Category Archives: bioethics

Today’s the Last Day to Make Sure Family Docs Learn about Contraception

by Karan Chhabra

I was pretty alarmed to read news today that training in contraception may be made optional for family medicine doctors-in-training:

The proposed new rules, they say, drop existing requirements that family medicine residents be required to undergo training in contraception and counseling women with unintended pregnancies.

Essentially, the board that oversees residency training (required for doctors to become board-certified) concluded that its educational standards needed more flexibility, and identified contraception education as one of those areas where it could lay off a little bit. Religiously-affiliated medical centers appear most likely to take advantage of this flexibility. But let’s be clear: this is a proposed change, not yet final, and it’s about training–not about whether reproductive health services can be provided. It’s also possible that trainees could learn a good deal about contraception through FOAM. So the sky isn’t falling, but I have serious misgivings about the precedent this sets.

A few months ago I offered my thoughts on the birth control debate as a whole:

The national conversation on birth control should look a lot more like ours on aspirin. When we talk about aspirin, we talk about about whether it’s right for you. When we talk about birth control, we get one-size-fits-all generalizations, political chaos, and name-calling. Something is wrong. These are individual, medical questions that demand individual, medical answers. Ethics have a place in medicine; faceless bickering and moralism do not.

I wrote those thoughts amid the debate on insurance coverage for contraception–a question that boils down to whether members of an employer-sponosred insurance plan ought to cross-subsidize people’s birth control expenses. In short, it’s thorny. Today’s question is different: should primary care doctors-in-training be required to learn how to provide services related to reproductive health? Should they be qualified to answer those individual, medical questions? To that, my answer is yes.

Family doctors are patients’ first line of trusted healthcare. In many parts of the country, they’re patients only line; not everyone can go to an ob/gyn for routine concerns like birth control. But we already have evidence that family doctors’ understanding of the research on birth control is inconsistent. Why make it worse? More importantly, though, what makes it okay to privilege certain types of medicine over others? Why is family planning any less a part of primary care than say, heart disease? If in fact it is, why can’t religiously-affiliated programs apply the same segregative logic to patients suffering from addiction or contemplating suicide, just because they disagree with it?

Medical education is about preparation. We go through medical school, residency, and all the rest to make sure that we can handle whatever our patients ask of us (within, of course, one’s specialty). Medical education should not be about judgment, about right or wrong, or about politics. It was one thing when the nation asked whether religiously-affiliated employers should pay for birth control. I believe it’s quite another thing when we ask whether our primary care doctors need to know about it. When authorities accept willful ignorance because of concerns that are at their core political, they attack the heart of a profession built on nonjudgmental service, and the patients who rely on it.

Today, April 25, is the last day for comment on this proposal. If you have something to say, do so in this form (courtesy of Reproductive Health Watch) and email it to familymedicine@acgme.org.

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Karan is a first-year student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Helping Your Doctor Help You (Part II of II)

by Karan Chhabra

Ubel critical_decisions_cover

This is the second in a two-part interview with Dr. Peter Ubel, a physician, behavioral scientist, and author of the book Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices TogetherMissed Part I? It’s right here

KARAN: You referred to patient education earlier, not just in terms of treatment information but also the types of questions to be asking. But what about the former? Our generation is definitely comfortable using technology to look up health information, and we get a ton of information through news, magazines, and the general media. But not all of it’s good. So how do you recommend people sift through the good and bad information out there, when they’re trying to inform themselves before a visit to the doctor.

DR. UBEL: Of course, the education system should help people learn how to objectively look at things and help them when things go over their heads.

But the other thing I’d say is, print out and bring in the stuff that you see online, show it to your doctor, and let them tell you what’s right or wrong about it. Then they’ll know what you care about more than they did before, which is really valuable. Your doctor shouldn’t be threatened when you bring these materials in; they should be happy that you’re helping focus the visit on the topics you care about. If you’ve got misconceptions that are affecting the way you’re behaving, like what pills you’re taking or not taking, the doctor should be happy to have a chance to address those misconceptions.

So: print it out; bring it in.

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Helping Your Doctor Help You (Part I of II)

by Karan Chhabra

Ubel critical_decisions_cover

Dr. Peter Ubel is a physician and behavioral scientist at Duke, as well as an author and personal mentor/hero. I recently read his latest book, Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together, and recommend it highly to anyone interested in making the right medical decisions—either as a patient or a practitioner. I spent a lot of time with the topic when I wrote my Honors thesis, but Dr. Ubel‘s book beats everything else I’ve read at dissecting the psychological and historical quirks that make decision-making such a complicated issue. In addition, it offers a lot of concrete advice on how to do the decision-making dance better.

