Friday, June 29, 2018

How not to handle conscientious objection

On the evening of June 21, Nicole Mone Arteaga went to Walgreen's Pharmacy in Peoria, Arizona (a suburb of Phoenix) to fill a prescription for misoprostol. The 9 week fetus in her longed-for pregnancy had no heartbeat, and the pregnancy would end in a miscarriage. She chose a medical rather than surgical removal of the non-viable fetal tissue.

When she arrived at the pharmacy, staff pharmacist Brian Hreniuc asked if she was pregnant. On hearing the answer he told her his "ethical beliefs" forbade him from filling the prescription. According to Ms. Arteaga's Facebook post her 7 year old and five customers could hear the exchange. The result: "I left Walgreens in tears, ashamed and feeling humiliated by a man who knows nothing of my struggles but feels it is his right to deny medication prescribed to me by my doctor."

Next day Ms. Arteaga was able to fill the prescription at another branch of Walgreen's. 

Arizona law allows pharmacists to exercise conscience as Mr. Hreniuc did. And while reflective individuals differ on whether professional responsibility to serve one's patients or individual conscience should rule in situations like this, my Catholic friends have helped me understand how for Mr. Hreniuc, filling the prescription could make him feel complicit in what he might see as a mortal sin. But as experienced by Ms. Arteaga, he did not communicate in the right way.

Here's what needed to be done. (1) "I'm so sorry for what you are going through." (2) "I have to refer you to another pharmacy/pharmacist." (3) "I want to wish you the best for the future." The conversation should have been private, not audible to others. The tone should be warm, caring and apologetic, not self-righteous. Ideally, Walgreen’s would have systems in place so that patients would not encounter pharmacists who were not willing to fill their prescriptions. And for those like Mr. Hreniuc, there should be rigorous training in how to communicate in a manner that respects the needs of patients as well as the conscience claims of the staff.

It's not impossible that Mr. Hreniuc conducted himself this way. The pain of the situation could have prevented Ms. Arteaga from experiencing an effort at compassion. I know from experience that this can happen. Many years ago I came upon a distraught couple at the health center where I worked. They had just received bad news. The husband had cancer. I had recently taken a course on dealing with bad news. I sat down with the couple and spoke with them. I'm reasonably confident that a videotape would have shown that I applied what I had learned.

A week or two later a letter of complaint came to the administrator of the health center (me) from the couple. The letter described the cold, cruel person they had encountered (me). For me it was a chastening lesson in the potential difference between what is intended and said by the clinician and heard by the patient.

Arizona state Sen. John Kavanagh, co-sponsor of the 2009 law that allows pharmacists to refuse to fill abortion or emergency-contraceptive prescriptions based on moral or religious beliefs, showed a shameful defensiveness and lack of empathy in his comments on Ms. Arteaga's experience:

He said he was surprised that Arteaga wasn't more sympathetic with the pharmacist, given that she eventually was able to get the medicine from another Walgreen's location. "What's the problem?" he said. "She got what she wanted. The pharmacist complied with the law. I don't see why she doesn't respect the pharmacist's right to not do this," he said.
In her Facebook post Ms. Arteaga shows an admirable understanding of the situation: "I get it, we all have our beliefs." She appears to accept the issue of conscience but rightfully does not accept the way the conscience exception was carried out. In her response - a public post and a complaint to Walgreen's management - she is being an ideal advocate. Her complaint gives Walgreen's, and  professionals who might invoke conscience in not offering a medically indicated legal service, guidance in how to conduct themselves in a more ethically admirable manner.

Sunday, June 24, 2018

The Moral Vision of Primary Care

The underlying vision of primary care is to do what is needed to promote and restore health. Sometimes this requires referring patients to specialists, but more often it is done directly.

An article in today's New York Times about Dr. Nicole Gastala describes how the young physician, just out of residency and paying off her loans through practice in a community clinic in Marshalltown, Iowa, encountered the opiate epidemic and decided to do something about it. She did the required training to be licensed to prescribe buprenorphine so that she could provide medication assisted treatment to patients with opiate addiction. She got a federal grant that facilitated starting a program and hiring a nurse to join her in staffing it. She continues her own education via telemedicine with a clinic in Connecticut that provides consultation and education to primary care buprenorphine providers. She has strengthened her own capacity for acceptance of patients who relapse. And, as she and her husband prepare to move back to Chicago, she is taking steps to perpetuate the buprenorphine program.

For the past twenty years I've had the privilege of co-facilitating a "patient-doctor" seminar for superb primary care residents throughout the three years of their residency. They've reported how frequent it is to hear versions of "you're so smart and capable - why aren't you going into a medical specialty?" As I thought about their choice of primary care, the Buddhist concept of Bodhisattvas of Compassion came to mind. I've written before about the statue of Guanyin at the Boston Museum of Fine Arts. In Buddhist tradition, Bodhisattvas are enlightened beings who choose to remain among mortals to alleviate suffering.

This vision is available to any and all health professionals, and of course to others in professions like education. But in medicine I see primary care as the purest form of the "Bodhisattva-like commitment," since it puts the fewest filters between the individual physician and the full range of human suffering. The article in today's New York Times does not contain high falutin language, but the simple story of a young physician's post-residency practice gives a down to earth picture of the moral vision underlying primary care.

