Physicians can no longer impede access to care: are we on the right path?

I was quite happy to read last week that the CPSO updated its policy to now state that doctors moral or religious convictions cannot impede patient’s access to care, and that doctors could face disciplinary action if they refuse to at least refer patients on. I have no problem with doctors refusing care in certain instances, as long as they ensure the patient gets to see another physician in a reasonable amount of time who is willing to provide appropriate access.

The ethics behind such a situation are interesting to consider. The core principles of medical ethics (autonomy, beneficence, non-maleficence, and justice) are widely accepted and generally hold across societies and cultures. But the rest of medical ethics, the shades of gray, are largely influenced by the moral standards of the society in which a particular doctor practices. That is why I believe that it is more important for patients to have access to medical standard of care than it is to “protect” doctors who have moral or religious objections.

The primary example that is always used in this argument is that of family or walk-in doctors refusing to prescribe oral contraceptive pills (OCP), which has happened recently in Calgary and Ottawa. Personally, I can’t believe that in 2015 there are Canadian trained doctors who refuse to dispense OCP even if their religious upbringing has taught them it is somehow “wrong”. But the previous CPSO policy of allowing doctors to refuse treatment *and* refuse to refer patients on sets a bad standard that places already vulnerable patients in a precarious situation. For example, what should happen if a pediatrician refuses to provide care for a baby girl because her parents are a single-sex female couple? Sounds like a disgusting situation that is made up, right? Nope, it happened just last month (in the US, but still). Under the CPSO’s prior policy, the pediatrician has the full right to refuse to care for the baby, and has no obligation to find another pediatrician who will. And what if that baby lived in a remote area with only one pediatrician in town?

I fear that the new policy doesn’t go far enough, as many patients will not be aware that their doctor must provide an appropriate referral; they also likely won’t know that this is now a situation whereby a complaint could lead to disciplinary action. I have argued before (in reference to physician assisted dying) that medical laws and practice guidelines in Canada should be dictated by the wishes of the majority of Canadians, not by the majority of doctors. That is why the 92% of the Canadian public who favor this new policy should outweigh the “vast majority” of doctors who oppose it. Physicians are employed to treat their patients, not to assuage their own moral or religious baggage.

CAM research: who are we trying to convince?

Like many others, I was quite surprised to hear this week that the Dean of the University of Toronto’s Faculty of Pharmacy, Dr. Heather Boon, was organizing an RCT evaluating homeopathy in the treatment of ADHD. I don’t need to include any links explaining why homeopathy is complete quackery, simple google it. Dr. Boon lectured my medical school class numerous times over my four years at the University of Toronto; she was an excellent teacher and was reasonably skeptical regarding the limited evidence within the field of complementary and alternative medicine (CAM).

Dr. Boon wrote last fall that universities are the best places to get “answers on integrative medicine”. While this is technically true, it doesn’t mean that time and money should actually be spent by academic researchers on disproving every claim regarding natural or homeopathic remedies. Before I could get this post up, Dr. Mario Elia wrote an excellent rebuttal arguing that CAM research is like throwing good money down the well. Dr. Elia explains that with limited funding for research, the scientific community should really focus on treatments that have some shred of scientific plausibility.

There is one other point I wanted to make in arguing that this type of research is a waste of time and money. Whose practice is going to change based on the outcome of this study, or of studies of other, (slightly) more scientifically plausible, natural remedies? Those in the medical community are in no way going to believe a positive outcome, particularly for anything with the word “homeopath” associated with it. And those who peddle this nonsense, and most of those who already believe in it, are not going to change their minds regardless of how well an RCT is run. Homeopaths make money selling their magic water, and will find some kind of excuse to ignore any negative studies. And some (or most) of their customers have this psychology of distrust of the medical community, and their conspiracy-type thinking will not be swayed by evidence that goes contrary to their fixed beliefs (similar to anti-vaxxers).

If a CAM remedy is shown to have some modest benefit for a disease or symptom, then great; that “alternative medicine” will forever be known as simply “medicine” and will have uptake within the world of healthcare.  But I am already dreading the first university-sponsored positive study regarding anything outlandish (like natural herbs to treat cancer, or again, anything homeopathic). Because here is what will happen: backlash from the medical community will expose how and why the results are invalid. And the backlash to the backlash from those who practice and preach CAM will further entrench their fixed beliefs. And in an attempt to take one step forward, we will have taken two steps back.

Choosing primary care: why is Canada different than the US?

It is a slow night on call at the hospital, and I came upon an excellent article called “Why I’m becoming a primary-care doctor” in which a medical student at the University of Pennsylvania discusses her choice to enter a family medicine residency. I was shocked at two aspects of the story: first, that only 12% of graduates in the US residency match ended up in primary care specialties, and second the disdain which the author feels many of her classmates and some of her preceptors have for family medicine.

In Canada in 2013 (the year I matched to residency), 37% of all graduating medical students matched to family medicine as their top choice of programs. Where I trained, at the University of Toronto, home to some of the most highly sub-specialized programs and staff physicians in the country, 33% of students chose family medicine as their top choice. And that doesn’t include pediatrics, from which many graduates will go on to become primary care pediatricians. (In Canada, internists are not generally considered primary care doctors, in contrast to the US).

In terms of attitudes, I have personally never heard any classmates, residency colleagues, or staff doctors echo the sentiment that “on family medicine, the intellectual rigor is not there”. And this article made me wonder what is fundamentally different between Canada and the US systems whereby primary care medicine is viewed so differently. While I cannot claim to know the answer, I have some hypotheses I would like the throw out there.

Many of the academic (and community) hospitals in Canada have family care practices based physically at the hospital (or close by). This fosters stronger relationships between subspecialists and family doctors. If a complete separation between family doctors and hospital-based specialists occurs, there is a greater risk of one group looking down on the other. And since in the US the differential in salaries between specialists and family doctors is enormous, it is not surprising that the general public, and the specialists themselves sometimes think that “a monkey could [practice general medicine]”. Also, since historically one-third to one-half of medical students go into family medicine in Canada, I would presume nearly all Canadian doctors have friends in the specialty and gain an appreciation and understanding for the job they perform.

During my time on the general internal medicine ward, anytime a patient was admitted with a complex medical history or in whom the diagnosis was unclear, my first act the next morning was to personally speak to the patient’s family doctor to gain further insight into the issues at hand. And every time I discharged a patient, I instructed them to see their family doctor the next week so that their GP knew what had happened to them, and to make sure the patients were coping well at home. I have no data to back this up, but I believe patient care is better because patients have access to excellent family doctors that provide continuity of care.

Overall I am glad that I work within a system with a strong and well-respected force of primary care physicians fostering long term relationships with their patients, treating a wide range of illnesses, and taking charge of preventative care where some of the biggest gains in the health of our population can be achieved.