Fear of lawsuits affects breastfeeding advice

I am doing a family practice rotation and trying to set up elective rotations and plan for applying to residency. I am also just busy and tired out in general. I can’t write about much of what I see day to day without discussing my patients or my attending physicians and residents in a way that might be ethically questionable.

But, I do want to write about something that happened recently.

A patient came in with a complaint that wasn’t life threatening or earth shattering. My attending physician wanted to treat it empirically. The patient is breastfeeding exclusively. The physician, without even looking up the medication, told her to stop breastfeeding.

I usually don’t challenge what my attending physician recommends. The patient said she would do what she always does, and call her baby’s pediatrician. When we did look up the medication, it did not have a contraindication for breastfeeding, but had a typical “well, we just don’t know if this is safe” disclaimer. This wasn’t a book specifically dedicated to medications and lactation.

I told the attending physician that the patient was exclusively breastfeeding, and breastfeeding is hard enough to pull off in this society as it is. I said that, barring a contraindication during breastfeeding, most medications are safe, and a little research on the topic and possible alternatives may be a good idea. The attending said that, in today’s litigious society (which is the topic of many lectures by many attendings), we just can’t take those kinds of chances these days. She apparently tells any breastfeeding patient to stop breastfeeding with any medication.

I hope I can take these kinds of chances one day. I respect my attending physician’s choices in balancing her medicolegal risk and the way she cares for her patients, but I hope to be able to strike my own balance one day that is more supportive of breastfeeding.

“MomTFH” is a medical student who blogs at Mom’s Tinfoil Hat.

Submit a guest post and be heard on social media’s leading physician voice.

Comments are moderated before they are published. Please read the comment policy.

  • Anonymous

    I wonder how the risks of formula feeding figure into her analysis? There is substantial risk to a baby from the effects of milk substitutes- allergy, intolerance, lack of immunity factors, and to the mother of abruptly stopping breastfeeding – mastitis, breast abscess. So she says to stop breastfeeding, baby get sick, mom sues.

    Glad to hear you are supportive of breastfeeding, “MOMTFH” … and that you are willing to speak up like this.

  • http://nourishourselves.blogspot.com Marie

    Boy, several words pop into my head here.  Lazy.  Condescending.  Indifferent.  Concern about lawsuits does not mean abdicating your responsibility as a health care provider, which also should extend to the baby.  Barring a life-threatening situation, breast is always best.  How irresponsible to advise a mother to suddenly stop nursing, with all the complications that can accompany that, including engorgement and a baby whose system is not used to anything else.  Yeah, that’s a good idea.  Give a mother with a health care problem even more trouble.

    Thank goodness she had you to advocate for her, MomTFH!  

  • http://twitter.com/DoctorPullen Edward Pullen

    I’m pretty sure your attending doc was far from the norm.   It’s so easy to check for the safety of drugs in breastfeeding in today’s information age that I think they are using this fear as a way to feel better about being lazy.  

  • http://www.facebook.com/people/Linda-Emmons-Bailey/100000892421648 Linda Emmons Bailey

    I can’t respect your attendings choices. Witholding relevant information from her patient seems unethical to me. With so much good information available on the subject of Medications and Mother’s Milk, I believe your attending is violating her patient’s right to informed consent.

  • Anonymous

    Defensive medicine? Defensive medicine doesn’t exist. My lawyer told me so.

  • http://twitter.com/HeartSisters carolyn thomas

    MomTFH, please remember this incident when you are out there practicing medicine one day. Your gut feeling here was correct. What’s to “respect” about the way your attending balances “her medicolegal risk and the way she cares for her patients”?  Her sweeping generalized rationale is an example of the worst kind of CYA medical care. Why not treat the patient as a sentient human being who can understand that all prescription drugs carry some risk (to the mother as well as the nursing baby) instead of this plainly stupid blanket advice to stop breastfeeding? Unbelievable…When my mother was bravely breastfeeding in the 1950s (when bottle-feeding was the norm), every possible scenario (colic, hiccups, teething, you name it) was enough for physicians to recommend giving up breastfeeding in order to “put the baby on the bottle’.  This from (mostly male) physicians whose wives were (mostly) bottle-feeding.  But that was then, this is now:  what’s your attending’s excuse?

