Fighting for Broccoli

Some days I wish I could treat my patients like children. It’s not my proudest admission, but I share it humbly. When Internet-eager, geriatric-aged patients with multiple comorbid conditions and a skepticism for all things pharmaceutical ask (again) after their second heart attack, “Doc, I’m not so sure about this statin. Why do you think I should take this medicine?” It takes more energy than I’d like to admit not to default to a curt, “Because I said so.”

I know that answer isn’t even acceptable for kids. Inquiring minds of any age want—and deserve—real answers. Sharing knowledge in a way my patients can understand is actually one of my favorite parts of my job. The frustration arises after I ask the patients about their worries, validate their concerns, review the evidence in a health-literate way, and reiterate the effectiveness and importance of the initial recommendation—and they still balk, “Hmmm…well, I don’t know about all that.” Translating science into practice is hard.

As an internist, my profession is dedicated to evidence-based, patient-centered care. We’re empiricists and scientists at heart, so I’m tempted to think patients—and colleagues—disagree because of scientific differences, competing studies, unique circumstances, or even lack of awareness of some new finding. But here’s the thing: Humans of any age disagree for a handful of reasons, and lack of equal information is only one of them. Some people are skeptical by nature—cautious of anything new, different, or recommended by someone they don’t know well. They’re like shy kids in a new school. As a primary care doc, I can circumvent this barrier by building trust over time. Some people are contrary just to be contrary, and I don’t think even the most skilled primary care physician can coddle or reason with the equivalent of a toddler who needs a nap.

But by far the greatest barrier I face to finding common ground is when my patients “just don’t like” my answers. The concrete example would be trying to prescribe potassium replacement: The pills are gigantic, and the liquid tastes terrible. The recommended treatment is just hard to stomach. The conceptual example is abortion. Abortion is the broccoli of medicine; some people “just don’t like it.”

Don’t stop reading. Please don’t stop. That’s the problem, see. Abortion is such a polarizing issue that even intelligent, evidence-based physicians shy away from talking about it. Some shy away from even hearing about it, or reading about it—despite the overwhelming evidence that supports abortion as a safe and effective medical procedure to terminate a pregnancy.

You don’t have to take my word for it—you don’t know me. Annals of Internal Medicine published a summary of one of the largest assessments of abortion in our country last summer. The National Academies of Science, Engineering, and Medicine’s (NASEM) “The Safety and Quality of Abortion Services in the United States,” found that abortion was not only an effective and safe medical procedure but that it has decreased in frequency over the last 30 years (1). The science is robust: Broccoli is safe to eat for most and in fact can be good for you as one part of a well-balanced diet.

The review was incorporated into the American College of Physicians’ (ACP) position paper on women’s health policy (2) published that same month, supporting equitable access to evidence-based treatments and interventions that ensure patient autonomy, reproductive decision-making rights, and access to comprehensive reproductive health care free from “unnecessary restrictions on health care professionals or facilities.” Not everyone has to eat broccoli, but for those folks who feel like it’s a part of their meal plan, it should be available.

These rigorously evidence-based positions have been challenged in recent months as many states pass legislation that is based in neither traditional science, nor other socioeconomic evidence.

As a result, ACP along with American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), American Osteopathic Association (AOA), and American Psychiatric Association (APA) have spoken out about these laws (3):

The insertion of politics between patients and their physicians undermines the foundation of trust this relationship is built on and inhibits the delivery of safe, timely, and comprehensive care. Outside interference endangers our patients’ health by limiting, and sometimes altogether eliminating, access to medically accurate information and to the full range of health care.

The cohort, known as the “Group of 6,” made the “You don’t have to like it. You don’t have to eat it. But you can’t take it off my plate and throw it on the ground in the middle of supper” argument. Overwhelming evidence supports the safety and quality of all 4 types medical procedures known as abortions.

In fact, they found that any variations in the safety and access that did exist were attributable to state-based regulations that were not founded in evidence—things like mandatory waiting periods and certain facility requirements. This would be like saying, “You can eat broccoli, but it can only be sold at stores that sell 100% organic produce that is rotated once a week, and you have to send them your grocery list at least 1 day in advance of when you plan to eat your broccoli-related meal.”

As the NASEM assessment illustrated, internists like myself are rarely the clinicians performing abortions. However, we frequently care for patients who need, request, or may have had an abortion as part of their overall medical meal plan. It is my job to know my patient and the evidence, and how to make recommendations that are supported by both. I also believe it’s my job to ensure my patients have access to those recommended treatments. If my patients want or need an abortion, I’ll fight for that broccoli.

References

1. Calonge BN, Gayle HD. The safety and quality of abortion services in the United States: what does the evidence indicate? Ann Intern Med. 2018;168:878-80. [PMID: 29554694] doi:10.7326/M18-0662
2. Daniel H, Erickson SM, Bornstein SS; Health and Public Policy Committee of the American College of Physicians. Women's health policy in the United States: an American College of Physicians position paper. Ann Intern Med. 2018;168:874-5. [PMID: 29809243] doi:10.7326/M17-3344
3. Group of 6. Frontline physicians call on politicians to end political interference in the delivery of evidence based medicine. 15 May 2019. Accessed at www.groupof6.org/content/dam/AAFP/documents/advocacy/prevention/women/ST-Group6-LegislativeInterference-051519.pdf.