Sunday, April 4, 2010

Sunday Editorial

Quite a few readers have written in asking what I think of the Florida doctor who's told patients that voted for Obama to go find another doctor.

I'm sure it's legal. It's his practice. He can do what he wants.

But I don't think it's professional.

Part of being a doctor means treating people equally. Regardless of who they are. White or black, men or women, gay or straight, Republican or Democrat, Coke or Pepsi.

I don't discuss politics with patients. They ask me what I think of the new health care bill, and I give them a generic "We'll see what happens." Divisive discussions aren't good for a doctor-patient relationship.

Some people can be quite outspoken in their beliefs. I've taken care of a variety of ideologies. White supremacists. American neo-nazis. Socialists. Communists. Right, left, and in-between.

Sometimes it's hard to separate personal dislike from clinical judgment. But I do it, and try my best to treat all equally. And I never discuss my opinions with them.

"Dammit, Jim! I'm a Doctor!"

I am a person. With my own political beliefs. But there's no room for them in medicine. My job is to take care of people, and try to make them better, regardless of what I may think of them.

When President Reagan was shot, he famously quipped "I hope you guys are Republicans" to the surgical team as they were getting ready to operate on him, and the surgeon replied "We're all Republicans today."

Dr. Samuel Mudd went to jail for setting John Booth's broken leg after Booth shot President Lincoln.

The same trauma hospital in Dallas that frantically tried to save President Kennedy after he was shot, worked to save the life of his assassin, Lee Oswald, a few days later.

Caring for people equally, regardless of our personal thoughts about them, is what we do.

And if you don't think you can live up to that, then maybe you should find another profession.


Mickey said...

Well said.

Moose said...

What it boils down to, in my unhumble opinion, is *ethics*.

Ethics is what makes you do the right thing even if the face of personal disagreement.

Ethics is what tries to keep bias and opinion separate from facts.

Professional ethics is a personal interest. Although I'm in the computer field, not medicine, there are similarities.

Professional ethics is why you can find web pages about racial superiority, abortion pros and cons, fundamentalist religious beliefs, hippies, and any other controversial topic you can think of.

Ethics is why you choose a vendor based on what products or services they provide at the best price, not what toys or food or other side benefits they offer.

Whether I believe in your cause I will fight for your right to have the same access as anyone else.

Anytime I hear of a person in my field who has clearly violated professional ethics it makes me angry. Although not enforceable there are codes of ethics out there for people in my field.

[and, for the pedants, this doesn't apply to anything illegal. As examples, pedophiles and those advocating the actual destruction of our country do NOT get the same ethical protection.]

So after that, Dr Grumpy, I ask you and/or your readers, the great hot button -- do pharmacists have a similar ethical code? I know there has been stuff in the news in the past about pharmacists refusing to hand out "plan B" and the like due to their personal beliefs. At the risk of being banned from here for starting WWIII, is this against a pharmacist code of ethics?

Today's captcha word: singlai. I am singlai a troublemaker.



Our political beliefs are our own, and that old custom of not discussing religion, politics and sex has some common sense element!

Barb said...

well said. And I love the Star Trek reference. :)

D. said...




Celeste said...

To me, that Florida doctor just showed a big emotional intelligence FAIL. For one thing, it's already hard enough to go to a urology appointment--clearly you have a problem someplace embarrassing and you would rather not have the problem or have to go seek help. Then you get there and you see this hostile sign on the door. How is that any kind of patient care? Frankly it would make me feel that the doctor was more interested in politics and/or his bottom line than in taking care of me.

And anybody who asks me how I voted is going to get told it's none of their GD business, no matter what year it is.

Anonymous said...

Grumpy, long been a fan of your blog. I certainly agree you have a right to your opinions (in general and totally on your own blog).

This doctor let people see the actual consequences of the passing of this bill - now - personally - not what they've been told by a political party.

How is this different than your position (that you wrote a blog about some time ago) that after the latest round of Medicare reimbursement cuts that you won't be admitting any more Medicare patients to your practice?

