Wednesday, June 27, 2007

Your Doctor Owns You

If you're a female patient of reproductive age and you hope to receive adequate care, that is.

Allow me to illustrate.

Patient #1

Breech presentation [feet first]; to convert to vertex [head first], in order to avoid a C/S and attempt a vaginal delivery, an external cephalic version is indicated.

"Doctor, I'd like to try a vaginal delivery ," the patient tells me. "No," I reply. "I can't do that. It's against my religion."

I can get away with refusing to provide adequate care because, for female patients of reproductive age, the applicable standard of care is What You Feel In Your Heart (TM)*. If you feel in your heart an action would cause harm to somebody—born or unborn—it's legitimate to decline to participate [in rendering proper care].

*[As I'm sure you're aware, What You Feel In Your Heart (TM) is not just a basic medical principle. It's also a fundamental legal principle. One recognized and respected by malpractice attorneys and juries everywhere.]

Also, keep in mind that any patient encounter is, ultimately, all about me, the physician. It's about my rights as an individual, about my constitutional right to freedom of religion. I'm not trying to deny anybody access to treatment. I'm saying, "Don't bother me with your silly medical concerns. Don't make your choice my choice."

Patient #2

Asks for some pain relief during labor. That's when I inform her that I'm a Scientologist and that pain relief for pregnant women is against my religion. Five minutes of verbal sparring later ['cause what would providing medical care be without the patient having to beg and plead for it just a tad], I relent with an order for pain meds—but only after the patient tells me she needs pain control for a toothache, not to ease labor.

"This is about the rights of the individual, about our constitutional right to freedom of religion," says Frank Manion, an attorney with the American Center for Law and Justice, a legal group in Washington, D.C. Founded by minister Pat Robertson....

I told you so! Patient encounters involving female patients of reproductive age are not about medicine and rendering care. They're about the doctor's rights as an individual and, of course, religion.

Patient #3

Comes in for a routine physical. "So, your husband is in agreement with your decision to come in today on your own, unaccompanied?"

"I'm not married," the patient tells me.

"You're not?" I calmly put down my pen. "Then I'm not comfortable continuing this exam."

Later, I explain that "My decision to not perform a routine physical and to refer the patient was not because she was unmarried; rather, it was based on my moral belief that a woman should not be allowed in public unaccompanied by a husband or a male relative." I add "Such religious beliefs are a fundamental right guaranteed by the Constitution of the United States."

In the end, all the women I mentioned were able to get the treatment they wanted, even if they had to go elsewhere. So one could see my refusal to render adequate medical care as a mere inconvenience. "In 99.9 percent of these cases, the patients walk away with what they came for, and everyone's satisfied," Manion asserts. "I know there's the horror story of the lonely person in the middle of nowhere who meets one of my clients. But those cases are so rare."

Mr. Manion couldn't be more right if a Sky Fairy lodged itself in his ear canal and told him what to say.

That is, he's right when you consider that the standard isn't the patient receiving appropriate medical care, but rather her receiving care at some point, somewhere, somehow, by somebody, fingers crossed she has adequate resources and know-how to arrange for alternate care, and pray to [insert deity of choice here] she's part of an imaginary 99.9 percent of cases who do manage to get proper medical care.

Now if this standard doesn't fill you, the patient and your loved ones, with satisfaction, I don't know what will.

But wait; there's more!

If there's one thing both sides can agree on, it's this: In an emergency, doctors need to put aside personal beliefs to do what's best for the patient. But in a world guided by religious directives, even this can be a slippery proposition.

"I was told I could not admit her [14 weeks pregnant with ruptured membranes] unless there was a risk to her life," Dr. Goldner remembers. "They [the nearby Catholic Medical Center] said, 'Why don't you wait until she has an infection or she gets a fever?' They were asking me to do something other than the standard of care. They wanted me to put her health in jeopardy."

Turns out, the definition of emergency depends on whom you ask. Dr. Christiansen, the pro-life ob/gyn, says she would not object to either method [medical or surgical] of ending an ectopic pregnancy. "I do feel that the one indication for abortion is to save the mother's life—that's clear in my mind," she says. "But the reality is, the vast majority of abortions are elective. There are very, very few instances where the mother's life is truly in jeopardy."

