Medical Student Professional Responsibility
Teaching about family planning provides an opportunity for learners to practice empathy and compassion in the face of patient behavior that they may not support and provide the building blocks of patient-centered care.
What is professional responsibility for physicians?
In order to act with professional responsibility, the physician must put aside their personal beliefs in order to prioritize the culture, family, and values of the patient.
According to a statement drafted by American Board of Internal Medicine Foundation, American College of Physicians Foundation and the European Federation of Internal Medicine, physician professionalism is based on three principles:
1. Principle of primacy of patient welfare. The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
2. Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
3. Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
How can these principles inform your communication and interactions with patients?
We know building rapport with patients can greatly improve health outcomes.
Studies show that patients who perceive their providers as kind and nonjudgmental are more likely to:
- Be satisfied
- Return for follow up
- Follow treatment plans
- Take better care of themselves overall
In the next few minutes, you will apply this lens of physician professionalism to think about unintended pregnancy in the US.
Unintended Pregnancy in the US
- Unintended pregnancy is extremely common.
- In the United States, more than half of all pregnancies are unintended.
- About 4 in 10 unintended pregnancies will end in abortion.
Why are there so many unintended pregnancies in the United States compared to other similar nations?
A sexually active patient who does not use contraception has an 85% chance of becoming pregnant in a year.
But why wouldn’t you use contraception?
List a few factors that contribute to the lack of contraceptive use.
Here are some of the reasons patients have listed:
- Fatalism about pregnancy outcomes. You might hear patients say, “If it is my time to get pregnant I will.”
- Belief that they are infertile or can’t get pregnant.
- Dislike or fear of side effects.
- Doubt of the effectiveness of contraceptives. You might hear a patient say, “my friend got pregnant on the shot, so I don’t think it works.”
- Lack of contraceptive knowledge.
Mar;41(2):258-74. doi: 10.1111/j.1552-6909.2011.01334.x. Epub 2012 Feb 29. Review. PubMed PMID: 22376055.
Patients experience institutional, social, and cultural barriers to contraceptive use such as:
- History of contraceptive coercion or manipulation within minority communities
- Stigma surrounding long-acting, reversible contraception (LARC)
- Health disparities
- Difficulty accessing care
- Diminished public funding for contraception
- Negative encounters with clinicians
Given the high rate of unintended pregnancy, if you are seeing patients of reproductive age, some of your patients will have had an abortion in the past or might need one in the future. It is your responsibility to be familiar with abortion.
Now let’s apply the lens of physician professional responsibility to think about abortion.
Abortion in the US
- Abortion is extremely common.
- In the United States, 19% of all pregnancies end in abortion (excluding miscarriages).
- In 2014, approximately 926,200 abortions were preformed. 1.5% of women aged 15–44 had an abortion.
- The number of U.S. abortion-providing facilities declined 3% between 2011 and 2014 (from 1,720 to 1,671).
- The number of clinics providing abortion services declined 6% over this period (from 839 to 788).
As a physician, what is your professional responsibility to providing abortion care?
- Provide pregnancy options counseling with accurate, unbiased information - not including your opinion
- Refer for abortion care
- Participate in abortion care
- Manage post-abortion care
- Provide emergency care
Nationally, 60% of patients who have abortions already have children.
Approximately 90% of counties in the United States have no abortion provider and 39% of reproductive age women live more than 100 miles from the nearest abortion clinic.
90% of abortions in the US happen in the first 12 weeks of pregnancy.
Patients who present after the first 16 weeks of pregnancy encounter more barriers to accessing abortion, including being denied an abortion if they are over a facility’s gestational age limit.
Research shows that, on average, patients report 2.2 reasons for presenting 16 weeks after their last menstrual period:
- Didn't realize they were pregnant (71%)
- Difficulty making arrangements to have an abortion (48%)
- Afraid to tell parents or partner (33%)
- Needed time to make their decision (24%)
- Hoped relationship would change (8%)
- Pressure not to have abortion (8%)
- Something changed during the pregnancy (6%)
- Didn't know timing was important (6%)
- Didn't know they could have an abortion (5%)
- Fetal abnormality diagnosed late (2%)
Source: Torres and Forrest, 1988
Patients who present in the second trimester face more logistical barriers than patients in the first trimester.
On average, patients in the second trimester cited three reasons why their procedure was delayed.
The most common reasons were:
- Figuring out where to go
- Referral from other clinics
- Arranging transportation
- Difficulty getting state-funded insurance
What are some reasons patients might seek an abortion?
- They fear they cannot afford to raise a child or another child.
- They have reasons related to the man involved in the pregnancy.
- They need to care for the children they already have.
What happens to patients who are denied wanted abortions?
Compared to women who receive wanted abortions, those denied abortions are more likely to live in poverty.
Patients who are denied wanted abortions are less likely to be working full time and more likely to live below the federal poverty line.
Children are negatively affected when their mothers are denied wanted abortions.
The children of patients denied wanted abortions score lower on standard child development assessments for the next five years.