The changing doctor-patient relationship: lessons from infertility

June 9, 2011Carole No Comments »

A recent USA Today commentary by Kevin Pho, MD,  “As health reform unfolds, involve the patients” caught my eye because the proposed “medical team” approach for delivery of health care in the future is how high tech infertility care is provided today. To provide in vitro fertilization (IVF) services, a medical team consisting of  physicians, nurses, ultrasound technicians, various lab staff (andrologists for semen analysis, embryologists for IVF and cryopreservation of eggs, sperm, embryos and reproductive tissues, chemistry techs for hormone assay testing and genetic testing lab techs for preimplantation genetic screening or diagnosis) and even clinical psychologists for pre-treatment counseling all may play a role in the patient’s treatment plan before the case is done.

Health care reform will move the doctor-patient relationship away from the traditional 1:1 doctor:patient relationship to a multiple health care professional  :1 patient relationship. Every patient will have a  “patient centered medical home“, defined as ” a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.”

In the IVF team example, the physician is responsible for coordinating the health care for the patient. He or she orders the diagnostic tests, interprets and diagnoses the results and suggests one or more treatment plans. The patient generally decides among options and the treatment plan is carried out by a team of health care professionals: lab technicians, ultrasound techs and nursing staff who follow the physician’s orders. In theory, the patient gets expert, well-coordinated care from the team, and doesn’t have to seek out each specialist on their own for consultation and treatment.

Dr. Kevin Pho points out that what is missing from these proposed  health care reform plans is patient input. Patients need to know that they are a crucial partner in their health care and can’t be passive recipients of various tests, prescriptions and treatment plans. If patients aren’t involved in the increasingly complex arena of modern health care, they may get run over. It’s ultimately up to the patient to say, “Explain it to me so that I understand what you want me to do and why you want me to do it”.

When I was pregnant with my second child, I went to have my blood drawn for a common prenatal test, the triplet screen prenatal test which tests for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG) and unconjugated estriol. These hormones have expected values for the various stages of pregnancies and values outside these norms may indicate that the baby has a abnormality or birth defect. The stage of pregnancy in which you have your blood draw makes all the difference in how the values are interpreted. When the nurse was drawing my blood, I noticed she had the wrong weeks of gestation written down. I pointed it out to her but she didn’t change it, either because she didn’t trust my calculation of weeks of pregnancy or she was too busy. About a week later, the doctor called, concern in her voice, to let me know my baby was at increased risk of Downs Syndrome or other birth defect based on this triple screen result. Fortunately, before my emotions completely took over, I remembered the wrong date and asked my doctor to check the weeks of gestation and compare it to the test date. She did, realized the weeks of gestation was wrong for that test date and suddenly the test results were within normal range. In this case, it was up to me to participate in my health care and make sure I wasn’t run over by all its moving parts.

We all could use some more supervision when giving or receiving health care. I swore I was done talking about Dr. Kamrava, the Octomom doctor who transferred an excessive number of embryos to his patient, resulting in octuplets, but on June 2, 2011 the California Medical Board decided to revoke his medical license, effective in July, because he was found to exercise poor judgment in three medical cases, the Octomom case being only one of the three.  Specifically, the board ruled that in the Octomom case, “While the evidence did not establish (Kamrava) as a maverick or deviant physician, oblivious to standards of care in IVF practice, it certainly demonstrated that he did not exercise sound judgment in the transfer of twelve embryos to (Suleman)” .

In his defense regarding the decision to allow Nadia Suleman to receive 12 embryos in a single transfer, Dr. Kamrava said that he only did it because Nadia really wanted them all transferred and she agreed to undergo selective reduction if excessive embryos implanted. So here is a patient involved in her health care –although it is unclear whether she really understood the dangers of multiple gestation pregnancies– and the outcomes were not optimal.

A “medical home” based treatment approach, perhaps involving a high risk pregnancy specialist might have been beneficial to the medical decision making in this case. Infertility practices are frequently operated in isolation from obstetrical specialists. Usually, the infertility care ends at 8-12 weeks when the pregnant patient is shipped off to the obstetrician to take care of the pregnancy. If the patient doesn’t do selective reduction to decrease 8 fetuses to something more compatible with the limitations of the human uterus, not the infertility doctor’s problem, unless it becomes very public and the infertility doctor loses his license.

Most of the time, whew, no harm done, no foul, when excess embryos are transferred but not because wise decisions were made, but just because the doctor and patient are lucky. Dr. Kamrava’s luck ran out in a very public way. Melissa Ford, Stirrup Queens blogger posted an opinion on Blogher on the Kamrava case, “Octomom” Nadya Suleman’s Doctor Loses His Medical License”, in which she succinctly discusses what bugs me about the Kamrava case. She points out, that except for the outcome, many other doctors have transferred excess embryos and when the outcomes were good, got congratulations about the miracle pregnancies they achieved. When the outcomes are bad and very publicly discussed, then the loss of a doctor’s medical license becomes a very real possibility. As Melissa rightly points out, we have a double standard when it comes to medical care which is often more an art than a science.  We yell “Off with their head!” when outcomes are poor; and “Bravo” when “miracle pregnancies” are achieved. For example, in a real case that I am familiar with in which 12 (terrible looking) embryos were transferred but only one took- it was declared a miracle! In that case, the doctor was a hero to the patient for a taking a risk and transferring 12.

The deafening silence from the IVF doctor community is telling. Many REs, if they are honest with themselves, know that but for dumb luck, their license could also be revoked if they were held to the same standard as Kamrava and similar decisions resulted in a widely reported bad outcome. Mistakes happen in IVF and most of them are settled quietly out of court, so there is no public review of poor medical decisions and few doctors lose their license.

So what can patients do to ensure they get good health care? Patients must become well informed about risks, benefits and alternatives to all suggested treatment plans before they go ahead- and take some responsibility for the treatment plan they choose. What can doctors do? Doctors need to refrain from taking chances with patients –even when patients beg them to do it– because when it all goes bad, they go from being a hero to a zero in less time than it takes to say “No, I won’t do that”.

 

 

© 2011, Carole. All rights reserved.

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