Confronting “Bad Faith” in Medicine

 

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This month’s reading focused on a sensitive topic – religion. When people mention religion and medicine, most people jump to abortion; however, there’s a frightening array of issues that involve religion in the setting of modern medicine. Bad Faith: When Religious Belief Undermines Modern Medicine covers these topics in depth. The preventable deaths caused by “faith healings” is the main focus of this book.

Several church groups and religious organizations shun the advancements of modern medicine on the basis of faith. Most notably, “Christian Scientists” refuse all medical treatments except those to set broken bones and a few other necessary treatments. Vaccinations, surgeries, antibiotics, and most medications are strictly forbidden by the Church. Instead, they seek “treatment” in the form of prayer.

Religious belief is a touchy subject. Many providers have difficulty understanding why people would refuse life-saving care in favor of prayer. There is little debate in how adults can choose to treat themselves. If a Jehovah’s Witness refuses a much-needed blood transfusion, that is their choice to make. This is the same for any patient, whether or not they choose this for religious reasons. Legal adults of sound mind are able to sign AMA (against medical advice) forms.

The greater problem lies in the children of these “faith-healers.” On the basis of their religious belief, parents deny their children medical care – which lawmakers refer to as “medical neglect. In the state of Arizona, there are multiple religious protections in place, including protections to avoid vaccinating school-age children. Although anti-vaxxers (religious or otherwise) have been refuted repeatedly due to overwhelming evidence in support of vaccinations, many continue to refuse to vaccinate their children against potentially deadly diseases.

It is my strong opinion that every adult person should be able to dictate their care. They have the right to refuse medical treatment and care. That belief, however, should not automatically apply to their children. An infant or a child cannot consent to medical care. In the medical community, we rely on the patient’s parents or guardians to provide that consent. The issue is that children cannot refuse medical care either, which unfortunately falls to the responsibility of the parents. The default practice should be, then, to provide care when children are sick and in emergencies, regardless of parental consent. The type of care provided may be subject to religious relief (such as avoiding blood transfusions), but parents should not be able to refuse care completely. Naturally that creates the issue of where the boundary lies. Providers and medical staff often end up court-ordering care for pediatric patients, which depends on the decision of a judge.

“Faith healers” can specifically refer to Christian Scientist “practitioners” who provide “care” in the form of prayers. The quotations are there because these people in no way provide actual medical care. Under Arizona law, these people are exempt from medical licensing. They can provide “care” yet they are not liable for the outcome of their “patients,” nor are they regulated in any way. This lack of accountability is something a physician would never dream of, a point made in Paul Offit’s book.

Doctors can be part of the problem as well. Per Arizona law, doctors and medical personnel can refuse to provide services based on their religious beliefs. This means refusing to prescribe birth control, perform abortions, collect umbilical cord blood (for stem cells), and end-of-life care. Notice that most of these cases are related to women’s health. (If you have the time, read Justice Ruth Bader Ginsburg’s scathing dissent of the Hobby Lobby ruling and the importance of reproductive rights). One pharmacist made headlines for refusing to provide a patient with abortion-inducing medication (even though the fetus had already died inside her.) Physicians and other healthcare providers should be required to perform and provide the services needed of them.

In the same way that providers would have to respect a patient’s religious belief, providers should respect their lack of religious belief.  Jehovah’s Witnesses do not believe in blood transfusions. I disagree with this, but I would respect that adult patient’s wishes. By the same logic, a patient requesting an abortion (for any reason) should be able to receive that procedure safely from a doctor, regardless of whether the doctor personally objects. A doctor’s personal conflicts, political leanings, or religious beliefs have no place in patient care. The physician is not a god, is not a judge of people’s moral actions. The physician’s duty is to provide the care needed.

I don’t have anything against religion in particular. In fact, Mr Offit’s book makes several points about the importance of faith. He even uses the New Testament and Jesus’ treatment of children to support medical care and protection for children. I would also like to note that some of the cases mentioned in the book involved religions and religious leaders who explicitly recommended medical care for the sick and dying, which individuals chose to ignore. The issue isn’t religion, but how religious belief becomes warped and causes harm in the realm of medicine.

