Thursday, July 31, 2014

Doctors and their beliefs

As usual I am a little behind the news cycle but two interesting stories have recently come up in Canada.

In the first two women in two different cities went to walk-in clinics to get their birth control pills filled.  They were either told by the physician they saw or in one case by reading a sign posted that the physicians would not prescribe birth control because of their personal beliefs.  There are two ways you can deal with this.  You can come back another time, go to another walk-in clinic, or get a family doctor.  You can also if you want post a nasty review on Rate MDs.   Or you could go to the press which is what both of them did.

This caused a big uproar with multiple stories and letters to the editor.  Many lay people felt that the physicians should have prescribed the BCP and that the women's rights had been violated.  Issues like the public funding of medicare, and  the subsidization of their education were raised.    Physicians who did comment sort of stickhandled around the whole issue.

There are several moral reasons why one might not prescribe birth control.  The Catholic Church prohibits it all together so if you are a devote Catholic physician you probably shouldn't prescribe it.  Some extremists believe it may lead to sex outside of marriage and refuse to prescribe it on that basis (if you went to medical school and haven't figured out that a lot of unmarried people are having sex, maybe you are a little dense).  There is also the whole abortion issue.   While the pill is believed to work by inhibiting ovulation, I seem to remember that another proposed mechanism was that it inhibits implantation which is technically abortion.  Another doctor I know claims he won't prescribe because it is too risky a drug to prevent what he believes is a normal physiological event (pregnancy).  

It is not therefore a new thing for physicians to refuse to prescribe birth control.  The general practitioner who delivered our second son refused to prescribe it.  He and his wife also a physcian, taught natural birth control.  They weren't terribly good advertisements for it as they had about 6 kids.  Not prescribing birth control wasn't an issue for us, he was otherwise a really good doctor.  

Now personally I think the two physicians in this case were being a little stupid and I can't believe that this happens in the 21st century.  (Actually much of what has happened in the 21st century I can't belive happened in the 21st century.)  Medicine is however an art not a science, most of us go on our beliefs which hopefully are formed on science.

Family docs have a lot of stupid beliefs.  Many of them believe that upper respiratory infections are caused by bacteria and must be treated by the most expensive broad spectrum antibiotic around.  Others believe that codiene will work for all pain no matter how severe.  Others believe it is not necessary to examine patients in order to arrive at a diagnosis.  I could go on.  These beliefs are at least as bad as not prescribing birth control. 

But I wonder if during the physicians in question's family practice "residency", did anyone point out the obvious economic benefits of prescribing the birth control pill to young women.  It has been a while since I was in primary care and I last wrote a prescription for the birth control pill in 1986 but here goes.  I used to love when women came for a refill of their birth control pills.  Even one counselled them about safe sex and warned about signs of DVT, we are talking about a 5 minute visit.  True you should probably do a Pap smear and cultures for STDs (actually they can test urine for it) but you can get them to schedule another appointment.  Young women on the BCP make great patients because they are mostly healthy.  Eventually they will get pregnant, if you do obstetrics you can follow their uncomplicated pregnancy; or you can refer them to OB.  After the birth you will get several years of well-baby care.  In addition by default, you get their husband who is also healthy and will present every couple of years for some minor problem.  It will be about 20-30 years before they will make you think.   This is exactly the patient a young family doctor wants in his or her practice.

In Canada the morning-after pill can be dispensed without a prescription by a pharmacist.  Shortly after the law came into effect a "researcher" for the CMAJ visited several pharmacies in rural Alberta posing as a patient trying to get the morning-after pill and was turned down by most of them.  This "study" was published in the CMAJ, incurring predictably the wrath of the Pharmacy community and when the editorial board stuck by their story the Board of CMA who charge me hundeds of dollars to belong fired the editorial board.  I don't recall being asked whether I wanted the board fired (or which board I wanted fired).