In both cases potential patients very well may be denied care by a specific physician. And both are related to - whether you like it or not - politics and government programs.

All my respect,

Anonymous said...

i am willing to discuss my opinions about health care policy with my patients, because i am in favor of universal coverage, and firmly believe it can provide better, more cost effective care for all. i do not push or start the conversation. on a recent vacation in the mojave, during lunch a man told me about his disdain for obama and the health care bill. i told him i am a health care provider, and feel that the current reality must change. he felt we are making the wrong change. i told him we have to try. we zipped up and left the urinals. not only did he have bad mens room etiquette but parallel bad teabagger ideas. the town was searchlight, and i had no idea that their rally was imminent.

08armydoc said...

Thank you

Li'l Azathoth said...

Fortunately, all you have to do to find a new urologist in Florida is attend a spring training game and look at the ads on the urinal cakes.

Anonymous said...

I know this is Dr. Grumpy's forum, and I personally agree with him in this well-written statement, but I think for all intents and purposes his point of view would be ethically consistent with all professional providers of health care; physical therapists, nurses, pharmacists.

I don't know about quasi-health advocates that label themselves as certain types of practitioners, but that is a different issue altogether.

Pharmacists are those designated by society to ensure safe access and keep track of the poisons, which all chemical exogenous substances potentially are. Ethics as a specific class wasn't part of the curriculum when I was in school or on residency. However, it only stands to reason, that if we're the profession so deemed by society, and the alternative to obtaining drugs legally by pharmacists are by agents that could be arrested for acting as unlicensed pharmacists, then it would well behoove me to do my job in the most ethically responsible way possible. Pharmacists that refuse to dispense Plan B must offer an alternative arrangement for dispensing it if they don't want to be personally involved.

I do have some limits. I don't think I could put myself in the position to be dispensing cyanide injections in state prisons. If that was in my job description, yes, I would have to find another job. And, sometimes, I wonder what I'm doing working in a mental hospital occasionally, when it seems that I'm in the business of sedating patients (so that their mind can be reached by the therapists), or mixing phenylephrine drips during a CODE when there's no chance the patient will make it in the next 10 minutes. or making a more concentrated epi drip while the organ procurement team helicopters in...but, intent is facilitating the most of a life and I think it's the basis of ethics.

This, of course, is my opinion, and it generally adheres to the Apothecary's Oath. Someone may disagree, just as any ethical health care provider may do so, because we live in the USA.

(The one philosophy course I took in college was scheduled at noon after physical chemistry and another intense class, so I very rarely made it through lecture without zonking out. Philosophy should never be offered during lunchtime!)

Cathy Lane RPh

Li'l Azathoth said...

"Don't shoot, we're Republicans!"

- Greeting that other Navy ships would routinely use for the destroyer U.S.S. William D. Porter, after an incident in 1943 when it mistakenly fired a live torpedo at the U.S.S. Iowa, which was conveying President Roosevelt to the Cairo and Tehran Conferences. Not exactly germane to the topic at hand, but the Reagan line reminded me of it, and I thought you might appreciate the bit of maritime history.

An Open Heart said...

Amen to that! Obviously health care professionals are people and have opinions and emotions, but part of that job is to set those aside and do your job.

Thank you for doing yours without prejudice.

Have a great weekend,

Chip said...

I just want to know why "Anonymous" was eating lunch in the men's room, yet still is critical of a "teabagger's" restroom etiquette or ideals.

And why a "healthcare provider" can't use capitalization and punctuation correctly.


Anonymous said...

Very well said, Dr. Grumpy. Thank you for that.

Anonymous said...

Unfortunately, not every doctor/nurse/hospital adheres to such a code of ethics. My mother was recanting a tale of how a distraught man who shot a police officer was brought to her operating room (she is an OR nurse) and while the surgeons did not deliberately harm him, they did not try to save him in the same way they would another person. At some point, the doctors say "no, it's not going to happen" and remove the life support. For people that the medical staff judge to be morally corrupt, that point comes much easier and earlier.

