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Monday Nov 28, 2016

Ensuring Appropriate Care When Views of Physician, Patient Collide

Patients often forget that we physicians are people, too, with our own hobbies, religions and beliefs. We might have beliefs and interests in common with some of our patients, but we also are just as likely to have some that are wildly different.

When we go into an exam room, we aren't there to gain anything for ourselves. We are focused on the patient. But we also are there as human beings who have a lifetime of experiences that have shaped us into the physicians we've become.

So how do we ensure patients receive appropriate care when our views and theirs aren't aligned?

A few weeks ago, I received a text from a former residency colleague asking for advice. The question she posed was, "What are your thoughts on a physician not writing a medication based on personal beliefs?"

This led us into a discussion about various ethical and personal prescribing conflicts, partly because my initial response was based on the incorrect assumption that we were talking about birth control. 

Turns out, she had a new patient who was taking Premarin. That medication is made from the urine of pregnant horses and, as with any product manufactured using a process that involves live animals, there are criticisms about animal welfare. My colleague does not prescribe Premarin because of her personal belief that its production method is inhumane. She offered the patient other types of estrogen that are not derived from animal sources, but the patient was furious and refused a trial of a different formulation. 

In medical ethics class, I was taught that if I did not feel comfortable providing a treatment option that may be in the patient's best interest because of a personal, ethical or religious conflict, it was my duty to get that patient to a physician who would. It is not appropriate for us as doctors to limit patient access to treatments that are appropriate, well-validated and, in some cases, the standard of care because of our own individual objections. An obvious example is prescribing oral contraception. A patient may see a family doctor for nearly all of her care but receive her birth control prescription from another doctor in the same office. Everyone's preferences are honored, and the patient receives appropriate care.

My friend's conundrum with Premarin was that she felt she had offered appropriate alternatives, and there is no established superiority of Premarin compared with other estrogens in the mainstream medical literature. Refusing to provide Premarin but substituting another estrogen did not prevent the patient from obtaining the same result from her medication with no disruption in treatment. But the physician was afraid she had overstepped her bounds, and she doubted her decision despite her passion for animal welfare. 

The conversation about hormone replacement therapy led me into discussions with other physicians about how we choose within our diverse family medicine offices to handle certain high-profile medications, including opiates and weight-loss drugs. I am a member of a robust Facebook group called Physician Moms Group, which has nearly 63,000 members. I am also a member of Physician Moms in Family Medicine, which has more than 2,000 members. There are frequent discussions on these forums about difficult treatment plans, hormone replacement included, and there is huge variation in who feels comfortable doing what. Sometimes a physician is just reaching out, as my colleague did, for reassurance (whether on the prescribing or conflicted side), and there is always support.

I practice in West Virginia, one of the states with staggering statistics related to opiate abuse(www.cdc.gov), so the decision about whether to write opiates is a heavy one. During residency, I had a preceptor who just didn't write narcotics -- no exceptions, no excuses. It wasn't going to happen, and patients shouldn't even ask. At the time, I had a hard time reconciling that. I felt it was our duty to take care of every aspect of our patient, even their chronic pain. I don't feel that way anymore.

I actually chose to work in a practice that has a policy of mandatory referral to pain management specialists for chronic pain. Just as patients have a right to a caring, compassionate physician who will provide appropriate evidence-based medical services, we as physicians deserve to have dignity and joy in our lives. And one of the fastest ways to squash that dignity and joy is to be put in a situation where you have to argue with the majority of patients you see in a typical day about narcotics, urine drug screens and board of pharmacy reports -- all while you still have five other important chronic medical problems to discuss that have more impact on that patient's morbidity and mortality than pain. I refer them to pain management so I can focus on everything else. It is a personal choice not to manage chronic pain, and I refer patients to physicians who will.

Weight-loss drugs are another group of medications that incite much division. We have an obesity epidemic in the United States, and, sadly, West Virginia is once again leading the charge(www.cdc.gov). So there is a part of me that feels I should do everything within my power and use every tool in my arsenal to help people lose weight. But every time I have a patient ask for help (aside from the obvious nutrition and exercise), I can't help but remember the message of the Hippocratic Oath to do no harm. I personally can't reconcile the risks associated with these meds with the benefit of weight loss.

So again, I refer these patients on to someone who doesn't have the same conflict I do, but I also counsel them about the risks and benefits. If meds are started, I ask that they please make an appointment with me two, four and eight weeks in so I can be part of their overall lifestyle modification plan, observe for adverse effects and help them decide whether this is the right thing for them. 

I'm sure other family physicians can rattle off a list of meds you may choose not to prescribe, although you may feel 100 percent comfortable managing opiates and weight-loss drugs. And I commend you for that. We learned the same things in medical school, we all attended family medicine residencies and therefore gained the same core knowledge outlined by the Accreditation Council for Graduate Medical Education and certified through the American Board of Family Medicine, but we have different personalities, different ways of coping with stress and conflict, and different experience bases on which our medical knowledge continues to be built.

So, as I reassured my colleague who did something not every physician would do, we do no harm by respecting ourselves in the delivery of health care. And it may sound cliché or hokey, but the next time you doubt a decision, actually read the Hippocratic Oath. Although the exact words "do no harm" are not in there, it is full of great messages.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 01:25PM Nov 28, 2016 by Kimberly Becher, M.D.

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