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, June 28, 2007

This Just About Says It All

Best post *ever* on the subject of "doctors' rights to freedom of religion" here.

(Go read it, then come back.)

Your doctor does indeed own you, but only if he (or she) is too infantile to understand that medical care involves another person -- the patient -- whose comfort and right to appropriate medical care does indeed supersede the right to "freedom of religion."

If you know that your religious views preclude you from providing appropriate, legal medical care to all patients (including women of reproductive age) then GET THE HELL OUT OF MEDICINE! You have no business passing yourself off as an American physician.

If you don't like the law of the land (ie legal abortion) go move someplace where your views are enshrined in law. But please, quit inflicting your views on unsuspecting patients under the guise of "freedom of religion."

Now if you want to post your views in your waiting room, on your website and in health plan physician listings, be my guest. Just make sure all patients know about them before they see you. And for chrissakes DO NOT go into Emergency Medicine.

Edit: Yo, TBTAM (The Blog That Ate Manhattan): as soon as you post this on your own blog, I'll delete it from here. But this comment of yours on The Well-Timed Period deserves wider viewing:

Here's what we do (taking a lesson from the anti-choice playbook) :
  1. Start a website that catalogues practices that don't provide birth control. Make it public, searchable and up to date.
  2. Picket the offices of docs who don't provide BC.
  3. "Rescue" women going into that office and refer them to docs who will provide comprehensive care.
  4. Take out advertisements locally that inform women which docs won't provide them BC. This is not illegal or libelous - it is simply fact
I figure this will have a financial impact on these practices, as well it should.

36 Comments:

At Thu Jun 28, 06:29:00 PM, Blogger Lynn Price said...

What a fekking eye opener. Dino, may I bug you at some later date about this? This plays very nicely into Book 3.

 
At Thu Jun 28, 07:22:00 PM, Blogger #1 Dinosaur said...

Lynn: Sure, but do check out The Well-Timed Period. So-so name but a truly awesome blog. I often send patients there when I don't feel I have time to adequately explain the benefits of continuous contraception. She's also spot-on with her analyses of the various political interferences with women's health care.

 
At Thu Jun 28, 09:10:00 PM, Blogger Lynn Price said...

I did check it out, and you're right - great blog. I was centering more on the idea of this notion of a doc not treating a patient due to their religious convictions.

 
At Thu Jun 28, 10:38:00 PM, Blogger MedStudentGod (MSG) said...

Damn straight!

 
At Fri Jun 29, 03:55:00 PM, Anonymous Anonymous said...

Keep on keeping on.

Mike

 
At Fri Jun 29, 06:06:00 PM, Blogger ema said...

Sure, but do check out The Well-Timed Period. So-so name...

Hey, don't make fun of the name. Not that it isn't lame [a constant reminder that I knew nothing about blogging when I started], but I like to pretend I'm the only one who notices that :-).

As to TBTAM's suggestions, I like #1 and #4. However, I'm not so sure about #2 and #3. Not comfortable with inconveniencing a patient on her way to a doctor's appointment, even if it's for a good cause. The parking lot is not the place to discuss medical matters.

Maybe if we could refine #2 and #3 a bit, it could work.

 
At Fri Jun 29, 06:33:00 PM, Blogger #1 Dinosaur said...

Ema, sweetie: never meant to dis you. It's your blog; call it what you like. A blog by any other name would be just as kick-ass.

And please; I'm pretty sure TBTAM's list was pretty much tongue in cheek, getting in a dig at the anti-choice folks' tactics by turning the tables on them. I don't think anyone was seriously talking about implementing any of them. (Who has the time?)

 
At Fri Jun 29, 06:43:00 PM, Anonymous Anonymous said...

Dinosaur, do you think that these people choose their specialties specifically so they can impose their religious beliefs on people? I would think that if you're opposed to birth control, then you wouldn't choose OB/Gyn because you know you'd be asked to prescribe it all the time...unless you specifically relished the opportunity to share your opposition of it with patients. Likewise, someone choosing Emergency Medicine surely knows that he or she will have patients who have been raped and want emergency contraception.

If you do think these people go into the specialty because of the chance to exercise their objections, then why aren't the residency programs doing a better job screening those people out?

Or do you think that many of these physicians would like to do things but can't because of the hospitals' rules? Are there Emergency Medicine physicians that have no problem with EC but can't dispense it because they work in a Catholic hospital, and they couldn't find a job at another hospital in the area, or that all the hospitals in the area are Catholic?

 
At Fri Jun 29, 08:20:00 PM, Anonymous difficultpt said...

Catholic hospitals will dispense emergency contraception; if they don't, it has nothing to do with the Catholic Church. The Catholic Church has no problem with EC in the case of rape . . . I don't have the reference handy, but I researched this in detail a few months ago and found the official statements from the Pope. Of course, individuals may choose another interpretation, but it isn't the Catholic Church, it is their own view.

