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Monday, February 12, 2007

I should have blogged on this NEJM article last week when the WaPo and several other newspapers picked it up. It's a study of the ethical behavior of doctors with regards to referrals, and whether or not they'll allow their personal morality to interfere with their job.

I'll admit I'm disappointed by the results.

A total of 1144 of 1820 physicians (63%) responded to our survey. On the basis of our results, we estimate that most physicians believe that it is ethically permissible for doctors to explain their moral objections to patients (63%). Most also believe that physicians are obligated to present all options (86%) and to refer the patient to another clinician who does not object to the requested procedure (71%). Physicians who were male, those who were religious, and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds (multivariate odds ratios, 0.3 to 0.5).

I think the moral of the story is that you should avoid male and religious doctors. They will make paternalistic decisions that are not in your best interests about your medical care, and they really should just eat shit and die for being so morally sanctimonious. I mean really, you're a professional! Do your job! Since when did it become ok to get a career when you know doing your job correctly will interfere with your moral code? And it's not like you couldn't still be a doctor. Just go into psych, or pathology, or derm, or orthopedics, there are dozens of specialties that would avoid such "moral" conflicts. While the survey was a cross-section across specialties the authors unfortunately did not provide information that would suggest that the doctors who responded incorrectly had decided on specialties that would remove such conflicts from their daily practice. It's hard to tell if this is a real problem if the majority of the docs who said they would withhold information and referrals were those involved in primary care or specialties like OB/Gyn. Either way, it's a sad sign, and taken on its own suggests that you should ask your doctor questions about their moral codes before allowing them to treat you. It's a sad day for medicine as a profession when 14% of doctors feel like they can impose their morality on patients, and a full 29% won't give referrals for things they personally object to.

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Jessica Smith said...

men anyways shouldn't be OB/gyns.

1:13 PM, February 12, 2007

DancingSamurai said...

Ms Smith, that is just about the most sexist statement I have ever heard. Care to back that up with any logical argument?

1:30 PM, February 12, 2007

Jessica Smith said...

In a patriarchal environment, men should not be allowed the kind of control/authority over reproduction that being an ob/gyn entails.

In my experience, male ob-gyns are less comfortable doing their job than female ob-gyns, and are more likely to oppose the use of birth control.

This is not an essentialist argument but one based on the political environment where secretly or not-so-secretly men expect women to be mothers or whores. Both of these expectations become a problem when you're naked in a room with a male doctor who's assigned to examine your genitals and prescribe or not-prescribe birth control.

1:37 PM, February 12, 2007

Jessica Smith said...

I also think that as a female patient, it's more difficult to talk to male doctors about issues that need to come up in a routine gynecological exam. Again, this is not because they're male (XY) but because of various social codes. The talking-to-the-doctor part is so essential that it would be better if women were just assigned to female OBgyns. not that all female obgyns are perfect either.

1:51 PM, February 12, 2007

Rev. Dr. said...

Interestingly, when studies are done on the quality of treatment women get the data usually shows that women generally get crummier treatment from male doctors when it comes to women's health issues (contraception, routine mammograms and reproductive health care). The exception is male OB/Gyns who do better than male PCPs.

Still, I understand why many women would like to have female Gyns, but compared to male PCPs, male Gyns are better at women's health.

2:00 PM, February 12, 2007

DancingSamurai said...

I feel your argument is overly simplistic. Simply because men are more likely to oppose birth control or abortions does not mean that we can conscientiously bar all men from providing those and related services. In addition, there are also women who take these moral stances. Should we now bar all women from practicing Ob/Gyn as well?

Your argument is analogous to saying, because black people are more often arrested for drug dealing or abusing drugs than white people, they should as a race not be permitted to be pharmacists.

The logical resolution to the problem is to bar those individuals whose behaviour or beliefs may interfere with the practice of their profession from said profession.

Note that many Ob/Gyns limit themselves to a subspecialty, such as gyne-oncology, where in my opinion an unwillingness to do abortions would not cause a dilemma.

And what about other medical professionals, such as Family Physicians? In Canada at least, they provide by far the majority of Women's Health services - contraceptive counseling and prescriptions, Pap smears, early abortions, and low-risk pregnancy care & deliveries, to name a few. Should males not be permitted to practice Family Medicine, either?

If we're bringing in anecdotal statements, I have seen many very competent and compassionate male Ob/Gyns, whose patients are happy with their care (and many of whom have been unhappy with care they received at a female Ob/Gyn).

Whether you have a penis or a vagina does not determine whether or not you are a knowledgeable, compassionate, or caring physician.

As a male physician who provides women's health services I am constantly up against a wall of discrimination. Some women take one look at me and decide I'm an inadequate physician not because of my skills or lack thereof (they have not even spoken to me yet), but because I have a penis. How is that different from some people looking at a woman and deciding she makes a bad -insert your choice of stereotypically male profession here-?

