AMA to Label "Ungrateful Patients"

It seems that the American Medical Association is discussing a resolution at their next meeting that will allow them to include "non-compliant" and "ungrateful" in patients' records.The article is featured on the ICAN website, because of it's implications in maternity care.

It can be read here. Please do me a favor - don't just read the response of ICAN. Scroll down to the bottom and open the actual resolution sheet (it's resolution 710) and at least skim the actual resolution. And while you're at it, take a look at some of the other resolutions on the table for next week's meeting of the AMA.

I do take issue with the Michigan Delegation's proposal to label non-compliant or ungrateful patients. I take issue with it because it opens a Pandora's box on what can be considered "non-compliance." But I happen to have also noticed Resolution 709, presented by the Kansas Delegation, which proposes that the AMA take into careful consideration how new payment methods might impact the patient-physician relationship, and provide action steps for physicians to follow in order to make sure that where their money comes from does not affect the way they care for their patients!

If we are going to talk about the arrogance of physicians who want to have a way to label patients as ungrateful, we must also mention the sensitivity of physicians who recognize that the patient-physician relationship is based on the statute of "First do no harm." and not, "first check how much I can get paid for this."

So, as I learned from studying the Rabbis of old, I will start with the bad and end with the good.

The problem with Resolution 710 is that it doesn't give any guidelines for what is considered "ungrateful" or "non-compliant." It seems clear that the purpose for the resolution is a measure of CYA (cover your a**!) where if a patient refuses care and has a negative result, or if the patient is hostile and therefore is difficult to treat, then having a code in their record about that helps the doctors to defend themselves.

But then we come to what else happens with those codes? For example:

A pregnant woman in her 3rd trimester is told by her doctor that she is measuring "large for dates" - that her baby is very big, and might be too big to be born vaginally. He tells her that it will be safer to induce early, before the baby grows anymore. Or he tells her that a cesarean delivery is very likely. She calls me (yes, it's a shameless plug!) and asks me why her doctor is saying this? She's very scared about birth and now she's even more nervous that she won't be able to get her baby out! And why would her body make a baby she can't birth?

So I reassure her. The measurements are based on ultrasound information, which is notoriously unreliable for measuring. There is absolutely lifesaving information that can be gleaned from the use of ultrasound, but accurate measurements are not one of them. In fact, the margin of error for u/s measurements after the first trimester is +/- 2lbs!! That's a huge margin!! That means if you are being told at 34 weeks that your baby is likely to be 8lbs - you may just as well be looking at a 6lb baby! And conversely, if you are told that your baby is not growing, and is measuring behind dates (another reason for induction) you may be told that you're baby is only 4lbs at 36 wks, when really, if allowed to go to term, you'd be having a bruiser of a 9 pounder!

'Please consider,' I tell my imaginary client, 'the risks of an early induction. That your baby really is up to 2 lbs smaller that the measurements and might require NICU care; that pitocin use can create overly-intense contraction which can lead to uturine hyperstimulation, stress in the baby, increased pain requiring the use of narcotics - which have all of their risks; and all in all you could end up with a cesarean to "save your baby" which you would have never needed had you been allowed to go into labor all on your own when you and your baby were ready. Plus remember that giving yourself the freedom to use different positions in labor and pushing will allow you to birth whatever size baby your body can grow!' (Except under 3 very specific circumstances, which are not the case with my particular client)

She weighs the pros and cons and decides that she does not want to be induced based on the ultrasound measurement, and thank you very much, Dr. X, but I will go ahead and wait until I go into labor on my own.

Unless there are very clear guidelines on the resolution to define what is "non-compliant," my client here may very well find that label on her chart (or not, depending on whether she has access to it!) and how will that affect her reception at the Labor and Delivery ward? How will the nurses and residents react to knowing that they have an "ungrateful," possibly "hostile" patient on their hands? And heaven help her if she also shows up with a doula! Now they know they're in for a fight!

If the resolution passes - and even if this resolution just brings to light a sentiment among doctors, then the need for women to be very well informed about their options and the research sky-rockets!
And that is my complaint with the AMA Resolution 710.

Now for the praise:

Kudos to the Kansas Delegation for bringing up a very real and tangible problem in the health-care world! This is something that Henci Goer talks about extensively. It is the problem of health care providers thinking about their bottom line when considering patient care. It is no secret that physicians can bill for every intervention they use. For maternity care this is especially problematic, because unfortunately money can cloud judgement and things that seem "harmless" like constant fetal monitoring, and mandatory IV fluids, and AROM (artificial rupture of membranes - breaking the bag of waters) are easy little things that can add to doc's paycheck - but evidence is very clear that these have very little benefit, and can lead to additional interventions directly from their use.

I do hope that resolution gets passed and that the AMA does take a good look at the importance of the patient-physician relationship and how to preserve the trust between doctor and patient by providing care that is solely beneficial to the patient's needs, regardless of the profit of the physician.

What does this all come down to? It seems to me that with all the pressures and limitations that physicians deal with from insurance companies and legislation, the standard of care has become more complicated than just serving their patients. Unfortunately, the true answer and cure for this is total health care reform, and complete re-education of the meaning of health and wellness for physicians and for us (those who are served by the physicians!). In the meantime, it would be very scary for doctors to have the ability to assign value judgements on their patients - even though there may be situations where they are justified. And at the same time it is extremely important for doctors to put their patients' health above their bottom line - after all, if you are studying to be a doctor for the paycheck, then you were always only going to be serving yourself.