Medical Nonpractice

A peak behind the scenes of clinical medicine

I started attending the eating disorders team meeting at student health at our university. The team was comprised of therapists, medical providers, and case managers who cared for students with anorexia or bulimia. I was the only psychiatrist, and a white male at that. This meeting was a chance to discuss challenging issues and share ideas.

A clinician brought up a transgender woman with anorexia nervosa. She was underweight and not engaging in treatment. I wondered aloud about the risks and benefits of continuing to prescribe estrogen to this patient. Natal women have higher rates of anorexia nervosa than natal males, so theoretically prescribing estrogen could worsen her symptoms. Likewise, estrogen can cause nausea in high doses or potentially suppress appetite. If prescribing estrogen was contributing to this patient’s dangerous weight loss, I wanted to consider the wisdom of continuing to give it? I suggested that there might be a way to set parameters around prescribing the medication such that the estrogen would continue if the patient met certain weight or follow-up goals. This strategy is consistent with contingency management, an established treatment used in other areas of psychiatry. My goal here was to stimulate thought and discussion around the role that giving the patient estrogen was playing in their weight loss and emphasize our duty as prescribers to do no harm.

A few days later, I was asked to meet with the group leader. I was informed that someone found my ideas offensive. I was not told who it was or what exactly I did wrong, just that offense happened. To verify the concern, I reached out to others who were at the meeting, and they said they appreciated my input, whether they agreed with it or not.

This was absurd on several levels. First, physicians are obligated to discuss the side-effects of medication, consider risks, and think about how medications work. That’s our job. If we gave up this responsibility, we would become ridiculously expensive prescription vending machines.

Secondly, I spoke openly about my ideas and acknowledged what I didn’t know. Anyone in that meeting had a chance to offer alternatives, but instead, someone belatedly claimed offense. From a learning perspective, we know that helpful feedback needs to be timely and focused. The “harmed” party was unable to provide either. Finally, an offended person’s feelings shouldn’t be able to dictate medical considerations for any patient. The patient is the focus. Full stop.

Unfortunately, this phenomenon is all too common. Repeated experiences like this create a fear of offense. People learn it is just easier to go along and think a little bit less every time. This leads to the nonpractice of medicine.