SP of Record vs. Alternate SP: A day in the ED

[PACdan]

So, just had a guest lecturer and this scenario came up.

 

A female pt. came into the ED after a rape. Pt. seen by sexual assault nurse examiner and a PA. Pt. is cleared medically and all evidence collected. Pt. states clear desire for an emergency conceptive (before they were available without a prescription). PA charts and writes up orders/script. Physician ON-SITE refuses to co-sign. States that they "did not get into medicine to do harm to anyone, born or unborn". Clearly this is a problem of personal beliefs interfering with approved medical treatments and patient's rights. I digress, the PA must waste time calling their SP of record, who is not in the ED that day, have them call the physician on-site and then have a round-about before he agrees. Time wasted for provider, and more importantly for the patient.

 

In this state/system, PAs have a SP of record AND a list of alternative SPs, which is often numerous (i.e., all attendings in the ED).

 

I find if difficult to understand a system where whoever is there that day dictates your practice and standard of care. Very upending for a PA in a setting with many "alternative supervisors".

 

When I asked why the PA didn't just have their off-site SP of record co-sign the order or proceed regardless of the on-site physician's personal feelings, I was told: "A. Didn't want to injure that relationship (Which I can kind of understand.) and B. What if SP or record was not willing to override the on-site doc?" My response was: "If you and your SP of record aren't in total agreement on emergency contraception availability for rape victims, maybe it's time for a different SP."

 

So my questions are: Does your SP of record, the one with which you have your practice agreement, trump the "alternative" SP of the day? Have any experienced PAs here encountered a similar occurrence and how was it dealt with?

[SocialMedicine]

My guess is the SP on record can trump provided the note is documented of his involvement and if your ED requires co signature he would sign.

 

I'm not so sure this scenario would present in real life. The physician would be committing malpractice in my opinion. I do not think you can refuse advice on plan B methods. This is an emergency scenario in the ED one would need to address it with evidence based medicine. No ?  Interesting scenario..

[ohiovolffemtp]

Some things to think about:

1. Is the "morning after" pill available without a prescription?  In some states it is.
2. Can a PA prescribe medications which induce an abortion?  Would this be considered that?  In some states PA's can't prescribe any medication with the intent of causing an abortion.

Working in the ED, dealing with the different treating & prescribing preferences of different attendings is the norm, not the exception.

[Evolute]

Good question, Ive never encountered that. In Montana our prescriptions do not have to be co-signed so that would never be a problem.

 

As far as one trumping the other, tough call. I would say no, b/c the alternative SP is there (or could be) and can lay eyes on the pt. Having said that I work in rural ED's as solo coverage. My SP of record reviews my charts, but my alternative SP is the doc on call for hospitalist/OB/ED back up. In some ED's I work/have worked my alternative SP is back up by phone only, and/or be over an hour away. I have never discussed a pt with one of them then thought I needed to call my SP of record for a different opinion.    

[PACdan]

My guess is the SP on record can trump provided the note is documented of his involvement and if your ED requires co signature he would sign.

 

I'm not so sure this scenario would present in real life. The physician would be committing malpractice in my opinion. I do not think you can refuse advice on plan B methods. This is an emergency scenario in the ED one would need to address it with evidence based medicine. No ?  Interesting scenario..

 

Unfortunately this scenario did present in real life, some years ago. I have no idea how this physician addressed his own pts. when the issue arose. I would assume malpractice as well, but what is unseen and unheard can only be speculated on.

 

 

Some things to think about:

1. Is the "morning after" pill available without a prescription?  In some states it is.
2. Can a PA prescribe medications which induce an abortion?  Would this be considered that?  In some states PA's can't prescribe any medication with the intent of causing an abortion.

Working in the ED, dealing with the different treating & prescribing preferences of different attendings is the norm, not the exception.

 

Plan B was not OTC at the time. ECPs do not cause abortion, as classified by the FDA, NIH, and ACOG.

[EMEDPA]

in my system my charts are reviewed days to weeks after the pt has already been d/c so this is a non-issue. I write a script, if they don't like it 2 weeks later, too bad.

[PACdan]

in my system my charts are reviewed days to weeks after the pt has already been d/c so this is a non-issue. I write a script, if they don't like it 2 weeks later, too bad.