Cate said...

Couldn't agree more. Even if I were a republican, I'd leave that guy's practice just due to a lack of professionalism. One of the first things they taught us in our clinical medicine class was to use an "ice breaker" when greeting patients but to make it something neutral- like how bout those bills. Great post.

Anonymous said...

How do you balance this with patients who are on Medicare and the doctor's refusal to see this type of patients?

I dont know what the current statistics are but I am sure the majority of current doctors arent seeing new Medicare patients. Why punish them just because of what insurance they have?


Stacey said...

Well, his lack of professionalism will play right into the hands of any patient/lawyer who files a malpractice claim against him. They can claim that they were intentionally treated inadequately due to differing ideology. I would imagine courts and review boards might not look too favorably on something like that.

Unknown said...


I understand what you're saying in regards to the similarities between the two situations, but in Dr. Grumpy's case, he isn't refusing to see the patient, he's refusing to accept the payment method.

bb said...

The only information that I have is what I read in the article. I did not glean from the article that he's actually ranting to his patients in the exam room (though he could be and that is just the wrong place for that). And it certainly did not lead me to believe he's dropping patients that voted for Obama. Also, nothing in the article leads me to believe he's screening new patients based on their political affiliation.

He put up a sign. That's it. Unless, of course, someone knows more than what the article stated. Granted it is somewhat distasteful. I wouldn't do it but then I don't have that kind of moxie.

I'm glad to see that people do have the chutzpah to speak out. What better place to voice his opinion, even if in a kind of a passive-aggressive sort of way, than the place where this bill will affect him. Seems to me he stepped up pretty close to the line but not over the line. Good for him.

Uro*MA said...

On the same token, have you ever had anyone ask mary what your ethnicity is before they make their appointment? In my office we have 2 indian doctors. One hails directly from india and they other from the states. At least once a day someone calls to ask ethnicity and weather they will be able to understand them... My answer, "i understand them just fine"... Maybe it's just me, but should the ethnicity of the dr even matter if they are the best doctor in their field? People are so biased these days its disgusting!! Good for you for keeping politics out of your practice!

Libertarian leanings said...

Just as Dr. Grumpy is free to refuse to see Medicare patients the Florida doctor is free to refuse to see any patient that approaches his door. Neither is a slave or an indentured servant so they should have the right to refuse service to anyone.

Sandra said...

Allie and Jed,

Refusing to see Medicare patients is not the same thing at all. Medicare is cutting their payments so the doctors can no longer afford to take care of those patieents. The doctor's office has bills and salaries to pay. The doctors who stop taking Medicare would rather not have to do that, but economic reality is forcing their hand.

The Florida doctor was refusing to see specific patients based on their ideology. That's more like refusing based on religion or race.

The Hatchling said...

I think it's important to note the physician in question never refused to see patients.

Its far from the most professional thing to do but at the same time the lack of unity in physicians and the inability to stand together is one of the problems in the field.

He's taking a stand for something he believes. He's not hurting anyone (physically) and hurting someone's feelings isn't a crime.

It's not something I would do, but I don't see the need to make such a big deal out of this as people are. Every action carries a reaction and this is this individuals.

Maybe its just the scary thought of what could happen if physicians on a larger scale refused to participate in UHC.

Karen said...

Well-said. It's a good thing unprofessional doctors like that seem the exception, not the rule. I never discuss politics with my doctors (even though here things aren't as 'bad' as in the US right now), and I see no reason why political beliefs should matter when being treated by a doctor.

NozDoc said...