 
At Fri Jun 29, 09:57:00 PM, Blogger ema said...

No problem sweetie. As to TBTAM's suggestions, tongue in cheek or not, you have to admit that the web idea would be most useful for patients. [I know, I know, if only there were more hours in the day.]

 
At Sat Jun 30, 10:20:00 AM, Blogger Dr. Smak said...

Last I heard, Catholic-based medical schools and training hospitals (ie Georgetown) do NOT instruct their medical students and residents in hormonal birth control. The student I spoke to said some of the instructors try to fit it into other lectures where able, but it is not allowed to be part of the curriculum.

There's a good plan. Is it possible to stick your head further in the hole in the ground all the while screaming "nah nah nah we can't hear you"?

Whether or not you prescribe OCPs, it is IMPOSSIBLE to practice medicine and not run across women on them.

 
At Mon Jul 02, 02:45:00 AM, Blogger Judy said...

There are, believe it or not, women who are looking for OB/Gyn physicians who do not prescribe hormonal (or other contraceptive methods than natural family planning). They would welcome a web site with listings of such physicians as much as women who would like to avoid those doctors.

There is one web site where physicians are invited to self-identify as NFP only practitioners. It is called One More Soul and the web site is http://www.omsoul.com/

Very few of the physicians listed are OB/Gyns.

 
At Mon Jul 02, 08:54:00 AM, Anonymous Anonymous said...

Hey Doc -

As one of your new readers, and as a pharmacist, just curious as to your stance on RPh's who refuse to dispense EC on basis of religious beliefs.

-MB

 
At Mon Jul 02, 02:05:00 PM, Blogger #1 Dinosaur said...

MB: "Get another job." The pharmacist has the right of religious freedom, but so do women. If the pharmacist has a problem with EC, they should limit themselves to employment that doesn't require dispensing it (clinical pharmacist in a hospital, eg.)

Should an observant Jew working in a restaurant have the right to refuse serving pork or shellfish products? Of course not. They can go work in a kosher establishment if they feel that strongly about it.

 
At Mon Jul 02, 02:13:00 PM, Blogger scalpel said...

I don't personally have any problem prescribing BCP or Plan B; I have never ever refused such a request. But I also firmly believe that a physician should have the right to prescribe medications (or not) as he/she wishes. And I think that those of you who encourage the picketing of these physicians are being ridiculous.

Will you next picket those docs who don't prescribe antibiotics for otitis media (or those who do)? How about picketing those docs who don't refer to chiropractors or homeopaths (or those who do)? How about those who use nylon sutures instead of prolene? Those who use 0.9 NS instead of 0.45?

How about you take care of your own patients, and we'll take care of ours? Hmmm?

 
At Mon Jul 02, 03:05:00 PM, Blogger #1 Dinosaur said...

For heaven's sake, Scalpel; don't you recognize sarcasm when you see it? That remark about picketing was meant purely to satirize abortion clinic protests.

As for your contention that "...a physician should have the right to prescribe medications (or not) as he/she wishes..." I have no problem with any clinical rationale you want to offer. It's when you start injecting religious or emotional grounds that I have a problem. No one should prescribe (or fail to) based purely on their "wishes."

 
At Mon Jul 02, 03:10:00 PM, Anonymous MB said...

Fair enough...but you're oversimplifying. The problem is two competing/conflicting ethics - the health care provider's and the patient's. As a health care provider (HCP), you'll always have to do stuff you don't *want* to (diabetic feet!). But what about stuff you're morally opposed to, that you believe is murder (I realize that's very questionable, but tell that to someone who honestly believes it). For example, what if you were randomly selected from all the state's AMA members to perform a lethal objection? Or you HAD to do 1 abortion/year? How do you justify refusing to do an abortion yet encourage all HCPs to do something that a few of them view as equally horrendous as abortion? Who's to say whose morals/ethics are most important?

Granted, it's different with pharmacists - for example, a place with the luxury of 2 pharmacists on at a time will usually have 1 or the other that's willing to fill plan B. Minimal, if any, disruption to patient care. But in a small town with only 1 pharmacy, it can be the difference between getting the drug and not.

Anyways, I'm just playing devil's advocate here. I would certainly have no problem filling EC scripts. My $0.02 is that any pharmacist who refuses to fill them MUST find another pharmacy/pharmacist to do so within a few mile radius and within a few hours' time. I know of at least 1 state's board who has passed a law requiring pharmacists to fill all EC scripts - is that too much??

 
At Mon Jul 02, 03:30:00 PM, Blogger scalpel said...