Addendum: The July 5th issue of the New England Journal of Medicine has an excellent article on "Primary Care and the Opioid-Overdose Crisis: Buprenorphine Myths and Realities." If you've read this far I urge you to follow the link to the NEJM article.

Friday, June 22, 2018

Civil Society and Doctor-Patient Sex

On June 4 the Boston Globe reported that for two years the Massachusetts Board of Registration of Psychologists had taken no action on Ms. Lisa Grover's complaint of abuse by her therapist, Dr. Mel Rabin. In a subsequent article the Boston Globe told readers that the next day Dr. Rabin surrendered his license, "acknowledging that he put the patient 'at risk of harm' and failed to maintain professional boundaries." In response to Dr. Rabin's letter the Board revoked his license, information that can be found on its website.

In cases with allegations as serious and believable as those brought forward by Ms. Grover, a professional board must act, as by suspending the practitioner's license while the case is investigated, by requiring monitoring of the practice, or some other way of protecting the public. Failing to act invites public distrust of the regulatory process and of the profession itself, and exposes the public to avoidable risks. In Dr. Rabin's case the media report accomplished what the Board of Registration should have done two years earlier.
 After I published my initial post on the situation I spoke with Ms. Grover. Our conversation highlighted two additional issues - the mysterious sources of resilience and the power of peer support.

When Ms. Grover came to see her relationship with Dr. Rabin as exploitative, she determined to land on her feet and to do all she could to protect others from comparable abuse. She's not clear where her strength came from. Her family was supportive, but there was also an internal resolve to speak out. It's not uncommon for legal settlements to include a gag order, under which the complainant agrees not to speak in public about the situation in return for the financial agreement. Ms. Grover refused to accept any such requirement.

She made her way to the TELL (Therapy Exploitation Link Line) website where she "met" others struggling with their own experiences of abuse. Meeting peers strengthened her resolve and sharpened her sense of how to take effective action on behalf of others and for her own healing. She is working with other volunteers to respond to the 40,000 hits TELL receives each year.

 In Ms. Grover's situation, government regulation (the psychology licensing board) failed, but civil society - in the form of the press (the two  Boston Globe articles) and peer support (TELL) - came though. Dr. Rabin did not govern himself by the ethics of his profession, and the licensing board was dilatory in its response, but resilience, the press and peer support helped Ms. Grover move from victimization to effective advocacy.

Monday, June 4, 2018

Doctor-patient sex and professional self-regulation

The topic that has attracted the largest readership on this blog is doctor-patient sex. In the past 10 years the 30 posts I've written on the topic have received 75,000 hits. An article in today's Boston Globe focuses on an aspect I've discussed only briefly thus far - professional self regulation.

The story concerns a complaint from Ms. Lisa Grover that Dr. Melvin Rabin, the psychologist she sought out when her marriage broke up, drew her into a sexual relationship. Grover's allegations dramatize the way "boundary crossings" like calling the patient at home "just to talk," calling the patient a "special person," and hugging at the end of the appointment, can lead, over time, to "boundary violations" like sex. Apparently Grover brought a malpractice action against Rabin which, the article reports, was "settled for an undisclosed sum."

In February 2016 Grover complained to the Massachusetts Board of Registration of Psychologists, but the case is still "open" and Dr. Rabin's license is still unrestricted.

A core component of the implicit contract between the health professions and society is that in exchange for the autonomy and trust society gives to the professions, the professions will regulate themselves with regard to quality and integrity. Two years is much too long for a professional board to leave a serious complaint like Ms. Grover's unsettled.

In dealing with complaints of the kind Ms. Grover brought, a board must consider three values:

First and foremost, safety for patients. If the board believes Ms. Grover's accusations, it should have suspended Dr. Rabin's license. A therapist who acted as Ms. Grover describes should not have an unrestricted license, which allows unrestricted, unmonitored access to patients. What Ms. Grover describes, if true, is very serious misconduct.

But second, a board must also recognize that complaints are not necessarily true. The board must consider fairness to the accused.

I know this first hand.When I joined the Harvard Community Health Plan practice in 1975, one of my first patients was a sensitive and vulnerable young woman with a mild autism spectrum disorder. The treatment was proceeding well until I cancelled an appointment because I was going away. My patient contacted the psychiatry board to complain that I had molested her. Psychologically my cancellation felt to her like a "molestation." By the time I heard from the board my patient and I had resumed meeting and the treatment was again on track. She explained that she had been upset by the cancellation and apologized for what she said to the board. I didn't appreciate at the time just how serious a threat a false accusation could be.

To the credit of the Boston Globe, the headline to the article refers to an "alleged betrayal." But if the Board does not believe Ms. Grover, it should have closed the case by now. Two years is too long for the case to be in limbo. A false accusation is a serious injury to the clinician.

Finally, a professional board should conduct itself in a way that fosters trust in the profession. The story reported in the Boston Globe does the opposite.

(In addition to the Boston Globe article describing Ms. Grover's allegation, readers may be interested in an interview with Dr. Rabin in which he describes himself and his approach to therapy.)