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Friday Jul 11, 2014

Acting on Our Convictions: Court Ruling Shows Need to Stand Up for Evidence-based Care

I recently had an office visit with a patient who was in need of contraception. She is 19 years old, going to school part time and working. With an ever-changing schedule, no plans to start a family and a history of migraines with aura and somewhat heavy menses, we discussed the evidence-based options of progestin-only methods versus nonhormonal methods.

Fortunately, her insurance covers all forms of contraception, and we were able to schedule her for a progestin intrauterine device (IUD) insertion. If her insurance had not covered IUDs, my patient would not have been able to afford the birth control method that is medically most appropriate for her.

The U.S. Supreme Court’s June 30 decision in Burwell v. Hobby Lobby Stores Inc., and Conestoga Wood v. Burwell has set off a flood of press coverage and commentary about what the ruling means. A major concern for many physicians is that the ruling could affect how we practice medicine.

“The Supreme Court’s decision allowing companies to deny coverage for important health services sets a precedent that threatens the nation’s health," said AAFP President Reid Blackwelder, M.D., in a statement. "With this decision, the court has moved health care decisions out of the exam room where patients can consult with their physicians -- and where such decisions should be made -- and put them into the hands of business owners who base decisions on personal beliefs rather than medical science.”

The American Congress of Obstetricians and Gynecologists (ACOG) and the American Public Health Association (APHA) issued similar statements.

Since the ruling, bills has been introduced in the House and Senate that would countermand the court's decision by preventing for-profit companies from using religious beliefs to deny employees coverage of health services -- including contraception -- required by federal law.

Laws that interfere with our ability as physicians to care for our patients using what we, in concert with our patients, determine to be the best, evidenced-based approach are problematic. In medical school and residency, we are taught to listen attentively to a patient’s history, perform a focused and careful physical exam, and obtain any additional resources we may need (laboratory values, images, etc.) to develop our assessment and plan.

As family physicians, we are attuned to considering additional factors when determining our plan, such as a patient’s social history, insurance status, access to follow-up and mental health. What is not usually part of our training, however, is learning how to navigate a health care system in which judges and legislators can create barriers -- that are not grounded in evidence-based medicine -- to our patients’ ability to access the care that will best serve their health needs.

As new physicians, we are often focused on ensuring that the day-to-day care we provide for our patients is appropriate and consistent with what we learned during all our years of training. As this new blog's posts have accurately portrayed, there is a lot to grapple with during these first few years out of residency; feeling confident in our diagnoses, asking for assistance when needed and figuring out how to balance our new careers with our life outside of work are just a few examples. I would add to this list finding a way to advocate for our patients on a larger scale, outside of our offices and clinics.

Physicians do not yet have a loud enough voice in the legal decisions and debates that have been politicizing medicine in recent years. But our voices are incredibly important and can affect our patients’ lives.

Making our voices heard may seem like a daunting task to add to our already busy lives, but there are simple ways to start advocating against any and all interference with the physician-patient relationship. If you hear about proposed legislation that is not evidence-based and would negatively affect your patients, call or write your lawmakers to let them know where you stand. Better yet, make a face-to-face appointment to explain your concerns as a physician.

If you see an editorial or article in your local newspaper about a legal decision or law that would interfere with physicians’ medical practice, write a letter to the editor to lay out your concerns.

You can also get involved with advocacy organizations (such as your state chapter) that can keep you informed about new developments and laws that may affect your medical practice and patients and will help you make your voice heard.

As physicians and patient advocates, we have a responsibility to speak up in the face of court rulings and laws that threaten our patients’ ability to access the health care they need. How will you fulfill that responsibility?

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.


I couldn't disagree more with the author. No one is telling her or her patient what she should do they are just saying what they will not pay for. When did it become the government's right to dictate to a private corporation what it must pay for whether the ownership may find it morally acceptable or not. Payment decisiones are different than restrictions on the patients rights. The patient clearly has the right to get her IUD or what ever other legal care she wants or needs but doesn't have the right to make anyone else pay for thing they find immoral.