 

Frankly, this is exactly how it should be everywhere. This wasn't a complicated or dangerous tx for the pt. In fact, withholding it would probably be much more damaging.

 

I feel like the physician was using his supervisory authority to impose his personal will/beliefs on the PA. No good.

[winterallsummer]

This demonstrates a core knowledge deficit in the SP as emergency OCP does not cause abortion and if the fetus were already implanted, it would not harm the fetus (per modern literature).  If I were in this situation, which I have yet to find myself in, I would probably call PCP or OB/GYN and see if they can get the pt seen that day (but unsure if this was in the middle of the night, etc).  Fortunately plan B pills are OTC in many states now.  What a headache!

[primadonna22274]

Dozens of scenarios just like this over more than a decade sent me back to med school so I could untether my license from any SP.

The real problem I see in this particular scenario is the cosignature requirement for a relatively innocuous drug.

That said, I wrote my share of ECP over the objections of my SP of record long before it went OTC.

It's a problem.

[KMD16]

Welcomed to being a PA. This happens all the time spoken and unspoken. It's business as usual. Politics, superiority and personal beliefs at play.

[PACdan]

Welcomed to being a PA. This happens all the time spoken and unspoken. It's business as usual. Politics, superiority and personal beliefs at play.

 

Sure. But there is an area between blindly capitulating and telling the doc to bugger off, and that area is doing what is right for the patient. The PA handled this particular situation quite diplomatically it seems, and eventually got the desired result (minus time and headache).

 

It seems the answer is that the co-sig really created the problem in the first place. Enter a system where this is not immediately required and that precludes said problem.

[Febrifuge]

Since I have recently added some new responsibilities in a second department, I am actually filing an additional practice agreement, and this is fresh in my mind: in my state (Minnesota), PAs can be delegated Rx authority for everything, nothing, or any combination of medications off the buffet line of check-boxes, on the delegation agreement form.

 

(It's pretty crazy; not only is it by DEA schedule, it's by organ system. In theory you could be legally able to prescribe everything BUT ear-nose-throat medications, or legally able to prescribe ONLY those. Likewise, exam/ lab/ imaging/ ordering responsibilities are laid out in exhausting detail, and you can be cleared to do some or all of it. I've always just had every box checked.)

 

The thing is, I've been delegated that prescribing authority. So I'm using it, to prescribe what I feel is appropriate for my patients. They aren't my SP's patients. My SP doesn't get to cherry-pick my responsibilities on a patient-by-patient or day-by-day basis. I would recommend that anyone thinking about this hypothetical situation take a good close look at how their practice authority and responsibilities are actually delegated.

 

Like EMED, my chart review is x% of charts, within n number of months, and nothing requires an MD co-signature at the time of prescribing or ordering, so this would never happen to me. The "doc of the day" might be on my list of alternate SPs, but as far as I can tell, the fact of their being there in person doesn't trump anything. It does say that the alternate may "act as the primary supervising physician," and that they agree to "accept full responsibility" for the care I provide, but I think that's separate from it being their care, know what I mean?

 

"Oh, you wouldn't write for that? Huh. Cool. I would, and I just did."

 

So the 'protecting the relationship' thing, the not rocking the boat thing, is what I would be concerned about, but if I felt it was definitely the right thing for the patient, we could sort that out later. I'm really glad not to work someplace like what's described in the original post.

[whoRyou]

...  I'm really glad not to work someplace like what's described in the original post.

[rev ronin]

ECPs do not cause abortion, as classified by the FDA, NIH, and ACOG.

The problem with this statement is that the FDA, NIH, or ACOG do not make religious decisions, only practical ones.  They can define pregnancy start as implantation, but that has absolutely no bearing on those whose religion defines the onset of life as fertilization.

[PACdan]

The problem with this statement is that the FDA, NIH, or ACOG do not make religious decisions, only practical ones.  They can define pregnancy start as implantation, but that has absolutely no bearing on those whose religion defines the onset of life as fertilization.

 

And particular religious beliefs of the provider should have absolutely no bearing on how one delivers care based on the best medical evidence & wishes of the patient.

 

Inability to reconcile one's personal belief structure and separate the imposition of their will on the patient should result in a reconsideration of their role in medicine.

 

Otherwise one could use a multitude of edicts, spanning many religions, to discriminate or withhold care, not based in medical science, but in personal belief.

