Government and the exam room

While the US headlines have been largely dominated by “religious freedom” laws, there have been a few states that are pushing regulations that affect patients and physicians.  Just last week, two bills were introduced – one in Arizona and one in Texas that affect the patient-physician relationship in the exam room.

The two laws are surround completely separate issues and while one works to block physicians from asking certain questions, the other is meant to force physicians to discuss non-evidence based treatment with patients.  The great irony is that these bills were introduced in heavily conservative states that largely believe in less government intrusion. While some of you reading this might think “well the government tells physicians what they can do all the time” – the fact of the matter is that government has until relatively recently allowed providers to practice their craft uninhibited as long as it met the standard of care for the profession.  Until recently, outside of abortion, government didn’t regulate what doctors could and couldn’t do in the exam room without some compelling evidence, and most of the current regulation has focused on improving the quality of medical care

Last week, a Texas state lawmaker introduced a bill that would prohibit doctors from asking patients whether they own a gun or whether there is a gun present in their home. Florida passed a similar law in 2011 which was challenged by the American Academy of Family Physicians as an infringement on doctors’ free-speech rights. The 11th U.S. Circuit Court of Appeals in Atlanta last year upheld that law as constitutional.

You may be sitting there wondering why a physician would ever need to know the answer to that question.  Well for one, physicians routinely ask all sorts of questions to assess a particular patient’s health and risk factors that may put them in harms way.  Physicians routinely ask about bike helmets, seat belts, dangerous chemicals, sexual behavior, smoking, alcohol use, domestic violence… and the list continues. Additionally, violence involving a gun hospitalizes or kills over 7000 children a year in the United States.  Victims of accidental shootings are more than three times more likely to have a gun in the home, and 89% of unintentional shooting deaths of children occur in the home.  Research has shown that pediatricians counseling parents about gun locks and safe storage, tailored to a child’s specific age and development, increases the likelihood a family will take the steps to store their firearms safely. In recent studies, 64% of individuals who received verbal firearm storage safety counseling from their doctors improved their gun safety practices.  Furthermore, gun ownership can be an incredibly serious issue for patients with a history of mental illness – particularly those with suicidal ideation.

While the Texas law would prohibit doctors from asking about gun ownership, the Arizona State Legislature passed a bill last week that requires doctors to tell women seeking abortions about an experimental “abortion reversal” procedure that has not been tested or studied by the mainstream medical community.  The OB-GYN community is appropriately up in arms, with one calling the bill “downright offensive” to doctors because it implies that doctors are not already counseling patients about their decision to have an abortion and practicing evidence-based medicine.

The “abortion reversal” procedure only applies to medical abortions which require a woman to take a dose of mifepristone (RU-486) and days later a dose of misoprostol.  Dr George Delgado claimed in a 2012 study that he could reverse the procedure before a woman takes the dose of misoprostol by injecting a dose of the hormone progesterone.  Four of the six women in Delgado’s study who were injected with progesterone went on to have live births.  The problem with Delgado’s study is that mifepristone only causes a complete abortion on its own about 40% of the time because it is meant to be used in combination with misoprostol. So the fact that four out of six women in Delgado’s study went on to have live births does not necessarily mean the progesterone was responsible for keeping the abortion from being completed. Additionally, there is no other research to back up Delgado’s study or to test the safety of his experimental procedure.

In essence, Arizona legislators are forcing providers to tell women that an abortion can be reversed once it’s been started and therefore legislating against evidence-based medicine. As OB-GYN Kathleen Morrell points out, “A politician is requiring me to offer you something that’s untested.” But even if you remove the debate surrounding abortion from the equation, the idea sounds preposterous.  For example, this law would be the equivalent of legislating that oncologists must tell a cancer patient about a medication that may or may not work and hasn’t been tested at all.

I, for one, would like for government – whether it be state or federal – to get out of the exam room and leave health care decisions between me and my patient.  Additionally, I’d prefer that if government continues to weasel its way into the exam room, it at least encourage doctors to practice evidence based medicine.


About justgngr

the ramblings of a medical professional by day, judgmental ginger by night
This entry was posted in health policy, medicine, politics and tagged . Bookmark the permalink.

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