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June 10, 2008

Provider-side issues in physician-patient relationships

Rahul K. Parikh is a doctor and writer for Salon. He recently wrote and article for the New York Times concerning the ability and ethics of a doctor rejecting people as patients. Parikh emphasizes that his situation is not about directly denying provision of care:

The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.

By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.

Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.

When I read this article I felt disturbed. The article ends with Parikh considering whether to tell his colleague - the mother's new physician - about his experience with them. He writes:

I decided to keep quiet. After all, it could have just been me.

While it was apparent that the mother was being non-compliant and even hostile towards the concept of preventive medicine for her asthmatic son - the patient was the son, not the mother. Parikh "fired" his basis on the grounds that the mother's refusal for preventative care was dangerous to the son, but at the same time he did not make an effort to explain why preventive care is important. This is particularly striking as he claims that preventive care is embedded in his DNA.

The concept of "firing" a patient becomes even more delicate when we factor in race. The relationship between race dis-cordant physicians and patient is already rocky. Ironically, Parikh has written an article based on Burgess and van Ryn's studies on the role of race and ethnicity within physician-patient relationships. Due to factors like pressure to make a diagnosis within a short period of time, stress, and lack of cultural knowledge on the physician side, it is easy to rely on internalized stereotypes and feel frustrated by patients enough to create bad feelings. This often results in poorer health outcomes for the patients.

Even class and sexual orientation can affect the physician-patient relationship just as much as race. To avoid these rash decisions, it's important to educate physicians on how to interact with patients and create interventions to act upon in certain situations.

For those interested in supplemental reading:
- The reader comments from the NYT article are interesting
- Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping (Burgess, van Ryn, et al)
- Reducing racial bias among health care providers: lessons from social-cognitive psychology (Burgess, van Ryn, et al)
- Why do providers contribute to disparities and what can be done about it? (Burgess, van Ryn, et al)

June 3, 2008

First-person: Providing Abortions

Retired gynecologist Waldo Fielding writes an essay for the New York Times on his experiences encountering at-home abortion attempts during his training during 1948-1953 . Needless to say, many of these attempts were failures and resulted in harm to the women themselves. Fielding's memories are quite clear so some might find the reading a bit squeamish.

Complications from surgically induced abortions is minimal; fewer than 0.3% of abortion patients experience a complication that requires hospitalization[1] and abortions performed in the first trimester pose virtually no long-term risk of such problems as infertility, miscarriage or birth defects, and little or no risk of pre-term or low-birth-weight deliveries.[2]

The societal hostility to abortion has also lead to a hostile medical environment. Although some hospitals offered abortion services alongside other reproductive health services, many no longer do so. As of 1998, the percentage of abortions performed in hospitals hovered at 7%, continuing on a downward trend.[3] 91% of abortions were performed at clinics, with 2% unaccounted for. [4]

Fielding writes:

What Roe said was that ending a pregnancy could be carried out by medical personnel, in a medically accepted setting, thus conferring on women, finally, the full rights of first-class citizens — and freeing their doctors to treat them as such.

Personal beliefs and philosophies aside, denying people the right to health care is unethical. Of course, while this occurs indirectly through lack of health insurance or others barriers of access, what we can do at least is to allow people to seek the care they need instead of criticizing their attempts.

1. Henshaw SK, Unintended pregnancy and abortion: a public health perspective, in: Paul M et al., eds., A Clinician’s Guide to Medical and Surgical Abortion, New York: Churchill Livingstone, 1999, pp. 11–22.
2. Boonstra HD et al., Abortion in Women’s Lives, New York: Guttmacher Institute, 2006.
3. Almeling, Rene et al. Abortion Traning in the US Obstretics and Gynecology Residency Programs, Family Planning Perspectives, 2000, 32(6):268-271 & 320
4. Ibid

For another first-person perspective concerning abortion, Susan Wicklund has written "Common Secret: My Journey as an Abortion Doctor." There is also a short NYT article about her as well.