Protecting Patients from Sexual Abuse

An orthopedic surgeon and his wife recently made headlines for drugging and raping women. The NPR article makes no mention of revoking his physician’s license, though if he serves the maximum sentence (of only 30 years for possibly thousands of women!!!) it is unlikely he would be able to continue practicing. The article does make a reference to his position as a physician establishing a sense of trust in his victims.

After 2 years, prosecutors were finally able to convict Dr. Shafeeq Sheikh of raping a heavily sedated patient while she was hospitalized. He was fired from the hospital and his license was suspended. He served no jail time. Unfortunately, Texas does not require permanent revocation unless a doctor agrees or when a doctor permanently surrenders his or her license in lieu of further investigation. He could potentially re-apply in a year.

These headlines are unfortunately not uncommon. Sexual assault and rape are hot-button issues in the US right now, particularly sparking outrage when rapists and sexual predators receive little to no punishment for their actions. There should be even greater outrage against physicians who take advantage of their position and their patient’s vulnerabilities.

There are watchdog organizations focused specifically on appropriate legislation and punishment of physician-offenders. Per one website, Arizona only scored 66%, but ties Massachusetts and Ohio at number 10 best patient protection states in the country. Mississippi is the worst, and Delaware is the best.

In Delaware:

  • Duty-to-report laws require any healthcare worker aware of an offense to report the physician within 30 days, or else pay hefty fines.
  • Physicians who have committed felony sexual offenses have their licenses permanently revoked.
  • Doctors must undergo background checks with fingerprinting, updated every 6 months.

In Arizona:

  •  Incidents reported by other hospital or clinic staff do not need to be made within a specific time period, and there is no requirement to report these offenses to the medical board.
  • State law does not require revocation for any type of sexual misconduct or convictions.
  • The medical board cannot refuse to issue a license based on previous criminal acts.

In Mississippi:

  • There are no criminal laws specific to sexual misconduct for physicians.
  • State law does not require physicians to report possible violations by fellow doctors.
  • Doctors whose licenses are revoked can reapply at “reasonable intervals.”
  • State law doesn’t require revocation for any type of sexual misconduct or convictions.

Physicians are with patients at their best in worth. They establish trust with a patient, and that patient trusts their physician to provide the best care possible without taking advantage of their vulnerabilities. When a physician rapes or assaults a patient, they violate that trust and the trust future patients would have given. Those physicians guilty of such crimes have violated the fundamental vow of doctors- “Do no harm.” I cannot fathom how a felony sex offender, a rapist, would in good conscious be allowed to continue practicing.

The laws need to change. We need to make hospitals responsible for the behavior of the physicians they hire. Physicians, patients, and staff should be able to anonymously and quickly report inappropriate and unacceptable behavior. The physicians responsible for these heinous acts should be punished severely, including the loss of their right to practice medicine.

Does anyone have any suggestions on how to get Arizona laws regarding license revocation altered?

Documenting Angry Patients

I’m not really sure what happened this week, but I had two patients whose sole purpose in coming to clinic, was to yell at us. The first patient “fired” us. Patients can fire providers, meaning that they no longer want to receive treatment by that provider. Providers can also fire patients, usually if a patient is non-compliant with treatment or has poor behavior resulting in their expulsion from clinic (violence, harassment, etc.).

Regardless of the reason for firing, the visit must be documented, especially if the patient is refusing further care. This is also true with patients who are suing providers or have additional complaints. Medical records and documents are all accessible by patients and other providers. This means that abrasive, offensive, irritating, or angry conversations must be documented with care.

1) Know When to Quote

Directly quoting patients is a common practice when using the patient’s own words to describe symptoms. When patients describe their palpitations as “fluttering” “sputtering” or in other layman’s terms, I use quotations. When I patient is angry or frustrated, it may be best to avoid quoting. Documenting threats is a must. Expletives and curse words might be better to document as a reference; for example, “patient became verbally abusive, shouting expletives,” as opposed to, “patient said, “**** you you stupid *****!”. Quoting angry phrases may best be re-phrased in more neutral language. My patient said, “You will never touch me again,” but I documented “Patient refused further care.”

2) Document the Reasoning

It is not appropriate to simply document that a patient was angry.  Why was the patient angry? Is it a reasonable complaint? My providers like to be aware of smaller issues to prevent them from occurring in the future. If it is an unreasonable complaint, the provider may review the note if contacted by the same patient.