Long time reader, first time poster. There is nothing that this urologist did was unethical or illegal, in fact it was laudable. I am otolaryngologist with a strong interest in ethics and policy. The problem, Grumpy is that you are confusing the issue and many of your readers are having knee jerk responses and are misrepresenting the facts. By law a physician does not have to enter into a physician-patient relationship with anyone unless they work in an emergency department. Furthermore, if they are in a relationship with someone they may terminate it by providing a copy of their records, finding them a replacement or transfer of care so that their patient is not abandoned. In this case, he posted a sign outside his practice recommending voters of a particular persuasion should seek care elsewhere. He is in an elective field and simply made a recommendation and putting out information for his patients to make an informed decision. Patients judge physician on skin color, nationality, religion, political beliefs and this helps them make a decision. He did not withdraw care from anyone, ask anyone their opinions or discuss anything within his office with them unless they brought it up. I am sure if an Obama fan showed up with a torsed testicle in his office he would not ask him what his political persuasion was and treat his testicle.
When I am in the room with someone I treat them and their disease and I treat them as best as I can or when they are on the operating room table, even if I am Jewish and they have a huge swastika tatooed between their eyes.
Once we have agreed to care for someone (unless we work in the ER where we don't have a choice), all our personal feelings should not get in the way of the best possible professional care. However, forcing a physician to treat someone against their will is illegal and unethical. Of course, these laws may change and physicians will soon HAVE to take Medicare, medicaid, perform procedures they are not comfortable with. As you said, Grumpy: We'll see what happens.

P.S. I definitely think your heart is in the right place and I understand what you meant to say but as I stated before you mixed the issues of the case. I could easily turn around and say if you don't respect the fact that your colleagues are human beings that have worked very hard to get where they are mainly at their own expense only to have it stripped from them by poorly conceived legislation and think they are bad physicians for voicing their first amendment rights then maybe you should find another profession.

Food Addict said...

I was once dealing with a road traffic accident with 3 casualties. They were all bleeding profusely and needed urgent transfusion.

It was at a weekend when I was there alone and you can only deal with one at a time.

There was a 6 year old boy, a motorcyclist and a drunk driver (who had caused the collision). The drunk driver was the most seriously injured and the child was the least, although all 3 were critical. It took every ounce of control for me to deal with the drunk driver first as his clinical need was the greatest but it REALLY did not sit well with me.

Overcoming your emotions and beliefs can be really difficult.

Anonymous said...

Medicine is being described as a business when Medicare patients don't bring in enough money to support the practice.
At the same time it is seen as an altruistic calling with universal responsibility when a physician refuses to see someone because of political beliefs.
Consistency anyone?

Swami Dil said...

A professional who cannot be true to his own profession is not likely to remain true to his politics. Legalities aside, this Florida Doctor has no business being in the healthcare business!

Anonymous said...

I believe when you decide to do a job, such as be a doctor, pharmacist or a taxi driver you either do the job the best you can even if you don't agree or get another job. If you don't want to have someone in your taxi who has duty free liquor, get another job. You don't like Plan B, GET ANOTHER JOB. I worked at a bookstore and I sometimes sold books that I found morally distasteful, but they had a right to buy them and it was my job to sell books. I don't have to like you to do my job.

Phillipia said...

I read you because your posts are usually hilarious - and laughter is the best medicine...

But I like you, doc!

You are good people - in my book anyway:)

Even tho my grammar sucks....

pharmacy chick said...

As a pharmacist I try to look at both sides of this issue. I see that as a private practioner her has the legal right to see whatever patients he chooses. If he wants to see only patients who like plaid pants, polka and oatmeal cookies, that is his right I suppose. Just because somebody WANTS to do business with you doesnt' mean that he has to accept your business. I am not saying I agree with what he is doing or that I would ever do it myself, but I would indeed DEFEND his right to do it. I have the right to allow into my home anybody I choose, but I do not have to allow anybody who comes to my door, entrance to my house. That is how i see this issue. He signs his own paychecks. I do not however. I dont have that privilege. I see all patients. I fill all legal prescriptions that meet the rules for my state/country. I am not an advocate for abortion but I dont pass judgement on some girl who comes in with a rx for Doxy and Methergine who has just had one. Its her life not mine.
All I am saying is HIS right to pursue his OWN business as a SOLE proprietor should be defended even if we dont necessarily agree with HOW he chooses to do it.

Grumpy, M.D. said...

Good points PC. Can't argue with that.

bb said...