As an emergency physician, I can say with absolute confidence that an unintended pregnancy in all but the rarest of circumstances is not an "emergency medical condition."

So I believe that emergency physicians are not obligated to provide emergency contraception or birth control at all. Again, I personally have never refused such a request, and I can't imagine a circumstance in which I would ever refuse, but I would defend a physician who chose otherwise on those grounds, no matter what their reasoning was. The same philosophy would apply to primary care physicians.

If someone is not satisfied with the care of their physician, then they are welcome to find another. I oppose any effort to force physicians or pharmacists to act in a manner which goes against their personal code of ethics.

I personally don't agree with taxpayer-funded sex-change operations or the overuse of medically-unnecessary hormone replacements in homosexuals. Picket me!

 
At Mon Jul 02, 04:09:00 PM, Blogger #1 Dinosaur said...

Scalpel: You don't believe that provision of EC is part of the standard of care for rape?

In a sense, you're right, if you don't consider rape an "emergency medical condition." Yet somehow the ER has become the generally accepted venue for care of rape victims, and EC is part and parcel of their treatment. If you're going to support a physician's right to refuse EC to a rape victim, I would say the responsible thing for that physician to do is not pick up that chart in the first place. I think it's despicable to begin treating a patient, leading her to believe she is going to receive standard treatment, and then refuse on "religious" grounds (per the article linked in the post.)

 
At Mon Jul 02, 04:26:00 PM, Blogger scalpel said...

I would offer it, but I am wary of calling any medically unnecessary procedure the "standard of care."

I read with interest your posts on circumcision, for example, and I wonder if you believe that it is every physician's duty to provide circumcision on demand if the parents request it.

How about conscious sedation for truly minor laceration repairs? If the patient requests it, must it be performed, even if medically unnecessary and not absolutely indicated?

I would agree that it would be compassionate for a doctor to try to find another physician who was willing to perform those procedures with which he was uncomfortable, but I don't think it should be a mandatory expectation.

 
At Mon Jul 02, 05:33:00 PM, Blogger #1 Dinosaur said...

Why are you combining threads? And since when is EC after rape a "medically unnecessary procedure"?

I'm making narrow distinctions here, and efforts to generalize them are not valid.

EC after rape is standard of care, and an ER doc should be expected to provide it (especially since its provision is time sensitive.)

Neonatal circumcision and elective abortion are elective procedures with valid pros and cons that a physician may either perform or refuse (preferably with referral) as conscience dictates. Ditto conscious sedation for minor lac repair, etc.

 
At Mon Jul 02, 11:20:00 PM, Anonymous difficultpt said...

I agree that EC should be standard of care in the case of rape . . . Also, it is my understanding that Plan B doesn't cause an abortion, but rather prevents conception. Am I wrong?

 
At Mon Jul 02, 11:20:00 PM, Blogger ema said...

As an emergency physician, I can say with absolute confidence that an unintended pregnancy in all but the rarest of circumstances is not an "emergency medical condition.

So I believe that emergency physicians are not obligated to provide emergency contraception or birth control at all.


Um, scalpel, just to clarify. You provide EC to prevent a pregnancy not to terminate it. The "emergency medical condition" is preventing a pregnancy, not terminating an unintended pregnancy.

Oh, and Dr. Dino is right; EC after rape is the standard of care.

 
At Tue Jul 03, 04:34:00 AM, Blogger scalpel said...

"Um, scalpel, just to clarify. You provide EC to prevent a pregnancy not to terminate it."

Umm, ema, I never said otherwise.

From the ACEP website, their policy states that:

"A victim of sexual assault should be offered prophylaxis for pregnancy and for sexually transmitted diseases, subject to informed consent and consistent with current treatment guidelines. Physicians and allied health practitioners who find this practice morally objectionable or who practice at hospitals that prohibit prophylaxis or contraception should offer to refer victims of sexual assault to another provider who can provide these services in a timely fashion."

So a referral to Walgreens would be appropriate, I assume, now that Plan B is OTC. Individual physicians are not obligated to provide emergency contraception directly, though I personally support such intervention.

 
At Tue Jul 03, 08:51:00 AM, Blogger #1 Dinosaur said...

And so we come full circle:

This doc did not offer said referral for EC (merely said, "That's against my religion") therefore failing to meet the standard of care. My original point was that guy should get the hell out of the ER (or at least not care for victims of sexual assault.)

 
At Tue Jul 03, 10:13:00 AM, Blogger beajerry said...

Your favorite religion sucks.

 
At Tue Jul 03, 10:26:00 AM, Blogger scalpel said...

Dino, it was the generalizations in your post that I was responding to. You were referring to "doctors" not just this guy, and my point is that "doctors" can still practice medicine (even in the ER) even if their religious viewpoints don't allow them to prescribe contraceptives.