2:28 PM, February 12, 2007

DancingSamurai said...

As an addendum, I'm not unsympathetic to the difficulty of talking about "women issues" to non-females in general. This is a large part of the art of medicine -- to be confident and comfortable in doing my job and handle the interview in a manner such that women are put at ease enough to talk about their concerns.

2:34 PM, February 12, 2007

Rev. Dr. said...

Who suggested banning men from these practices? Nobody. I think Jess was expressing a personal preference rather than a discriminatory policy.

If a patient is more comfortable seeing a male doctor or a female doctor for whatever reason, it's entirely reasonable to let them make that choice for themselves. It's also not your job as a doctor to try to correct your patient's sexism, especially if there is a risk that not being able to see the physician of their choice will mean they will avoid getting care.

A lot of people disagree with me on that one, and at UVa they kind of make a point of not letting patients choose the sex of their students/interns/doc once they're in the hospital. I think it's a mistake, it's just not that hard to find a male or a female doctor to take over (in most situations) if that makes the patient more comfortable. You don't want to drive patients away from care, and you're just not going to change the mind of some 70 year-old bigot or sexist, but that doesn't mean they don't deserve medical treatment.

I'm sorry if you get crap over this in your experience, but this data does suggest men are making reproductive decisions for women and not informing them of alternatives. Women, understandably, would look at this and say at the very least if they are going to have a male doc they probably should determine first if he's going to be a moralistic/paternalistic/patriarchal asshole, and decide for her what she should do with her uterus. To be safe, they should do that with female docs too.

I wish there was a breakdown of this phenomenon by specialty. I would suspect that male Gyns are usually more sensitive to women's health issues. Most the OB's I know throw out birth control like candy and never would make choices like this for their patients. They really have no business doing the specialty otherwise, man or woman.

2:45 PM, February 12, 2007

DancingSamurai said...

While Jessica may have meant a personal preference, "men anyways shouldn't be OB/gyns" certainly doesn't say that. If I had said "women shouldn't be lawyers" or perhaps a closer "women shouldn't be urologists", I would (quite justly) have my views questioned.

As for the rest of your post I largely concur with your stance on things. If a patient is uncomfortable with me as their physician, for whatever reason, they're better off seeing someone else. I do worry about this trend and my future career options, though. I have an interest in obstetrical and women's health care and I would hate to lose that as part of my general practice in the future, which is why this topic is such a sore point for me.

The issue in my experience tends to come up with group practices, for example for deliveries. It's usually not a problem to find a female provider to do prenatal care, but the on-call physician (or consultant, in case of complications) for delivery may very well be male. I have heard horror stories of these prejudices disastrously affecting patient care (e.g. a patient refusing to allow the male staff obstetrician into the delivery suite while the poor female resident is unsuccessfully trying to manage a shoulder dystocia).

While physicians have a role in educating patients (and setting a good example), I think part of the onus is on society as a whole to realize prejudice can cut in more than one direction.

Anyway, I didn't mean to sidetrack this post. Thank you for highlighting this important study!

3:54 PM, February 12, 2007

Jessica Smith said...

Sure, when the Rev. Dr. says "I think the moral of the story is that you should avoid male and religious doctors" it's "Thank you for highlighting this important study!" and when I say "men anyways shouldn't be OB/gyns" it's "just about the most sexist statement I have ever heard."

That is why men shouldn't be ob-gyns.

4:20 PM, February 12, 2007

Rev. Dr. said...


If men are acting in a sexist fashion it's not sexist to suggest to women that they avoid their sexist behavior.

Saying men can't do something at all comes across as the reverse extreme. And the Samurai was all pissed because he's clearly in this field. He knows he's avoided, and understands the reasons why, but I'm sure he doesn't feel he should be banned from practice, which was what it initially sounded like you advocated.

4:33 PM, February 12, 2007

Anonymous said...

That is why men shouldn't be ob-gyns.

I though you were just concerned with the male ob/gyn's loss of innocence and romance after a lifetime of poking and prodding through malfunctioning poon.

4:35 PM, February 12, 2007

Jessica Smith said...

rev: i don't think they should be banned, just more thoroughly de-patriarchized before practising. i didn't say they *couldn't* do it.

anonymous: that's actually not a bad point.

4:39 PM, February 12, 2007

Jessica Smith said...

Plus, Rev., you didn't say "I think the moral of this story is that female patients should avoid doctors who act male/patriarchal and/or act on their religious beliefs rather than their professional duties," not in so many words. You said "I think the moral of the story is that you should avoid male and religious doctors." The action/behavior argument is neat, but it's not what you said.

4:47 PM, February 12, 2007


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