Posted by Michael D. DeLisi, MD on July 11, 2014 at 01:35 PM CDT #

In response to Dr. DeLisi's comment - The money for the health insurance plan is earned by the workers, it is part of the benefit package of their employment. It is not the personal money from the pocket of the employer. Yes, it would be preferable if we had a public health insurance system like almost every other industrialized country so that workers at individual workplaces would not have to each negotiate their own benefit package, and so that the employees health needs could be kept private. But since we have this employer/employee benefit package, it seems much more reasonable for the employee's religion to determine what medications she has access to through her health plan than her boss's religion. Why should he be the decision maker? I just can't see how that seems just. If he doesn't believe in a form of birth control, he can limit his own usage of it. It is really over-reaching and paternalistic for him to decide what she can get. And, she cannot just afford to go pay for an IUD on her own - those often cost $800-$1000. While they are cost-effective in the long run, most working women cannot put up that kind of money up front for them, and asking doctors to accept a payment plan is also not realistic. What if her employer didn't "believe in" vaccines? This is a slippery slope, allowing employers to regulate what their female employees can use for birth control. Next thing you know, they won't want to cover Viagra because it is most often used for sex outside of marriage! Wouldn't that be an outrage?

Posted by Linda Prine MD on July 12, 2014 at 12:54 PM CDT #

Careful about slippery slope arguments in this matter. They can go both ways. No one is forced to work for company A that morally doesn't want to pay for the morning after pill. No one is taking women's birth control away. I find it scary that there are those who feel we should force employers and insurances to pay for anything and everything they want.

Posted by Doc B on July 12, 2014 at 08:33 PM CDT #

Companies are not people and have a responsibility to the society that supports them to to help cover their employees. Furthermore, they do not have the right to interfere in the medical decisions between a doctor and her patient. The slippery slope is that further "unconscionable" treatment in the eyes of the employer will be included. Stay out of my practice.

Posted by David S Smith on July 17, 2014 at 07:29 AM CDT #

This ruling has nothing to do with 'evidence based medicine' or the relationship that exists between patient and physician. The Supreme Court decision was strictly a decision that affirmed the Religious Freedom Restoration Act of 1993 (signature legislation of Bill Clinton). If you will research the case, you will find that this Act holds the government to a high standard in imposing restrictions on groups that might have religious views contrary to governmental overreach. Hobby Lobby - which by the way does provide 18/20 of the contraceptives mandated by Obamacare - fought for the right to limit 2/20 contraceptive options on the basis of religious values. The Supreme Court finally made a correct decision in this case. To suggest that this has anything to do with evidence based medicine is not only a non sequitur but misleading. Referencing Linda's comments above, this decision reaffirms the validity of one's religious views in light of government overreach - Obamacare in this case. The real issue here is 'who pays the bill?" At this juncture, there is still choice in the system. The employee, if unhappy with Hobby Lobby's religious views, can either leave, pay for the medications herself, or structure her finances (including choosing another healthcare plan) so that she might have the necessary funds to buy her choice of contraceptive. I disagree vehemently with Linda's flawed argument for a universal healthcare system that will not marginalize quality but limit choice. Yes, healthcare is a benefit that is SHARED by corporation and employee. Frankly, if a female wants the 2 contraceptive options not offered through Hobby Lobby, GO BUY THEM! By the same token, if a male wants #30 of Viagra and the plan only pays for #10 per month the solution is simple - go BUY THE ADDITIONAL MEDICATIONS. It is all about choice and priorities Linda. The suggestion that universal healthcare can provide everything free is a mirage. 'Evidence based medicine' is not even an issue here. The dirty little secret here is that 'evidence based' absolutism may very well not be the best option for any given situation.

Posted by m turner on July 17, 2014 at 05:02 PM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.