and family would never consciencly ever say 'it's acceptable to have an eating disorder'
There IS the mindset of "at least it's not a drug addiction"
"at least it's not alcoholism"
"at least their not driving drunk"

Dr. Dino, if this woman has a form of an Eating disorder of any kind, and you give her the shots, or participate teaching her how ... you are essentially handing a bottle of alcohol to an alchololic and hoping for the best. "But it's in a medical situation"

Nuh huh.

Eating Disorders are an incredibly difficult battle to fight. Part of the battle is that it's sooo easy to fool our medical teams. Part of it is that the severity of the disorders are never fully taken seriously until an IV and stomach tube are needed, or till someone dies. Part of the severity is that we still have to deal with the problem of our addictive issue while we recover (food).

Don't participate, educate her, offer her a referral to an eating disorder therapist ... If she's really that determined, then she'll have to make the drive to the gynocologist.

You never know Dr. Dino, She may be assuming you won't, and is hoping you'll intervene and give her help. THAT is the mindset of many eating disordered women, especially over 25 who don't know how to say "help"

At Thu May 10, 03:41:00 PM, Anonymous Anonymous said...

You told her you'd teach her, so if you don't plan to do that, you should indeed call and cancel the appointment. You've already charged her that extra $20 for phoning, right? so take 30 seconds to explain that you don't think the shots are appropriate.

Jbean's script, well, worried me. S/he has places in there marked "LISTEN!!" but then gives a scripted response, suggesting that the response doesn't really have anything to do with what the patient says. It's just a script. It's fake listening.

At Thu May 10, 03:42:00 PM, Blogger Midwife with a Knife said...

I agree. Talk with her about it, don't do the injections. And because I don't know that gynecologist, I can badmouth him/her! The only reason HCG makes people loose weight is because it makes them a touch nauseated. It causes morning sickness. For a gynecologist to administer it for weightloss is a bit like you prescribing ipecac. It's quackery! Also, nobody knows what the long term effect of sustained daily hcg injections are. Even in the fertility world, it's usually used once/cycle to trigger ovulation.

At Thu May 10, 03:59:00 PM, Anonymous Anonymous said...

I am studying to take my Step 3 soon, and I have never been in your position, but ethically I am certain you should not give a patient a treatment she doesn't need, even if she asks for it.

And, the second you accepted to teach her how to make those injections, you established a doctor-patient relationship and you might be liable if, God forbid, she dies from her eating disorder and her family sues. And you might not have a leg to stand on. Very improbable things always happen to very nice doctors.

At Thu May 10, 07:40:00 PM, Anonymous Anonymous said...

Another patient perspective here....

Here's the important question: why is a woman of perfectly normal weight willing to undergo a very drastic, unproven, expensive course of therapy for weight loss?

Something's wrong.

Let's pretend for a moment that the whole issue of the gyn and the HCG injections never came up. That she came to you and told you that she feels that she's overweight, and asked about treatments/diets that you felt were extreme.

Of course, you'd sit right down and start asking questions until you came to her reasons for feeling like she needs to lose so much weight. Because she's your patient, and it's your ethical responsibility to counsel her when she's made you aware of a health problem.

Now let's go back to the real scenario. Is it any different, really? You're her doctor and she's made you aware of a problem. IMO, the ethical responsibility is the same, and you're still duty bound to find out what's behind the desire to lose weight.

Keep the appointment; talk to her about her weight. See if you can resolve that problem. Maybe that will, in a roundabout way, talk her out of getting the injections.

If it doesn't, well, then you need to trust your own good and strong ethical instincts. This is snake-oil medicine, and you'll hate yourself if you participate. You know you will.

If she badmouths you...well, is it so terrible to be badmouthed for doing the right thing? I can't imagine it would cost you any patients, or potential patients. Anyone with an ounce of sense who heard this story would agree with your decision.

At Thu May 10, 08:33:00 PM, Blogger Just A Midwife said...

I feel certain that dinosaur will choose either option 1 or 3, and it comes down to this, as the overall outcome to the patient will undoubtedly be the same (i.e., she will end up getting the injections).

Which course will better allow dinosaur to sleep at night?

At Thu May 10, 08:39:00 PM, Blogger Lynn Price said...