I've most of the comments and it seems that most are taking the position that the doctor is refusing to see patients who don't hold to the same political view as he does. That's NOT the case. HE'S NOT REFUSING TO CARE TO ANYONE. In fact, that's what he states in the article. All he has done is voice his opinion via a sign.

We can ALL refuse to provide a service. A taxi driver does not have to transport someone if they do not wish to. If he's employed by a company, he may be required to by the employer but if he's independent, he can choose to either transport or not.

@anonymous 6:16 A person working at a bookstore cannot refuse to sell a book per the employer's rules of employment but an independent owner CAN refuse to to carry certain books.

A lawyer does NOT have to take a case if they don't want to. But if they are employed by a law firm, it's much more difficult to refuse to do the assigned work that they are being paid to do by their employer.

A doctor does not have to take on a patient. In fact, I was once denied an appointment by a doctor's office. Had nothing to do with lack of insurance, payment or even being a "difficult" patient. He was my PCP at one time but since I had not needed to see him for over 15 years, my chart went to storage and he was not taking on new patients. That was his right. I was very disappointed because I liked him as a physician but that's life. He's not obligated to enter into a doctor/patient relationship with me and he's not obligated to reestablish that relationship.

The Florida doctor has a right to voice his opinion even if people find it distasteful. State law addresses race, religion,
gender, sexual preference and disability as a prohibited reason to refuse service or employment but does not address political affiliation.

While it may be highly distasteful to refuse to enter into a patient/doctor relationship based on a political choice, it's not a legally protected class. I would imagine that whoever governs physicians (the AMA?) could have their own rules and regulations that would prohibit doctors from putting up such signs.

Even so, it's a MOOT point BECAUSE this doctor did NOT refuse to enter into a relationship with anyone based on a political choice. He's telling people before they even enter the door what he feels and patients can make up their mind to say to themselves "I don't want a doctor like that treating me." I don't know why everybody thinks he's refusing care unless they read an article that said he did refuse care that I have not seen.

I still think it's cool that he had the moxie to do such a thing. I wish he'd bottle some of that moxie and mail it to me.

ERP said...

That guy is a 4+ tool. I heard him blathering on the news about the downfall of our country. Fine dude, move the hell out.

Rescuedog said...

Dr Grumpy, you are refusing to see Medicare patients because of low payments and you back this health care bill? That just doesn't make sense. Once this law takes full effect all of your reimbursements will drop! Hope you have an old, rich Uncle out there!

Grumpy, M.D. said...

Rescuedog- I didn't say that anywhere above.

Anonymous said...

The problem with a general urologist (doubtful in this case being in Florida and all where those rich old geezer hang out) is they often have to be referred to, so it's not like the patient always goes out and chooses whichever doc he wants to see and if there aren't that many urologists, then said patient is upppa creek. So, what's the patient going to do? Keep mum? We do have private ballots in this country..., but if the TURP turns out badly, can the patient sue on the ground of being a Democrat?

The guy is a jerk, IF what he did was irreprehensible. Sure, it is his option to state a preference, and he doesn't have to serve, but he is taking insurance, or is he privately paid cash-only?

Anonymous said...

I am a nurse - a neuro nurse, not that it matters. My biggest nightmare would be that my ex- who sexually abused our daughter for much of her childhood, and who still lives in the area, turns up on my floor requiring care. No question; I'd be gone.

Anonymous said...

I 100% support this doctor's rights not to accept people who voted for Obama, but I do not understand why people are saying he's not refusing to see the patients based on the information from this sign.

The sign says "If you voted for Obama ... seek urologic care elsewhere." It doesn't say "I would prefer you seek care elsewhere". It's a simple if, then statement

He SAYS that he won't turn anyone away as that would be unethical, but the sign does not support that statement.

RevDisk said...

