State legislatures should not enter the exam room

The doctor-patient relationship is under threat from state laws that try to shape what we can and can’t do for our patients. Many state legislatures are proposing laws that limit the questions doctors can ask patients in our confidential clinic visits. Do you smoke? Drink soda? Exercise? Do drugs? Is there a gun in the home?* Do you want to be pregnant? Is there fracking near your home?*

The questions followed by asterisks may soon become illegal in a state near you.  Perhaps the other ones will too.

For example, Florida has made it illegal for physicians to ask whether there are guns in the home.  This matters.  People who live in a home with a gun are three times more likely to be murdered–most frequently from domestic disputes. As Arthur Kellerman showed in his 1993 paper “Gun Ownership as a Risk Factor for Homicide,” 70% of homicide victims are killed by people they know, after an argument. Having a loaded gun within reach makes people much more likely to kill each other in the heat of the moment.

In Connecticut, one of my patients was a middle-aged woman living with her schizophrenic son. He occasionally muttered he wanted to kill her.  “Do you have a gun in the home?” I asked.  This was important.  It would change how likely he was to succeed in his wish.  A gun with bullets in the home would increase her chances of dying dramatically.

“Yes,” she said.  “I keep a loaded gun on me at all times.” She ignored my advice to get the gun out of her home. Or at least take the bullets out. “It makes me feel safe,” she said. That was her right as a patient, to ignore my advice.  It was my duty as a physician to let her know the increased health risks.

After violence escalated in the home, and her son stabbed her with scissors, undeterred by the gun, my patient decided for herself to get rid of the gun before he used it on her or she used it on him. Did my doctorly advice make a difference? Maybe. Or not. But it was my duty as a physician to provide the evidence-based information that could guide her in making a decision that could mean life or death for herself.

I don’t want a state legislator to prevent me from doing my duty as a physician to provide sound health advice or curtail my patients’ freedom to ignore it at their will.

State legislatures should not crowd themselves into the clinic room.

Kohar Jones is a family physician who blogs at Prevention Not Prescription.

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  • QQQ

    “The doctor-patient relationship is under threat from state laws that try to shape what we can and can’t do for our patients”
    ————————————————————————————————
    -A government big enough to give you everything you want, is strong enough to take everything you have.-

    -Thomas Jefferson-

    • KoharJones

      Too true. What’s funny is how we have state governments and national governments seeking to insert themselves (unwanted) into the doctor-patient relationship.

  • QQQ

    If our Gov’t is bad at one thing, it is writing poorly worded
    legislations, then depending on political appointees in responsible agencies to write the regulations to enact that legislation. Problem is always in wording and knowledge of definitions. When paint rollers first hit the market place, DA, Ft Knox Purchasing and Contracting “let” a multi-million dollar paint contract, requiring 2 coats, period. Contractor painted, up, then down, using the paint roller method. IG would not sign the inspection report because in their view two coats were not observed. It went to court. After a few years, local contractor
    prevailed and won his payment with interest to boot. Why? Because the Gov’t Contracting Office did not call for drying time between those two coats. One would have to read the ACA Legislation, cover to cover, have insider knowledge, then you will be able to correct this insanity. There is one side of ACA missing, the providers. In 1979, HHS committee decided there would be 140,000 too many specialty doctors by year 2000 in USA. Solution was deemed to 1. Convince Specialty Doctors to switch over to Primary Care Gatekeepers to support the upcoming HMO’s, 2. Medicare would stop funding the Residency slots for Specialty Doctors, 3. Federal Employees would come into the eligible Beneficiary ranks and start paying that 1.35% Medicare Income Tax rate, 4. Create Part B Medicare Services (to treat Doctors the same as CMS treats the Hospitals, by contract adjustments to their submitted claims). Every 10 yrs that same HHS committee met and reported their progress.

