Thursday, May 19, 2011

Modern Medical Ethics

The issue of obesity is a really big one, no pun intended, and is only getting increasingly so, across all areas of medicine. Obese patients have a higher risk of complications in general, and the patient population in this country, as a whole, is becoming more obese. But it is particularly relevant, and of personal importance to me, regarding obstetrics. OB/GYN is a specialty I am very, very interested in... it's only my first year of school, and I'm trying to keep an open mind, here, but I really just think I would love to do OB. I get really excited thinking about it; I even think I might be kind of good at it. 
Anyway, there are serious downsides to this choice. The lifestyle of delivering babies aside, obstetricians face some of the highest rates of malpractice suits, and consequently, some of the highest malpractice insurance rates in medicine. Anything wrong with baby, and it is pretty tempting and pretty easy to turn around and blame the OB--and then pretty much impossible to prove that it wasn't her fault. For the most basic and natural of human processes that can and does go wrong in any countless number of ways and to any countless number of degrees, this strikes me as a tad unjust (can you tell that this is already a little bit of a personal sore spot for me?) All that to say, pregnancy for an obese patient can be a huge risk--in a medical specialty that already faces a lot of risk and high penalties for taking on that risk. 
On the other hand, it seems pretty clear that refusing a patient based on their weight is downright unethical, and most certainly not in the spirit of caring for those in need. And as the population continues to get bigger and bigger, this issue will only continue to grow as well.

What do you think about this?

Some ob-gyns in South Florida turn away overweight women

By Bob LaMendola, Sun Sentinel

In a nation with 93 million obese people, a few ob-gyn doctors in South Florida now refuse to see otherwise healthy women solely because they are overweight.

Fifteen obstetrics-gynecology practices out of 105 polled by the Sun Sentinel said they have set weight cut-offs for new patients starting at 200 pounds or based on measures of obesity — and turn down women who are heavier.

Some of the doctors said the main reason was their exam tables or other equipment can't handle people over a certain weight. But at least six said they were trying to avoid obese patients because they have a higher risk of complications.

"People don't realize the risk we're taking by taking care of these patients," said Dr. Albert Triana, whose two-physician practice in South Miami declines patients classified as obese. "There's more risk of something going wrong and more risk of getting sued. Everything is more complicated with an obese patient in GYN surgeries and in [pregnancies]."

Plantation ob-gyn partners Jeffrey Solomon and Isabel Otero-Echandi turn down any woman weighing more than 250 pounds.

Solomon and Otero don't want to begin seeing heavy women and then have to send them to specialists if they later develop problems, said their office manager, who asked not to be named. The two doctors, like several of the others with weight cutoffs, declined to comment.

"This is not a high-risk practice," the office manager said. "They are not experts in obesity."

Turning down overweight people is not illegal for doctors, but the policy worried leaders of physician groups, medical ethics experts and advocates for the obese, all of whom said it violates the spirit of the medical profession.

"If I had that policy, I wouldn't have a practice. I'd lose half my patients," said Dr. Maureen Whelihan, a West Palm Beach ob-gyn. "We never turn down anyone. We would see them, and if we had to, we would refer them to a specialist."

Leaders of eight local, state and national medical associations said they had never heard of doctors turning away patients solely because of weight. Several said obese people with no other health issues do not need special treatment.

"No doctor should be unable to treat patients just because they are heavy," said Dr. Bruce Zafran, a Coral Springs ob-gyn.

So far, the weight cutoffs have been enacted only by South Florida ob-gyns, who have long complained of high numbers of lawsuits after difficult births and high rates for medical-malpractice insurance. More than half go without coverage.

Ob-gyns for years have declined to see pregnant women who are overweight, typically sending them to specialists. It's new for them to turn down overweight women who are not pregnant, physician groups said.

Several ob-gyn offices said their ultrasound machines do not give good images of internal anatomy in obese women, making it harder to diagnose some medical problems.

The Plantation office manager said weight limits are not uncommon at offices owned, like hers, by the Coconut Grove medical services company VitalMD.

VitalMD treasurer Kerry Kuhn, an ob-gyn in Coral Springs, said he was unaware of his doctors setting weight limits, adding the company has nothing to do with doctor decisions.

"This is individual choice by a doctor," Kuhn said. "Doctors know who they want to treat."

Physicians, like any business, can decline service to whomever they choose for any reason — including personality conflicts — as long as it's not discriminatory. The American Medical Association advises doctors that they cannot reject patients because of race, gender, sexual orientation or infectious diseases.

Doctors also are allowed to drop patients, if they believe they lack the medical skills to properly treat them. They must send notices and refer them to other doctors.

But decisions about patients typically are made after assessing the individual's condition during an exam, not by ruling out an entire group, said Dr. Robert Yelverton, a board member of the Florida Obstetric and Gynecologic Society. He said he would discourage physicians from excluding the obese.

"Do I think it's a good policy? No," Yelverton said. "Overweight people need doctors. I don't know where a patient in that situation would go if every practice had that policy."

The AMA and the ob-gyn group declined to comment on doctors setting weight limits. A spokesman for the Obesity Action Coalition in Tampa said the restrictions sound like discrimination.

"This completely goes against the principles of being a doctor," James Zervios said. "Health care professionals are there to help individuals improve their quality of health, not stigmatize them according to their weight."

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