Keeping politics out of the exam room

Written by Mark Ryan, MD, Vice President of Communications for the National Physicians Alliance, and crossposted from Ramifications – the Richmond Academy of Medicine magazine

As a family physician, each time I see a patient I have a number of issues I try to cover. I see how my patients are doing with their chronic medical problems, assess for side effects of treatments, update refills and order necessary labs and tests. I also try to handle any current or newly developed problems that might have arisen since a patient’s last visit. Finally, given the long-term relationship that is central to what I do, I look at any preventive care that might need to be addressed and counsel my patients on areas where their choices may impact their health. We talk about smoking and tobacco use, alcohol use, STI prevention, using bike helmets and seatbelts and other important issues that can help avoid injury or illness.
This process is seen most clearly during well child visits for our pediatric patients. An important part of these visits is providing anticipatory guidance, which means we talk about the child’s current development, discuss what developmental milestones are coming up (moving from crawling to walking, speech development, social interactions and new language skills) and what safety measures need to be considered — being sure to childproof the home, avoiding choking hazards and the like.
Central to all this work is the physician-patient relationship. When I work with patients, my principle responsibility is to do right by them, provide the care they need and avoid interventions that are not needed and that could be harmful. I partner with patients to share the decisions as to how best to proceed and advise what benefits and what risks might be present in any decision. My commitment to my patients’ health builds confidence and trust and makes our physician-patient partnership ever stronger.
So imagine a scenario in which I am unable to provide the medical care that I believe is needed or the anticipatory guidance that is appropriate because a legislature has decided that it knows better than my patient and I do. Imagine that legislation dictates what I can or cannot share with my patient or that legislation dictates what I must say, even to the extent of requiring me to give my patient medically inaccurate information. If we value our relationship with our patients and if we feel our obligation to do right for and by our patients is central to who we are as physicians, how can we accept this legislative intrusion into this privileged doctor-patient relationship?
This may seem far-fetched, but it is not. Already in Virginia, the legislature has dictated what we must tell our patients under certain conditions. In 2013, the General Assembly passed, and the governor signed into law, a bill that requires any physician ordering Lyme disease labs to provide a written advisory to patients about the potential issues with the labs. Not only that but the legislation also contains the specific language physicians must use in this advisory. There is no choice: Patients must receive this written information. It’s the law.
As someone who values the doctor-patient relationship, and is fortunate to teach this topic at the VCU School of Medicine, I believe physicians should counsel patients on issues such as this. However, I do not agree that the exact and specific language of this counseling should be codified into law. As Dr. Sterling Ransone, past president of the MSV, worried in a 2013 interview, “It’s a dangerous slide by the General Assembly. We don’t feel it’s the General Assembly’s job to codify the practice of medicine. My worry is, ‘What is next? What is the next disease du jour?’ Emotion frequently rules the day.”
Another example of legislative overreach in Virginia is the requirement that any woman seeking abortion services must undergo a transabdominal ultrasound before the procedure. Initially, this legislation could have required a transvaginal ultrasound, but this option was removed during the legislative deliberations around the bill. However, the law was passed and signed into law, forcing women who seek a legal healthcare service in the commonwealth of Virginia to undergo a medically useless test — even if their physician does not see any need or if the patient attempts to refuse.
Sadly, this legislative intrusion is not unique to Virginia — it is an example of a national trend of legislators deciding that they know the practice of medicine better than physicians and dictating medical care accordingly. A new report released in October 2015 —and co-authored by the National Physicians Alliance (NPA), the National Partnership for Women and Families, the Natural Resources Defense Council and the Law Center to Prevent Gun Violence — outlines the extent to which legislatures have intruded into the practice of medicine and the sanctity of the doctor-patient relationship. Some examples:

  • The chemical solutions used in hydraulic fracturing (“fracking”) have been identified as trade secrets whose specific chemical components may be known to a limited number of people. The treating physician may be informed of this information, for example, but be unable to tell his/her patient to which chemicals that patient may have been exposed.
  • A number of state legislatures have intruded in the areas of reproductive health and abortion services. States may require unnecessary ultrasounds (as is the case in Virginia), and in some cases if a woman declines to view the ultrasound, the ultrasonographer is required to describe the image to the patient. Other states require abortion providers to give medically unfounded or inaccurate counseling.
  • In Florida, asking patients if there is a gun in the home — an important part of pediatric well child visit anticipatory guidance, given the risk of harm that results from firearms in a home, especially if not stored safely — can result in a physician facing a fine and/or losing his/her medical license.

No matter their politics, I trust that all physicians would agree that the obligation physicians have is to care for their patients in the way that best meets their patients’ needs. I also trust that all physicians would agree that legislatures — state or national — have no role in dictating the nature of medical care that occurs in the exam room. Every physician I know bristles at insurance companies imposing their overview on our medical decisions. We struggle to work with medication formularies, we complain about the need to request prior authorizations for treatments, imaging or procedures, and we argue over third-party reviewers who deny our requests. How much more upset should we be, then, when the very foundation of trust between physicians and patients is threatened?
The NPA has led the medical community’s response to this issue as a co-chair of the Coalition to Protect the Patient-Provider Relationship. NPA has been joined in this coalition by multiple medical organizations which together represent the vast majority of American physicians, including the American Medical Association, American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association. In Virginia, the coalition’s work can build on the existing policies of the state’s constituent chapters of these national organizations, including the Medical Society of Virginia’s focus on protect ing the physician-patient relationship.
Physicians’ ability to provide evidence-based, patient focused care is under threat across the United States, and Virginia’s General Assembly has already forced its way into our privileged obligation to our patients. As we move through the 2016 legislative session, we must all be mindful of this risk and work with the MSV and our respective state specialty societies to preserve our special place in patients’ lives and continue to help them live the healthiest lives possible.