From your MSNBC article, "The American Medical Association in Chicago, the nation's largest physician group, effectively agrees with her; its policy allows a doctor to decline a procedure if it conflicts with her moral ideology."

But you are right about that particular doctor...a referral elsewhere was indicated.

 
At Tue Jul 03, 05:57:00 PM, Blogger rlbates said...

Maybe we'll have to begin disclosing our religous as well as economic conflicts of interest in our care for patients.

 
At Wed Jul 04, 12:09:00 PM, Anonymous Anonymous said...

Plan B is now OTC, but for a victim of rape, I think it would be appropriate to provide EC in the hospital if possible rather than spare her the possible shame she might feel by having to walk to the pharmacy and ask for it, not to mention the judgmental conclusions that the pharmacist might jump to.

Also, in my state, you have to be 18 or older in order to get EC at the pharmacy without a prescription. So a rape victim under 18--and there are a lot of those unfortunately--needs a prescription.

 
At Thu Jul 05, 06:54:00 PM, Blogger Mother Jones RN said...

#1 Dinosaur, thank you for your great post. Well said!

 
At Fri Jul 06, 06:56:00 PM, Blogger squishybrainster said...

While it's difficult to argue that any physician should be *forced* to do something that conflicts with her moral code, let us be honest: religious superstition is a particularly weak excuse for someone to not perform one's duties. This is especially the case in a field such as medicine where we are caring for people. Otherwise it just comes down to preference. As a medical student, perhaps I simply should have claimed that performing all those guiacs was against my religion?

Someone who chooses to limit their ability to practice medicine by also practicing some sort of religious nonsense is fooling themselves and doing a disservice to their patients. In my opinion, they should simply stay out of medicine if they feel they can't do the things that doctors actually do. And that goes double or triple for the pharmacists.

 
At Fri Jul 06, 08:43:00 PM, Blogger Sid Schwab said...

Good on ya', Dino. I'm with you 100% on this. I'm happy to say that in my state, after lots of generated heat, the governor led the way to telling the pharmacy board that pharmacists must dispense properly prescribed drugs. Doctors have the same obligation, or they shouldn't be doctors.

In a related situation, I was asked to operate on a rapidly bleeding ulcer own by a Jehovah's Witness, whom other surgeons had refused to see unless she'd agree to receive blood. I operated without the stipulation. She recovered. Think I'll blog about it, matter of fact...

 
At Mon Jul 09, 02:19:00 AM, Blogger Richard said...

There was an excellent article in the NEJM on this topic recently:

http://content.nejm.org/cgi/content/full/356/6/593

The long and the short of it is this:

Dino, I realize you feel quite strongly about this matter, but there are many physicians (a significant minority) who would take an opposing position quite strongly.

In my mind, the doctor-patient relationship is intimately associated with morality. A physician is not just a service provider, he/she is an independent consultant. As such, patients trust the judgment of a physician assuming that the physician is beneficent. If a physician is to betray his or her own moral integrity to provide a treatment that he/she feels is wrong, then we are not only diminishing physicians to mere service providers, but also destroying the foundation of the trust in a doctor-patient relationship.

 
At Mon Jul 09, 06:27:00 AM, Blogger #1 Dinosaur said...

Thanks for the reference, Richard, but the essence of my point is there too.

If a physician is an independent consultant, then the patient is (or should be) free to choose another whose views more closely match her own.

The NEJM abstract concludes, "Patients who want information about and access to [legal but potentially morally objectionable] procedures may need to inquire proactively to determine whether their physicians would accommodate such requests." This is not a reasonable solution to an emergency situation.

Unless you expect a rape victim to tell the police or ambulance personnel, "Wait; do any of the ER doctors at the facility to which you are transporting me have religious objections to providing EC and/or STD prophylaxis to victims of sexual assault, and if so, can you ascertain if they are the one(s) on duty now?" then in a sense, the ER physician is acting more as a service provider.

What I am saying is that people contemplating Emergency Medicine as a specialty ought to recognize this and select a different career so as not to make it an issue.

 
At Thu Jul 12, 05:26:00 PM, Anonymous Anonymous said...

One of my selection criteria for a obstetrician is that he/she does not perform elective abortions.

Since elective abortion is [mostly]legal, it would seem you are arguing that my physician should not be allowed to practice.

What about my right to pick a doctor I feel comfortable with?

I'm not in medicine, but if I were I would have no problem prescribing Emergency Birth Control to a rape victim. I would not prescribe it to an "oops, I got carried away last night" person.

 
At Fri Jul 20, 01:51:00 PM, Anonymous Anonymous said...

anti-choice/anti-life/pro-choice/pro-life. Interesting how the simple selection of terms bespeaks so much on the position of the utterer.

 

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