[rev ronin]

And particular religious beliefs of the provider should have absolutely no bearing on how one delivers care based on the best medical evidence & wishes of the patient.

 

Inability to reconcile one's personal belief structure and separate the imposition of their will on the patient should result in a reconsideration of their role in medicine.

 

Otherwise one could use a multitude of edicts, spanning many religions, to discriminate or withhold care, not based in medical science, but in personal belief.

So... you'd throw out, what... 20-30% of the potential provider population?  Or you'd expect them to take actions that, according to their own belief system, amounted to murdering babies?

 

Mind you, you don't have to agree that causing the non-implantation of a fertilized ovum amounts to murdering babies, but if you want to have a realistic discussion about medical access and ethics, you need to acknowledge that for a substantial minority of the population, that is in fact precisely what their personal beliefs entail.

 

In the situation as you presented it, no one imposed anyone's will on anyone else.  The MD, from his or her perspective, was asked to take an action that could have ended what he or she believed to be a human life.  As you presented it, no one said "No, the patient may not have Plan B", but only "I will not sign off on that because I believe it has the potential to end a life".  You can argue whether that constituted legally substandard care, but as far as I know, there is no case law contradicting the right of a physician (or any healthcare practitioner) to adhere to the Hippocratic oath.  In fact, if you'll look up Stormans v. Wiesman, you'll find the case law is, at best, unsettled.

[Boatswain2PA]

And particular religious beliefs of the provider should have absolutely no bearing on how one delivers care based on the best medical evidence & wishes of the patient.

 

Inability to reconcile one's personal belief structure and separate the imposition of their will on the patient should result in a reconsideration of their role in medicine.

 

Otherwise one could use a multitude of edicts, spanning many religions, to discriminate or withhold care, not based in medical science, but in personal belief.

You are wrong.  My personal beliefs, including my religious beliefs, have absolute bearing on how I deliver my care, including basing it on the best medical evidence and "wishes of the patient.".  If a patient "wishes to die", I will not assist in their death due to my personal (and religious) beliefs.  Even if I'm sure the "medical evidence" indicates that they will die soon anyway.....I will not push the KCL. 

 

If I were to have a patient who wanted something that I would not do due to personal (or religious) beliefs, I may refer them to someone, but then again I may not.  You want a tattoo of a swastika?  Nope, I'll just walk out of the room.  You want a nipple ring?  I'll hand you a phone book, after telling you a few horror stories.  You want an abortion (or, last time this came up with me it was a mother DEMANDING that her 16 yo daughter have an abortion), then I will simply tell you I don't do that, I might add "Congrats, you're a grandma."  If you want me to prescribe RU-486, nope.  I may point you to someone who would, but then again I might not (haven't been put in that situation yet).  You need methotrexate because your ectopic is going to die anyway, and might take you with it?  Okay.

 

Don't pull the "discrimination" bullshit.  The only populations in the United States that it is "legal" to discriminate against are white males and Christians.  I could just as easily say that YOU are discriminating against me.  But...like I said, that's okay in our society.

[rev ronin]

Don't pull the "discrimination" bullshit.  The only populations in the United States that it is "legal" to discriminate against are white males and Christians. 

I wouldn't narrow it down like that.  At my last job, the freedom of conscience issue was recently raised by a physician who was concerned that without a good policy, she would have no defensible reason to avoid offering or referring for female genital mutilation, should it be asked of her in the future.

[PACdan]

If you're not willing to provide the standard of care, and you're the provider that is the barrier to that care, you should be obligated to find someone who is able to replace you. That's the situation as described. The patient desired an ECP. The only physician on-site was not willing to co-sign the PA's script. Everyone had to run around for him to solve the problem.

 

I wouldn't be so callous to dismiss the rape victim and what they're going through. Your beliefs are your own, that's fine, but don't make others suffer for them. If you're not able to provide the medical care, go get someone in who can so your conscience can be clear. We're not taking about nazi tats or crazy mothers, we're talking about widely accepted medicine. Treatment accepted by Islam according to the Hadith and Catholicism to name a few.

[Boatswain2PA]

What is the "standard of care" in this situation? Can you provide a reference for that?

 

I would never "dismiss a rape victim" or any (intentionally) dismiss any other patients concerns.