Abortion is of course another issue.  We used to do the odd abortion at the Centre of Excellence.  We had at least two anaesthesiologists wouldn't do the anaesthetic.  That was no problem, we simply swapped lists for that case.  Now our health authority contracts them out to private facility where they are done under local.  When I was in general practice, I worked briefly at an office in Northern New Brunswick.  The first thing I noticed was that the waiting room was plastered with anti-abortion posters.  The clinic did prescribe the pill, there were lots of samples around.  One day a distressed university student came to see me.  She was pregnant and adamantly wanted it terminated. I then and now support the right to abortion but I was in a quandry where I was in what I thought was an anti-abortion clinic.   Just to show how old I am, at that time, if you had money it was easier to get an abortion in the US than in Canada.  It was in fact not possible for patients from our community to get abortions in our province (the hospitals that did them, would only do them for their immediately catchment area)  so it was necessary to refer her to a clinic in Bar Harbour Maine.  I realized if I phoned from the clinic, it would appear on the long distance bill and I might be in trouble.  So I went home at lunch, phoned the clinic from home (long distance was not cheap then) and arranged the abortion.  A couple of months later when I knew one of the docs in the clinic better, I asked him what he would have done.  "All of us in the clinic send patients down there," he said.  The anti-abortion posters were in the waiting room because these are the type of people you don't want to say no to.

The hospital where I interned in OB did abortions.  Most of these were first trimester abortions done as day surgery but they did the odd second trimester abortion by saline induction which as I found out is quite unpleasant.  These patients usually generated a few calls to the intern for various problems.  The other two interns on the service refused to see abortions which meant I ended up dealing with the problems.  As I told one of them when she told me she didn't feel she had to see patients having an abortion, "I can't believe you would refuse to see a patient in distress".

But religious beliefs affect other areas of care not association with birth control.  Take end of life care for example.  Just how heroic or not heroic attempts to prolong life for a few days are often influenced by the doctor's religious belief sometimes going beyond the patient's or his family's stated belief.

The second issue involved a Caucasian woman who visited a private fertility clinic in Calgary to get inseminated.  She asked to be inseminated with the sperm of a non-Caucasian patient.  The doctor refused stating, "we don't do rainbow babies".   This caused the predictable storm, most fertility programs in Canada stated they don't have such a policy and the clinic in Calgary has back-tracked; they are now saying it was just a misunderstanding.

I think most of us would think, it the lady wants a mixed race baby so be it.  I am sure an ethicist can probably take this simple quandry and make it much more complicated.  

I sometimes think the world would be a happier place if we were all encouraged to mate with somebody of a different skin colour so that in several generations we were all the same shade of brown  .  Having said that I married a women with similar skin colour to mine and am quite happy with my marriage (not because of her skin colour),  

I wonder how the non-white sperm donors who perhaps donated sperm intending it to go to somebody with their skin colour and who now find out it is going to help white women make designer babies feel about all of this?  Of course most sperm donors don't really want to come forward or attract attention to what they do.  

When artificial insemination was in its infancy, our of our Obstetricians was a local pioneer.  He collected a lot of his sperm from medical students who we all know are genetically superior.  He paid $70 for a course of two donations two days apart which in 1980 was serious cash for a student.  I never did it, nor and nobody I knew admitted to it;  there were rumours about some of our class who were making big bucks in the insemination game.  (We did a skit about it at skits night)  Donors were matched with the spouse of the recipient by "race", blood type and eye colour.  We were assured that the process was anonymous, the identity of the donor would be kept in case of genetic problems later but that there would be no way of the recipient or offspring ever finding out.  That promise was of course not worth anything, about 20 years later, some of the offspring started to want to know who their natural father was.  I am not sure of the outcome of that one.  I can just imagine  at 42 years of age, a 20 year old showing up claiming to be my son after I joylessly inseminated his mother 20 years earlier.   Imagine explaining to my 8 and 10 year old children where their half brother came from.  


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