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Today a young woman came to see me for the first time at my OB/GYN clinic who very recently had a massive PE and is now on blood thinners. She has no known risk factors or family history other than being on the OCP and hypercoag labs are still pending. According to the CDC's US Medical Eligibility Criteria for Contraceptive Use (USMEC), progestin only contraception for a patient with acute DVT/PE is a Level 2 risk ("Advantages generally outweigh theoretical or proven risks"). After a long conversation and a review of the possible remaining risk of potential problems, the patient elected to start progestin only pills (readily reversible) to control what she describes as very heavy menses that interfere with her ability to go to work and school. As a courtesy, I sent the chart with my very careful and detailed documentation to her primary care doctor and she went INSANE. She fired back at me that POP and Nexplanon (didn't even mention this ...) were CONTRAINIDICATED (Uh, no, they're not) and of course ... wait for it.. YES, a real doctor needed to make this decision. After 15 years of practice and so much care and concern for this young women (I have a daughter her age!!!) why do I have to be left feeling like some kind of unqualified moron ... Ugh. So tell me, what would you have done in this situation?

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As a primary care PA i would have referred to obgyn to discuss options and then likely followed their recommendations. I had a very similar situation happen, referred to OBGYN, who didn’t want the patient to be on any hormonal therapy. My patient also was concerned about hormonal therapy and opted for an ablation procedure to control bleeding after finishing anticoagulation, as she was done having kids. Given the avaliable evidence, POP isn’t unreasonable either, and as long as the patient knows the benefits and risks you’ve done your job. If you were my consultant, I wouldn’t have questioned your thought process or decision making in this case. If you have a good SP who has your back just have them call or send the PCP a message stating that they as the real doctor agree with your decision-making and that they will no longer recommend this PCPs practice for their patients who are looking for PCPs. 

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ugh...

well on her I would have d/w the doc - just CYA for this exact issue - the joy of "dependent" practice..... grumble....

you can guarantee that this PCP will now through a  B**** fit about "those darn midlevels not knowing anything" and make us all "look" bad for what seems like a very reasonable plan

 

 

Also in these cases I will actually make the patient sign and informed consent also as CYA

 

 

I am not a ob/gyn provider so take this with a grain of salt - I would say a copper IUD 

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Guest UVAPAC

If I were you... I would speak with your supervising physician... explain the situation... and have them call the primary care physician and lambast them for their use of words.  Then explain that your decision was well within medical guidelines/standards, and next time to speak with them directly prior to criticizing your decision making or qualifications.  

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14 hours ago, marktheshark89 said:

...If you were my consultant, I wouldn’t have questioned your thought process or decision making in this case. If you have a good SP who has your back just have them call or send the PCP a message stating that they as the real doctor agree with your decision-making and that they will no longer recommend this PCPs practice for their patients who are looking for PCPs

I don't really do undercarriage work, but your thought process sounds well thought out and reasonable.  I think there are a number of studies showing that progestin only formulations don't increase clotting that support your clinical desicion making.

1. If the pcp referred the patient to you, and doesn't take your advice, hey, that's on them. Document.  Talk to your pcp.  If they act surprised at your decision, probably time to find a place that practices EBM.

I would talk to your physician colleague.  If their response is anything other than Dr Femaledog did that?  I'll set her straight" then polish your resume.  You don't want "oh, she's just like that", "don't worry about it", "you fix it", or the worst, "yeah, she mentioned that, and I said I would talk to you".  If they appear anything less than shocked, well, you deserve better.

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Your decision is well within the MEC guidelines.  I'm sorry you had to deal with the PCP and I agree; it would be very helpful to all concerned if your CP would be willing to address her crappy behavior directly, physician to physician. 

My CP, by the way, had never heard of the MEC.  I carry the wheel in my coat pocket.  Not sure she would have had my back in a similar showdown.  

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