 

I dont think RU-486 is acceptable to Catholicism because life begins at moment of conception.

[PACdan]

What is the "standard of care" in this situation? Can you provide a reference for that?

 

I would never "dismiss a rape victim" or any (intentionally) dismiss any other patients concerns.

 

I dont think RU-486 is acceptable to Catholicism because life begins at moment of conception.

 

You are confusing RU486, an abortifacient, with Levonorgestrel (Plan B), which is not. 

 

 

They are very different drugs, with different mechanisms. The drug in this case is Levonorgestrel. Plan B is designed to prevent fertilization by inhibition of ovulation. It is generally accepted that it cannot prevent implantation of a fertilized ovum. Nor disrupt an already implanted one. This is acceptable to the Catholic Church, as this is not then conception.

[rev ronin]

If you're not willing to provide the standard of care, and you're the provider that is the barrier to that care, you should be obligated to find someone who is able to replace you. That's the situation as described. The patient desired an ECP. The only physician on-site was not willing to co-sign the PA's script. Everyone had to run around for him to solve the problem.

 

I wouldn't be so callous to dismiss the rape victim and what they're going through. Your beliefs are your own, that's fine, but don't make others suffer for them. If you're not able to provide the medical care, go get someone in who can so your conscience can be clear. We're not taking about nazi tats or crazy mothers, we're talking about widely accepted medicine. Treatment accepted by Islam according to the Hadith and Catholicism to name a few.

Rape is indeed horrible, but there was nothing in that situation that that MD could have done to change what already transpired.  All he or she can do is react to what is within his or her control.  Again, what does that MD ostensibly believe? That "emergency contraception" can act to prevent the implementation of a fertilized egg.

 

That potential fertilized egg is a second, living human patient to the provider who believes life begins at conception.  Is it ever OK in medical ethics to risk killing patient B because patient A is hurting?  Again, medical consensus groups do not get to decide what life is or is not, that is a fundamentally religious--if not *the* most fundamentally religious--question. So, to the MD in the events as you posed them, the standard of care would be to NOT act in a way that could jeopardize the potential second patient, and there is no other action consistent with the Hippocratic oath other than to refuse to act as requested.

 

And while I'm sure you can find some Catholics who support any particular stance on anything, the plaintiffs in Stormans v. Wiesman specifically cite their Catholic beliefs as reasons for choosing to not carry Plan B in their pharmacy.

[rev ronin]

It is generally accepted that [Plan B] cannot prevent implantation of a fertilized ovum.

It may be generally accepted, but it is specifically at issue in Stormans v. Wiesman that the state doesn't get to sit in judgment on what conscience beliefs are reasonable or not.

 

How about reading a Friend of the Court brief on the matter--from those wackily fringe religious nutjobs... the American Pharmacist Association! http://www.becketfund.org/wp-content/uploads/2011/02/Final-APhA-WSPA-Amicus-Brief.pdf

 

TD;DR version: They believe the right of conscience should not be infringed upon by state regulations.  Oh, and 33 other pharmacy organizations do, too.  Several of them are quoted starting on page 15 of the brief.

[PACdan]

I wonder how far I can take my "right of conscience" in abstaining from providing care, as my conscience and personal beliefs deem fit.

[rev ronin]

I wonder how far I can take my "right of conscience" in abstaining from providing care, as my conscience and personal beliefs deem fit.

Well, one test the courts have made is whether a particular belief system is sincerely held.  If you want to declare yourself an adherent of the Flying Spaghetti Monster and only practice with a colander on your head (Wikipedia it), you're going to have a harder time establishing that than if you're a registered tribal member asserting that hallucinogenic mushrooms ingested as part of traditional Native American religious practices do not make you an impaired provider despite Peyote being Schedule I.

 

Many secular objections to religious conscience clauses fail to address this--that only a sincerely held religious belief counts, and even if you make up your own religious body (e.g., the Church of Body Modification) to try and claim a religious accommodation, the courts are not idiots and don't let everything go with an "Oh, ok, well, it's a religion then, so all hands off, right?"  In order to obtain conscientious objector status in the U.S. at various times one had to demonstrate membership in an established religious denomination which had an historic objection to armed service--one couldn't simply be a conscientiously objecting Roman Catholic, but one could as a Seventh-Day Adventist, Mennonite, or Jehovah's Witness.