3) Physical Violence

Physical violence may be more difficult to document. You should never compromise your own safety, just to document what is happening. Fortunately, I’ve never had to worry about this, but I advise documenting as soon as possible (once you are safe, of course). Your memory is more accurate immediately following the incident. Use a voice recording if needed.

4) Use Neutral Phrasing

Medical terminology has several phrases designed to avoid offense, not only for describing physical aspects of a patient but also their emotional state. “Non-compliant” is better than saying “stubborn” or “rude.” Use neutral, accepted language to describe patients whenever possible. You’ll avoid aggravating patients further.

5) Take a Breath

The most important factor is the physician’s frustration. It may be wise to document, then take a break. Step away from the situation, calm down, then return to the note. Read back through your note. Is the note insulting to the patient? Are you heavily biased? Avoid belittling or insulting the patient in their own record. Try to address the cause for misunderstanding in your note while avoiding placing any blame. Sometimes you can explain something 20 times, but the other person won’t understand. It is common sense not to imply a patient’s lack of intelligence, though if you’re caught up in a moment of anger it may be implied.

Do you have any tips on how to handle angry patients?

Overcoming Obesity Bias in Healthcare

A woman’s obituary has recently gone viral. After suffering from inoperable cancer,  a Canadian woman named Ellen Bennett passed away. In her obituary, she criticized healthcare professionals for discriminating against her due to her obesity. According to the news outlets, it took many years to receive her cancer diagnosis. She had felt unwell for several years, but apparently was told to lose weight. There has been a wave of sympathy from other self-proclaimed “fat” women who share stories of how diseases and ailments went untreated because healthcare providers encouraged weight loss instead of other treatments.

I can imagine a discussion Mrs. Bennett must have had with her primary care doctor. Perhaps she complained of general fatigue and malaise. If she wasn’t puking, bleeding, or passing out, it wouldn’t be considered an emergency. Unexplained weight loss is usually the biggest red flag for cancer (in my experience). Providers may have assumed depression or fatigue related to her weight. “Lose weight you’ll feel better,” seems to be a pretty common response.

Obesity has been linked to increased risk of several diseases including heart disease (CAD), diabetes, sleep apnea, and high blood pressure. Many have argued that obesity does not indicate health. At age 18, I was nearly 200 lbs. with a BMI of 27 (considered overweight, though I have my issues with the BMI measurement). I had no significant health problems. My heart worked well, and my BP was normal. For all intents and purposes, I was a healthy adult. Though obesity may not indicate general health of a person, studies have shown that even having extra weight can put you at risk regardless of lifestyle. Being obese can also put you at risk during procedures and surgeries. My hospital will often refuse elective surgeries for patients with a BMI over 45 (with the exception of bariatric surgeries).

There’s a dangerous stigma associated with obesity. Many people feel that obesity is the result of “laziness” or “not caring enough” about their health. For some people, this may be the case. For many others, there are multiple unseen issues at work. I once met one woman who had a BMI of 56. A tragic miscarriage had resulted in depression and finding comfort in food (in addition to the weight gained during the pregnancy). Psychological problems, stress, genetics, disease processes, income, and many other factors affect weight.

Our responsibility as physicians is to provide the best care. We cannot approach patients assuming that they do not want to get better. It is irresponsible to place the entirety of a problem on a patient’s weight. When I worked with orthopedics, weight was often a discussion of topic. Surgeons performing knee replacements mentioned weight to alleviate strain on the joint, but also provided medications and injections prior to surgery. Weight was addressed, but not a reason to discriminate or withhold most treatment options. A spine provider encouraged weight loss for a healthier overall lifestyle, not necessarily to alleviate back pain. In his words, “skinny and fat people both have back pain.” Their weight wasn’t the cause, so it likely wouldn’t do much to help alleviate the problem.

Since I used to be overweight, I remember being sensitive about my weight. The training I’ve received at my clinic regarding obesity has been focused on sensitivity. No one wants to be wheeled in the “big” chair, so we’re supposed to refer to it as “bariatric” when necessary. Though we’ve improved hospital and clinic facilities to be more size-inclusive, sensitivity training doesn’t address the stigma associated with obesity. We need to look at weight management as part of the treatment plan, not the only treatment plan.