  • Anonymous

    Thanks for keeping us abreast of the situation. Sorry, had to be said.

  • http://pulse.yahoo.com/_TOVEZZPRMCSECEXUPZVF5KWTNA Duck Lady

    Um, what ever happened to educating the patient in the risks versus benefits and allowing HER to make a decision this crucial? As patients we’re told repeatedly to educate ourselves, ask questions, take responsibility for our health. This attending sounds the very opposite–no discussion, no perception of the patient as an adult, no responsibility on the patient’s part. 

    Doesn’t the attending realize s/he could just as easily get sued for some problem with the child who was deprived of breastfeeding? If you want to get sued, just keep doing what you’re doing, Dr. Attending. You’re part of the problem and using a bad “solution.”

  • Anonymous

    The medication was probably pregnancy/lactation class C which means no study has been done. All you great legal minds explain to me how to balance the risks and benefits when there is no data as to what those are.

  • http://www.facebook.com/profile.php?id=580060807 Anne Montgomery

    Maybe she will get sued someday because some harm was caused to a baby from being weaned too early and that will cause her to change this practice.  (The harm is certainly possible, not so sure about the suit.)  Thanks for trying to educate this attending.  With few exceptions, not breastfeeding is almost always riskier than continuing to breastfeeding while taking a drug.  And there is usually a safer alternative to the meds that are less optimal.  (Exceptions are chemo drugs, antimetabolites, drugs of abuse, a few others.)   A great resource for drugs in lactation is LactMed from NIH, http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT.  They also have a very user-friendly iphone app, just search LactMed.

  • http://www.facebook.com/profile.php?id=1704425455 Lianne McNeil

    As a patient (who breastfed exclusively), I would have considered that attending physician’s advice to be bad advice and would have refused the proposed treatment. I also very likely would have “fired” the doctor and found a replacement that was more breastfeeding friendly. I understand the concern about potential lawsuits. But it seems to me that presenting the information to the patient, including the information that the effect of the medication on breastfeeding and infants is not known (and could be harmful), and let the patient decide what treatment options she will do, would lessen the likelihood of lawsuits, since it would be the patient’s decision, not the doctor’s. (When I was a young mother, if a medication/supplement had not been studied and shown to NOT be harmful, I assumed it would be harmful, and refused to use it.)

  • http://twitter.com/#!/CloseCall_MD Close Call

    This was likely a Category C med.   Unfortunately, informed consent comes up short here because there is no good information about the medication in humans… BUT it did some bad things to cute little animal fetuses.  This could mean – it gave them heartburn or it caused them to sprout a second head. 

    What’s a breastfeeding mother to do?  

    1. You could refuse the proposed treatment.  I like this idea.  Probably protects the physician legally, and helps patients reassert their autonomy. 

    2.  Pump and dump while you’re on the med, then restart breastfeeding after finishing the med.  I like this option too.  Little Jimmy Jr. will survive for a few days on the organic formula you’ll give him, don’t worry.

    3.  Take the medication, continue breastfeeding, then when you think your 2 year old isn’t focusing as well as he should be, get someone to make a diagnosis of ADHD or autism spectrum, and then promptly sue your physician for messing little Jimmy up.  Yay!

    Kidding aside, this boils down to an assumption of risk in an information void.  People will have different thresholds of what they want to do… most of these thresholds will not be derived from rational thought – goes for both doctors and patients.

  • http://MindOnMed.com Danielle Jones

    Absolutely unacceptable. This is not practicing good medicine. I could never, ever respect those decisions with lawsuit fear as the major determining factor. Weigh risks and benefits, exolain extensively, chart that you explained the risks and benefits and have patient sign that they understand and make their own decision regarding the med. Absolutely not okay.

  • http://www.momstinfoilhat.wordpress.com Anonymous

    Thanks for all the replies!

    I wish I could share a little more about what drug it was, and what the presumed diagnosis was, but I want to respect the privacy of the patient.

    I looked up the drug on the ToxNet / LactMed, and the entry states that the drug has determined to be safe for breastfeeding mothers at the recommended dosage. I went back to the rotation site, and showed the attending physician and her staff the LactMed resource, and bookmarked it on the computer there for future reference. 