    Until,1999, when they were suddenly stunned; by year 2000, there would be a SHORTAGE of 140,000 specialty doctors. HHS did nothing to correct that shortage. In the year 2003, Forbes reported it would take 25 new medical schools to begin to correct the shortage of Providers. Today, 2014, each and every day 10,000 new Medicare Beneficiaries join the ranks of red/white/blue Medicare Health Insurance Part A Hospital and Part B Medical Services. ACA in Mar 2010, effectively tries to reinvent the wheel, changing/reorganizing everything, even the CDC in Atlanta. “All Things Health” in the hands of an agency that has never been able to rein in Waste, Fraud and Abuse. I would much rather have seen these Tax Payer Dollars sent to each County Health Dept in all 50 States, building new facilities, sending new Doctors out of their residency to local
    health departments, and the HHS forgiving their student loans after serving 6 years in the local health departments. Gosh, sounds too reasonable doesn’t it. Just handing out new health insurance cards to 36,000,000 citizens does not take care of the problem of affordable nor sufficient health care.

    • KoharJones

      The doctor shortage is a thorny problem. Are you familiar with the National Health Service Corps? The Affordable Care Act both provides funding for community health centers ($10 billion in new construction) and pays to cover the loans of the primary care physicians who staff them through the NHSC. New facilities are being built, and new physicians enticed to staff them with government-paid loan forgiveness. But as you point out–health insurance does not equal health care unless we have the providers to provide the care to everyone.

      • RuralEMdoc

        The NHSC is a noble goal, but it just does not throw enough money at doctors to get them into rural areas. The most you can get is $30K a year, but most get $20K IF you work in a federally approved site for full time for 3 years. $30K/yr is nothing to scoff at, and most people would take it if it meant driving an extra 20 miles or so, but it simply is not enough loan repayment to get a doctor to move to rural Kansas if their family is from Chicago.

        • KoharJones

          The question of getting doctors to relocate to rural areas is difficult. The best bet is to recruit more rural students to enter health care professions, so that they will move to Kansas to be near family:-)

          In the meantime, the Center for Medicare/Medicaid Services is throwing a 10% bonus to all rural docs for a few years, trying to incentivize folks to go rural.

          And the NHSC, depending on the Health Provider Shortage Area score (or how needy the neighborhood is), may give more money than the numbers you cite above.

          I checked out their website, and it looks like you can get up to $50,000 each year depending on how needy the site is.

          http://nhsc.hrsa.gov/loanrepayment/nhscloanrepayment/index.html

  • NPPCP

    And on another note – governors should not collude with medical societies to override a unanimous state legislature decision; really no arguing for this governor’s move.

    http://www.modernhealthcare.com/article/20140422/INFO/304229977

    • ErnieG

      FYI- It falls within the right of a governor to veto legislation, even if it is unanimous. Nebraska governor’s veto is different than the legislative intrusions cited by the OP. The Nebraska legislature was defining who can practice medicine, and what the scope of that practice is, which the governor vetoed. The examples by the OP cites are defining how medicine should be practiced. These are examples are differences in kind- the Nebraska issue is about WHO can practice medicine, the issues by OP are about HOW medicine is practiced. About “really no arguing for this governor’s move”.. .there are very strong cases NOT to have nurse practitioners practice without physician collaboration. Either physicians are overtrained, or nurse practitioners undertrained. Practically speaking, the only reason NP’s have any chance of practicing without physician supervision is that there aren’t enough doctors to do “primary care”, and there will less physicians willingness to do “primary care” when the older generalist physicians retire out, and the younger ones flock to specialty care, realizing that primary care really is not about “doctoring” but in buffing charts for the administrators. So in that case, I’ll let NP’s chase “primary care,” into the abyss.

      • NPPCP

        We are pretty much all on our way there….hand in hand.

