Do You Tip Your Doc for Botox®?

In the last few years, an increasing number of General Practitioners, Family Practitioners and OB-GYNs in the United States, Canada, and Australia have added revenue-enhancing cosmetic procedures to their core practice. Because 91 percent of cosmetic procedures are performed on women, OB-GYNs have a ready-made client base—but is the integrity of the physician-patient relationship, the practice of medicine, and ultimately the care of patients compromised when physicians offer cosmetic procedures and products that don’t increase the health and welfare of their patients?

“We are physicians who limit our practice to women,” writes David Levine, MD in the Journal of Minimally Invasive Gynecology, an OB-GYN and outspoken proponent of the practice, “and these same women are responsible for the bulk of the $6 billion per year spent on cosmetic treatments, it seems natural for us to consider offering these treatments.”

Levine’s argument seems logical on the surface, but in medicine, what makes sense financially is not always what makes sense ethically. We must face the fact that there are deep ethical implications of the rapidly increasing trend of General Practitioners (GPs) Family Practitioners (FPs) and OB-GYNs adding revenue-enhancing cosmetic procedures and products such as skin rejuvenation, Botox®, Radiesse®, liposuction, breast augmentation, and mesotherapy to their core practice.

As GPs, FPs and OB-GYNs continue to add cosmetic product lines and menus of cosmetic procedures to the general fare of PAP smears and annual checkups, they risk demeaning their profession by creating a public image that physicians are mainly businesspeople working to increase their income. This trend makes it easy for patients to wonder whether their health and safety is the priority or whether the physician’s income is the priority.

Daniel Frank, MD, an internist in Seattle, established his primary care practice in 2002. At the time other primary care practices were starting to offer cosmetic procedures, but he rejected the idea, “When setting up the practice, we were called upon by a number of sales people who wanted us to offer cosmetic procedures. I believe if there is too much of a financial incentive to offer a procedure or service, then my objectivity could be comprised, and even the best and most diligent and objective among us can’t help but be swayed by the economic factors, particularly in primary care. We did not want to detract from our primary mission, which is the care of our patients, so we declined.”

Until the medical community does something about this trend, we as consumers of healthcare need to raise awareness in our GPs, FPs and OB-GYNs. We need to let them know of the potential moral harms of adding cosmetic procedures to their practice, and we need to lobby for reform. Trust is central to the patient-physician relationship and little is more destructive to patient care than a widespread degradation of the public trust in the medical profession.

The integrity of the physician-patient relationship, the practice of medicine, and ultimately the care of patients is compromised when physicians offer cosmetic procedures and products that don’t increase the health and welfare of their patients. Let’s work to make this trend-line spike down.

Read the full Women's Bioethics Project white paper here.

*Question on Yahoo! Answers forum: Do you tip the doctor who does your Botox? How much? Answer: Docs are not supposed to get tipped as it conflicts with their Code of Ethics.

When is a Painkiller Not a Painkiller? A Patient's Right To Choose

Most patients trust their doctors. If prescribed a treatment, therapy or drug, many would not question the necessity, or authenticity of the physician's advice or prescribing strategy.

Indeed. In a study published this month in the Journal of General Internal Medicine, of 466 physicians surveyed at medical schools in the Chicago-area, 45% admitted to prescribing placebos to patients without the patient's knowledge, a practice striking at the very heart of Western medical ethics: informed consent.

Even more startling, one in five doctors admitted to actually lying to patients, claiming the placebos were medication, in clear violation of American Medical Association (AMA) guidelines, which directs its members to use placebos only if the patient is aware of and agrees to it.

Perhaps some might argue that the issue is not that significant--since placebos are viewed as harmless--but just how important is it? Particularly in terms of the doctor-patient relationship? Others might argue it raises major trust issues, and even a violation of patient rights.

See the full Time.com article here.

Are you an obnoxious patient?

CNN recently did a writeup on how to approach your doctor with your own research on a health condition. This seemed really timely in light of a previous set of comments I had previously written and some of the topics that have been recently discussed.

The question being asked is: Are you an obnoxious patient? I wonder how many of us can admit it if we are. In my case it becomes especially difficult to be objective since I feel like I have a vested interest in getting better, unlike my doctor to whom I may be just a patient. I also feel like I have learned a lot about my specific condition and I know which symptoms specifically apply to me. Yet, on the flip side, it is important to realize that the physician has probably seen a thousand patients like me and probably knows more about the progress of the condition and what I should expect. I guess its difficult being a partner... and trusting your partner.