  • http://www.facebook.com/profile.php?id=100000977601479 Melissa Gastorf

    While I am not saying you are necessarily wrong in this case, not knowing the specifics, I would suggest you not show this particular blog when you interview for residency positions.  Seriously.  The blog itself is where your problem lies.  It is easy to criticize when it is not you license you are practicing under. Did you ever ask her why?  Could it be the result of some previous case or lawsuit or even literature she had read? 

     I will tell you if you show this particular blog to many program directors it will be viewed as a medical student, who while might be correct in this assessment (hard to say without more information) thinks that her two to three years of training outweighs the practice and experience of an already established physician.  

    • http://twitter.com/HeartSisters carolyn thomas

      Hi Melissa – I’ve never been an attending, never been a medical student, have not undergone two or three years of training, but even I can deduce that a drug that has been “determined to be safe for breastfeeding mothers at the recommended dosage” doesn’t mean you have to stop breastfeeding.  (And bladedoc, this was clearly not one of those “clearly contraindicated for breastfeeding” drugs). The attending apparently makes a blanket pronouncement (while teaching future doctors!) that she “tells any breastfeeding patient to stop breastfeeding with ANY medication” – THAT is the serious problem here, not MomTFH’s blog post. To think that this entire graduating class will some day be let loose on the nursing mothers in their practice with this kind of “training” is frightening.

      I do see Melissa’s point, however.  If that particular attending is reading KevinMD right about now, and takes a gander at the rash of comments here about her questionable advice to patients in this case, MomTFH will indeed be in big trouble for exposing her attending’s questionable advice to the criticism of strangers.  Interesting that somebody genuinely looking out for the appropriate care of the patient should be worried about consequences of doing so if she dares to question the great and powerful Oz….    But to assume that an “already established physician” should never be questioned by a lowly med student is even more alarming to me.  Good grief.  All patients can tell you horror stories of what “already established physicians” have said to them. I interviewed many of them for “Stupid Things That Doctors Say to Heart Patients” at http://myheartsisters.org/2011/01/13/stupid-things-doctors-say-heart-patients/ 

    • http://www.momstinfoilhat.wordpress.com Anonymous

      Thanks for your input. I did have a conversation with her, as explained in the blog. She tells all breastfeeding mothers to quit for every medication. This goes against the American Academy of Family Physician’s Position Paper on breastfeeding. I will not potentially violate HIPAA and give more specifics about the situation, but the diagnosis, possible etiology and medication were nonremarkable, and the literature supports the safety of the medication’s use during breastfeeding. 

      I understand your point of view. I respectfully discussed evidence based medicine with this physician, and she was happy for the resource I provided to her. I don’t think my three years of training make me superior to her or any other attending physician. I happen to have been trained in lactation support and happen to have breastfed two children. I was familiar with a resource, ToxNet’s LactMed, that she was unfamiliar with. I can’t imagine that a residency program wouldn’t want a resident with experience and critical thinking skills. In fact, I have heard many hospitals think care is improved in teaching situations, because residents tend to research and challenge attendings, and keep them up to date and thinking critically. I didn’t challenge her in front of the patient. I didn’t tell her she was wrong. In fact, I didn’t say I thought she was wrong in the blog. However, I made it clear that medicolegal concerns trumping evidence based care isn’t something I prioritize now. Especially when governing body position statements and the best resources on the topic would be available as back up in the minute chance this did end up in court. I said she was able to strike her own balance, and I was clear that I respect that. I will be able to strike my balance of supposed medicolegal risk with evidence based care when I have my license, as every physician does. 

  • Anonymous

    Right, and this assertion is based on what? There are myriad medications that are CLEARLY contraindicated while breastfeeding, and many hundreds that there is no data on. Anne, your statement is unfounded and misguided as you are underestimating the risk in the unstudied medications and assuming that if it hasn’t been proven bad it must be OK.

  • Stacie Cannon

    As a woman who exclusively breastfed 3 children if I could have a nickel for every doctor who told me to stop breastfeeding at one point or another, I could probably buy a hamburger.

    It really would just make me mad.  I would go to them with my problems, thrush, mastitis … whatever and the answer was always the same -  “If you’re having problems, just quit.”  NO NO NO!  Was my response.  I’m not going to spend a ton of money on formula, I have to lose the baby weight, and I’m not giving up any of my baby’s IQ points.

Most Popular