Dr. Ubel and I had this interview to elaborate on how his book applies to the Millennial generation and our unique medical needs. Because the conversation was so chock-full of decision-making goodness, we had to split it up into two parts—the second half can be found here.

KARAN: Though I hope our readers all read your book, for those who haven’t just yet, I want to start with an example that touches on the issues it discusses. I recently got a bad ankle sprain. The following week, I went to a local orthopedic surgeon for it. He was a very old-school doctor; before even talking about treatment options at all, he was getting his stuff out to give me a cortisone shot for my ankle. I was still trying to give him my history and symptoms and I had to stop to ask what he was doing. It was a little scary; I had no desire to get a shot, and from whatever little I know, I think cortisone might’ve even hurt more than it helped. But I’m obviously not residency-trained in orthopedic surgery, so I didn’t feel right questioning his opinion. So while I have seen how the patient autonomy movement has affected the way doctors are ethically trained, which you discuss in your book, I still think there are a lot of doctors who fit the old mold. As a patient, especially a young and inexperienced patient, it’s difficult sometimes to know how to respond.

DR. UBEL: I don’t think this is an old/young issue. If anything, people tend to think their older patients are more deferential than the younger ones. Most people in their 20s are more into the “consumer” mindset than older people who grew up in the “doctor knows best” era. But when you are young, the age difference between you and the doctor is bigger, so that could make it harder to be assertive when interacting with your doctor. But patients ought to feel they can assert themselves because, even for mundane issues, any time there’s more than one way to go about it, the patient deserves to know what their alternatives are and to be a partner in the decision. So what happened to you is not the best possible medical care. Whether the doctor made the right choice, that’s one thing. But if he didn’t say “One thing we could do is this, but you should know, there are other alternative. For example, if you don’t want to get a shot, we could just give it time, etc.” If the physician didn’t speak to you that way, that’s a problem.

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Electronic Health Records Get Personal

by Ross White

As I discussed in my first post, electronic health records hold great promise to improve the efficiency and quality of healthcare, but also raise a number of important questions about how best to ensure the preservation of patient privacy. Some of these concerns came to fruition at a recent annual appointment with my asthma and allergy specialist, a physician I’ve known since before I can even remember. His practice, which includes three other physicians, adopted electronic medical records about four months ago. Luckily I didn’t have any significant changes in my health, so I was able to slip in several questions about his general impressions and uses of the new electronic medical record system.

Before seeing the physician, I was asked several questions by the nurse about my basic medical history, current medications, and other relevant health and personal data for input into my newly minted electronic health record. Much of this health data will presumably not need to be entered at subsequent visits, but it added at least an additional five minutes of nurse work. Once I finally saw my physician, he seemed less than enthusiastic about the practice’s decision to adopt electronic health records. He expressed the commonly cited critique that they seem to slow down clinical practice and reduce the amount of face-to-face interaction with patients, at least initially. Some of these issues will likely subside as technology progresses and physicians are more easily able to attain “meaningful use,” but they remain a practical concern at this time.

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Progress at the Cost of Privacy?

by Ross White

As we all anxiously await the Supreme Court decision on the Affordable Care Act, it is worth remembering that for many reforms, “the train has already left the station.” Many payment and delivery changes are going to continue regardless of the Supreme Court ruling. One such reform is the continued implementation of health information technology, particularly electronic health records (EHRs). While these technologies promise to increase the transmission, sharing, and use of health data across the health care system—thereby improving quality and reducing unnecessary costs—they do not come without raising serious ethical questions about the use of that data and how patient privacy can best be assured.

The incentives to implement electronic health record systems have never been greater. The Health Information Technology for Economic and Clinical Health Act (HITECH Act), which is a portion of the American Recovery and Reinvestment Act of 2008 (ARRA), designated incentive payments of up to $44,000 from Medicare and $65,000  from Medicaid per individual physician who demonstrate “meaningful use” of an EHR system. In order to meet CMS-defined criteria, providers must demonstrate improvement in the collection and sharing of health information to improve quality, efficiency, and patient safety. A Health Affairs study from last year suggests that it would cost a five-physician primary care practice approximately $32,400 per physician and $85,500 in maintenance expenses during the first year to meet these criteria, which is largely consistent with incentive payments.  Providers who do not demonstrate meaningful use of EHRs by 2015 will be penalized with a 1 percent annual reduction in Medicare reimbursements. The Affordable Care Act continues us down this path. While many physicians are embracing this opportunity, others continue to resist—or have already experienced adverse effects after having done so.

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