I notice plenty of folks are outright hostile towards this doc. True, lots of folks consider it unprofessional. Unethical, probably not. He is expressing an opinion, not denying care. I noticed no one mentioned the more disturbing aspect of this situation. Rep. Alan Grayson has publicly announced he will seek to file complaints with all relevant boards or agencies as retribution for the doctor expressing his opinion. Florida Department of Health has already announced that Dr. Cassell has broken no medical laws. Doesn't matter.

Regardless of whether or not you agree or disagree with Dr. Cassell's unenforced sign, you should be fairly disturbed at politicians directly attempting to harm medical professionals for expressing disagreement with medical laws.

I am personally not entirely fond of the way Dr. Cassell is making his point. But I don't think he is being ethically or morally wrong for attempting to educate his patients on the new health care law. It is shocking how few people, even in Congress, have ANY knowledge of what the law contains. Whether you support or oppose Patient Protection and Affordable Care Act, READ THE BLOODY PROVISIONS. I have no idea, NONE, why people will moan, bicker, and scream over this without even skimming the Wikipedia entry. (No, I'm not saying you should rely on Wikipedia for anything, but ANY knowledge of the law is better than NO knowledge of the law.)

In the interest of providing educated entertainment, here is the short version. Folks will be required by law to obtain coverage by 2014 or face a 2.5% fine or $695 per family member up to a $2,085 cap. Medicaid eligibility will be expanded. Tax credits and subsidization for insurance premiums. Restrictions on insurance policies barring certain practices. To compliment the expected increase in Medicaid patients, Medicare and Medicaid reimbursement schedule is being cut. Numerous taxes added, including a 40% excise tax on certain health insurance premiums.

Don't take my word for anything, do your own research and make up your own mind. This shouldn't be Left vs Right, Tea Party vs Obama, or any other "Us vs Them" arrangement. It should be "Is it legal? Is this law good or bad for our country? Do I think this is the right way of achieving what I believe should be done? etc etc" I personally don't care what your opinion is. If you have an informed and reasonably educated opinion, you and your opinion are worthy of respect.

That said, there is one huge aspect of the law that perturbs me. I've talked to doctors, nurses, ambulance drivers, administrative folks, etc. In short, Medicare/Medicaid will likely only be widely accepted at very large hospitals or Medicare-mill practices. Numerous private practices started dropping Medicare and Medicaid prior to this law passing. The reimbursement schedule was cut to the point where most doctors lose money each and every time they see a client paying with Medicare/Medicaid. I don't mean "don't make much profit", I mean "directly lose money".

A friend of mine that does IT stuff for medical billing systems explained that any normal practice with more than 30% of patients being Medicare/Medicaid will fold. There are exemptions to that rule (certain specialists, Medicare mills, etc), but it's more or less an industry rule of thumb. With the reimbursement schedule to be further cut, expect numerous additional private practices to flat out be unable to accept any Medicare/Medicaid. They cannot operate on a loss. The power company, the employees, the supply company, landlords, etc all expect to be paid.

Pharmd Biker said...
This comment has been removed by the author.
Anonymous said...

What this urologist did is just downright immature. We all have taken care of patients with all sorts of abhorent behaviors like violent crime or drug addiction, and do it without being insulting or intimidating. So this guy is drawing the line at voting? No, he didn't do anything illegal, but that's kinda moving the goal posts. There's all sorts behavior that is legal but is still unprofessional.

Pharmd Biker said...

ok, wrong or right i have 2 questions.

1- why are people calling for his head on a platter?


2-should he lose his license to practice? some congressman (to late- its waaaaay political now), and some "concerned" citizens are demanding it.

My opinion: Have we come to the point in out history that if you do not agree, you must be attacked and silenced?

Grumpy, M.D. said...

PharmD Biker- No. He should not lose his license. He has a right to his opinion, just as I have a right to mine.

Like I said originally, it's his practice. He can do what he wants. I don't agree with what he did.

I agree that this has gone out of proportion. He was an expressing an opinion. I just disagree with the way he did it.

Pharmd Biker said...

I do agree. I think the whole thing is way out of control with those in congress asking for his license to be removed. I think he would almost be in a better situation if he would have kicked a puppy instead.

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