I dare you to challenge Dr. Christiansen's statement. Let me save you some time; you cannot.

As long as it's acceptable in this country to debate and set policy based on the premise that, if a patient is female, she may only receive care if, and only if, her life is in danger, you don't have a leg to stand on [chances are, quite literally if you're female and your condition isn't deemed life threating enough to operate and save said leg].

As things stand now, the Drs. Christiansen of the world, your neighbors, politicians, and complete strangers get to decide how close to the brink of death you may be permitted to get, before you're allowed to receive adequate medical care.

So, to sum up, if you're a female patient of reproductive age:

1. Medical decision: Based on what your doctor feels in his/her heart, not science.

2. Doctor's visit: Not about you and your medical problem; rather, about religion. [The doctor's, of course, you silly goose.]

3. Treatment: It's not about receiving adequate medical care. It's about receiving something, at some point, somehow, somewhere. [Kinda like magic, really. Do-it-yourself magic.]

4. Indication for treatment: If, and only if, your life is in danger.


UPDATE: #1 Dinosaur has more.

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At 4:03 PM, Blogger sailorman said...

Outstanding post!

At 5:04 PM, Blogger ema said...


Thank you. I was quite miff when I wrote it.

At 5:26 PM, Anonymous Anonymous said...

Just want to second the opinion of sailorman. Absolutely brilliant post!

At 8:11 PM, Blogger #1 Dinosaur said...

So brilliant I linked to it, then added my own rant.

Well done!

At 11:36 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

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 comprhensive 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.

At 10:09 PM, Blogger ema said...

Thank you, all.


I responded on Dr. Dino's blog, but forgot to post it here. Here's my take:

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 2:11 PM, Blogger beajerry said...

Good post!

At 12:36 AM, Blogger Sid Schwab said...

Excellent post. Your examples are perfect, and demonstrate the essence of the problem. Well done.

At 1:12 AM, Blogger ema said...

Thank you Dr. Schwab.

At 5:44 AM, Anonymous Anonymous said...

A lot of the problem is the patients' reverence for the doctor, which is common in American culture.

Of course you cannot and should not force a professional to do something that s/he he is morally opposed to - but neither does s/he and the employing insurer have any business representing themselves as being general providers for urgent care if they are not prepared to minister to the general situation (ie, no special limits).

IOW, you should not be wasting each other's time in the assumption that you see eye to eye; and just as MDs are not entitled to any particular trust or reverence, you cannot be surprised when they do as they have done historically, ie, defer to their cultural prejudices. Medical history has ALWAYS been full of quackery, and it remains that way today, EVEN in major HMOs. Courts don't even try to sort it out, they only mediate disputes, where the more powerful usually wins.

I'd go back to the insurer and tell them to get me somebody who doesn't mix their moral and medical issues. Who may be responsible for what assumptions may be an open question, but meanwhile, don't be so foolish as to revere your MD.

Cross-examine them until you're satisfied they make sense, because you are the one who will go home with your body; they won't.

At 1:40 AM, Anonymous Anonymous said...

How about this scenario?

Female patient: "Doctor, I'm bleeding all the time but it's not my period."

Doctor: "We'll have to wait until your bleeding becomes life-threatening. Then we can treat you, but not before."

At 5:38 AM, Anonymous Anonymous said...

And then once she is seen at a hospital, she is interrogated in order to determine what "sin" contributed to her current condition.

At 10:21 AM, Anonymous Anonymous said...

Or how about this?

If a male patient said to his doctor, "Doc, I can't a take a whiz!", I somehow doubt the doctor would tell him, "Wait until it falls off and then we can help you".

At 1:44 PM, Anonymous mirena intrauterine device said...

This was a very intelligent and satirical post, but I was kinda looking for a happy ending in there somewhere - like how to avoid or manage those types of situations. I know you painted a very bleak picture to get your point across, but even with those circumstances, do you also know of any options a female patient might take so as to avoid the very things you warn against? You know, short of running for high public office and setting policy yourself? (Yeah right, like it'll happen in MY lifetime in THIS country!)


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