Medical Googlers

Are you a medical Googler? This is the term used by a doctor to describe a difficult patient who used Google to both research her disease and options - and him. Apparently the fact that she used Google contributed to her ill-behaved child and rude manners, who knew?

Tongue less in cheek, of course there's a problem with relying too much on the internet for medical advice - if you're not a doctor (or medical personnel of some sort), chances are pretty good you can't sift out the good advice from the bad advice with 100% accuracy. A doctor has the training to do this; some, like the author of the rather paternalistic Time article, view this as the primary purpose of a doctor - to have the training to separate out good from bad.

But as others note, the problem doesn't appear to be a patient who Googles their condition, so much as it is a patient who doesn't laugh at his jokes, or place full trust and authority in the doctor's hands (like nurses, who are apparently the best patients for just this reason).

The doctor claims this woman tracked down so much information on him, she even knew where he lived. And if this is true, then the patient certainly stepped over a line from researching disease/provider offering treatment to "kinda scary stalker behaviour" - and it's understandable anyone would be creeped out by that. But researching your own disease, and being able to ask "excruciatingly well-informed questions" (a problem, according to the doctor), seems like the precise thing patient-advocacy groups advocate for: a well-informed patient who is making the most informed decisions possible.
-Kelly

The Left Testicle Would Have Been Right

NOT JUST FOR WOMEN

Most patients are nervous before undergoing a surgical procedure, however routine. High anxiety and the fear of unexpected outcomes are often more burdensome than the actual recovery process. Though our imaginations cause us to anticipate the worst-possible-scenario, rare medical errors can sometimes transform these worries into reality.

Benjamin Houghton, an Air Force veteran, received chemotherapy for metastatic testicular cancer over 10 years ago (1). Though he has been in remittance ever since, Houghton has experienced atrophy and considerable discomfort in his left testicle (1). In June, Houghton agreed to have his left testicle surgically removed at the Los Angeles VA Medical Center. In addition, he expected to have a vasectomy performed on his right testicle. His surgeon, a fifth year surgical resident, had Houghton sign an informed consent on the morning of his scheduled surgery (1). According to Houghton and his wife, the surgeon claimed that the form outlined the surgery details they had already discussed. Houghton, who was not wearing his glasses at the time, trusted that the consent was consistent with previous medical deliberations he had had with his surgeon (1).

Apparently, the form stated that Houghton would be having the right testicle removed, instead of the left, and that the vasectomy would be performed on the left testicle (1). Before being surgically anesthetized, Houghton was asked to indicate which testicle he was having removed. Contrary to typical surgery procedures, traditional markings were not made on the surgical site (1). This "wrong site surgery" led to the removal of Houghton's healthy testicle (1). Houghton will have to undergo additional surgery so that the left testicle can be removed. Without the benefits of testosterone, he is likely to experience sexual dysfunction, depression, increased susceptibility to weight gain, and an elevated risk of developing osteoporosis (1).

Houghton and his wife have filed a claim and are hoping to gain monetary compensation for this grave medical error (1). They are also hoping that their case will help rectify inadequate medical procedures that have accounted for these irreversible mistakes (1). Changes have already been implemented at the medical center where Houghton had his surgery. Why were these precautions not in place before? What if you were Houghton? What if you were Houghton's wife? How do you think this incident would adversely affect your family and quality of life?

This unfortunate case certainly stresses the importance of reading everything before you sign. It also exposes patients' vulnerabilities when their health is entrusted to a medical team. Occasional medical mistakes are inevitable because we are human, but an error of this magnitude should never happen!

Reference:
1. Engel, Mary. "VA Patient Has Wrong Testicle Removed" Los Angeles Times. 3 April 2007.

Doctors Dishing the Dirt

"I informed a patient's parents that we would call them when their child was off the heart bypass machine and back in the intensive care unit. That went down like a lead balloon as the child was in fact having spinal surgery. Oops...." (From http://mediblogopathy.blogspot.com)

An article in the Washington Post today examines the troubling trend of doctors blogging about their patients (sometimes rather harshly and crudely). The phenomenon is so new that medical boards, schools and professionals disagree on what is acceptable. The trend is troubling because not only because of the risk of compromising patient privacy but also because of potential liability for hospitals. I certainly could envision lawsuits -- can't you just see the latest lawyer ads? (Is your doctor talking about you behind your back? Dial 1-888-SueTheBastards or visit our website at www.SueTheBastards.com!)

For more on this (the Washington Post article, that is), click here.