You know, Dino, I'm hearing that your conscience is going to haunt you for doing this. You're a terrific person, and this is not a terrific thing she wants you to do. Using unproven meds to lose weight is a frightening proposition, and I’m guessing that you don’t want to be a party to it.

"Downside (potential): she gets pissed and badmouthes me to friends and neighbors."

(scoffing loudly) What can she possibly say that won't make her sound like an idiot?

At Thu May 10, 09:18:00 PM, Blogger Dr. Smak said...

You may be surprised by her reaction, Dr. Dino. It may be that she has a borderline eating disorder and was looking to Dr. Gyne for reassurance that weight loss medications weren't necessary for her. (I'd hate to even consider the possibility that Dr. Gyne suggested it without provocation.)

Or she may thank you for your honesty, given that your clear primary goal is to follow accepted medical practice with her health in mind. It may be that if you present the information in a skilled manner that she will reconsider.

(Or perhaps you know her well enough that these aren't realistic possibilities.)

At Thu May 10, 10:40:00 PM, Anonymous Anonymous said...

Dino, this is a no brainer. #1 is the only option unless you want to take a step down the slippery slope of quackery for profit. You can't practice with the fear of losing a patient and being badmouthed for doing the right thing. One of these gynecologists will end up with a subpoena and their name in the paper. You don't want to join in that kind of fun. If you can't make in practice by doing the right thing, find somewhere else to practice. You will sleep better at night.

At Fri May 11, 09:01:00 AM, Anonymous Anonymous said...

I'm a "really old" PA. I worked with a doc in 1973 in California who tried this. Unfortunately, the biomarkers for blood products in those days were not optimal; some of the stuff was contaminated, and you know the things that were incubating during that decade. So "harmless" is not necessarily so in retrospect.

At Fri May 11, 10:43:00 AM, Anonymous Anonymous said...

Perhaps you have assigned the risk of litigation by her as low.

What happens if she dies or is incapacitated in some manner and her family members are making this decision? Even if she dies in a car accident, you could face the (remote) possibility that they litigate that the meds caused her to be less alert or somesuch.

Ethically, I don't know. It seems to me that you already know that Option 1 is the only option for you. I would hope my family doctor cares enough to give me this wake up call (of course, I'm the odd patient that prefers my family doc to do my gyn care too).

At Fri May 11, 01:02:00 PM, Anonymous Anonymous said...

The appointment is a chance to counsel her about her weight and its management. I think you should definitely do that.

I don't see that teaching her to self-inject is ethically the same as doing the injections yourself. She has the prescription from somebody else (who may really BELIEVE this is a good treatment)and she has the choice whether to continue or not. I think she is coming to you for a reason; I totally believe that she could learn to self-inject from the internet if she really wants to. I think she wants to talk it over with you.

I think the injections are not a good idea, and that this is the seed you should plant.

At Fri May 11, 04:13:00 PM, Anonymous Anonymous said...

I hope to hear that you stuck to your conscience. Patient autonomy has gotten overemphasized in our consumer oriented society. But our duty is to give patients what they need to the best of our ability. (NOt what they want.) To me, this means I don't participate in treatments I don't understand or endorse. It also means I'm less popular than some of the easy-going characters around here.

If she is upset about the bait and switch, you can apologize: "I was wrong" and offer to waive fee for today's visit since she came under an expectation. Today's visit might be your opportunity to really speak to her; I hope so, but maybe not. I don't however believe you can do good by doing wrong.

At Fri May 11, 04:22:00 PM, Anonymous Anonymous said...

P. S.
I must qualify my statement about being less popular. I am not as much of a well-connected hail-well-met as some of my colleagues. But I do have a reputation for integrity and kindness that I would not trade. "A good name is better than riches, and esteem is better than silver and gold."

If you are worried about your patient bad-mouthing you, consider the damage to your reputation if she goes around gushing to her friends about dear Dr. Dino who is helping her get hCG injections for weight loss.

At Fri May 11, 04:32:00 PM, Blogger Sara said...

I think that if you are honest, and nonjudgmental, she won't badmouth you if you refuse, and also it may sort of sour what she thinks of as an easy fix. I mean, what bad can she really say, if you say you just don't agree, for her own good? Especially if you leave her space to talk and open up and respond and be heard.


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