        • ErnieG

          But why are NP’s so happy to go along? It seems like a bad strategy for NP’s to argue for more independent practice. Let’s face it– NP care is not equivalent to IM or FP care. I work with and have trained a few NP’s, (as well as med student, PA students and PA, interns, resident, fellows, etc) and without a doubt NP’s are not at the same level as either MD or DO’s; perhaps at level of late 1st year intern, but guess what– they become 2nd and 3rd year residents. Furthermore, my sense is that NP’s have a chip on their shoulder. Unlike PA’s (who train within the medical model alongside physician trainees), NP’s grow inside a nursing model, and become NP’s because they think “they can do just as good or better” than docs. Instead of going to medschool, they go to NP school.
          In essence, arguing that NP’s can practice independently is buying into the idea of “primary care” as defined by insurance and gov’t. That is fine, but that really is not practicing medicine.

    • Mengles

      If it saves a patient life (which it will), it’s worth it.

    • KoharJones

      I believe that professional licensing does fall within the rights of state government to decide.
      I don’t believe that governments belong in the exam room alongside patients and providers.

  • NPPCP

    ak123,
    I don’t have any problem with more residencies, more physicians, more doctors. I am in agreement with you. As well trained and educated as physicians are, NPs have been providing safe and effective care for over 50 years. Some under direction, some independently. The independent states have many NPs operating in that capacity. The results cannot be ignored. The day after Memorial Day, I saw 37 people – competently, professionally, and provided appropriate care for each of them. Perhaps family physicians are over educated for the job they do? That is a thought you know. I am an odd duck in the fact that I believe specialty care should be handled by physicians. Many NPs disagree. But primary care – I have been doing it for years. When new patients transfer into my clinic from physician clinics, I review their notes, specialty referrals, etc. I “NEVER” see any new and advanced care that I would not have provided at the previous clinic. Your belief is well founded. So is mine. It is what it is. My point with this article was don’t gripe about the legislature one minute and then perhaps “be glad ” about what they did the next when you agree with a result. The Nebraska decision was an atrocity; completely politically motivated. It happens on “my side” too. Again, it is what it is. Finally, I do not have the same rights and privileges as you. There are a few things I cannot do that you can – deliver babies, prescribe certain scheduled drugs, certify home health orders, employ NPs and gain financially. I agree with you on many points. But it does not change what I do – and it does not change the fact that people will go without healthcare without me. That isn’t going to happen. I’m not going to let it happen. I refuse to debate pathways, beliefs, whatever. They have been covered over and over in the past here – I just let it go now. For every argument there is a counter argument. In the end, the state legislatures will get in our business and they will decide; and I will abide.

    • KoharJones

      Interesting–it sounds frustrating to be practicing efficient, effective care and feel it is not being recognized by payers and others.
      Am I overeducated as a family physicians? Maybe. But I learned the systtem, and what works and doesn’t across different care environments, and that training was priceless.
      Thansk for your commentss.

      • NPPCP

        Hi Dr Jones, I post here often and never mean disrespect. Well, perhaps in the past I did after being verbally assaulted so many times. We need more physicians. We need more slots. We need more competent everything. NPs are continuously being denigrated and I have been used to it for quite some time. I just hold my head up and the patients keep coming in. Any physician who started a family practice residency after around 2000, maybe a little earlier, knew what they were getting in to. We were already there practicing on our own license. So the shock and doomsday propagated by them is unwarranted. State legislatures are currently debating this even more vigorously. Most of them are coming up with additional collaborative hours that NPs must complete to practice independently. Sounds very reasonable to me. As long as there are professional disagreements, I guess the legislatures will have to decide.

  • Dorothygreen

    What states are pushing for doctors to not ask these questions? Who is pushing the state legislators? It’s pretty clear, don’t you think? It is not that the state legislators are doing this all by themselves because of their personal convictions or that of their constituents. You can ask your patients all you want about unhealthy and or other risky habits but and as long as Big Beverage/Big Food and the NRA are card carrying members of the “proverbial Big Brother organization” that controls our government, you won’t make much progress.

    Only with the reduction of tobacco smoking has the US been successful. And that was a tough battle. Why aren’t physicians and their organizations taking a strong stand developing a model (like the tobacco model) for processed sugar (not just soda)/gram and using the money for public education and escalating the community programs already working very hard to grow vegetables in communities?

    The gun problem? Change campaign financing and we change American politics.