Reproductive health and more....

[WestCoastSunRN]

First off, I in NO way am looking for debate in this thread. I hold no judgement at all toward any poster whose opinions and understanding on these topics are different from my own. That said, I want to very gently ask:

In the world of primary care, specifically family practice, is it naive to think a person would be employable who doesn't want to prescribe certain treatments such as IUDs or the Plan B pill?

And what if a provider feels it is in his/her patients best interest to vaccinate on an alternative schedule from what CDC guidelines are?

I think these are some hot-button issues for some people. I guess my ultimate question is, Is there a place for an NP in family practice who has alternative viewpoints or moral questions regarding some of the daily stuff you'd see in a primary care office.

I don't deal with this stuff as a critical care RN. Sure, there are ethical dilemmas in critical care -- and I guess I feel like I've learned to navigate those as best I can. Sometimes we get it right and sometimes we get it wrong.

But I picture myself in a clinic setting talking about alternative vaccine schedules and my co-workers/colleagues eyes bugging out and them thinking, "what the heck are you even doing here?!"

Regardless of where anyone lands on any of the subjects I mentioned (and I'm sure there are others I didn't mention), I really appreciate whatever constructive feedback is offered.

[WestCoastSunRN, MSN, CNS]

Thanks UrbanHealthRN for such a thoughtful response. I agree patients absolutely deserve and need to be fully informed about their various choices. And almost all choices in healthcare come with upsides and downsides.

[traumaRUs, MSN, APRN]

Great topic.

I would hope that you wouldn't take a position where this care would be necessary. If you do decide to take a position where women's health/peds vaccination schedules are part of the expected care then I would hope you would discuss this in the job interview.

As to alternative vaccination schedules, usually if you are part of a practice, they have guidelines they go off of and if you the provider don't follow the guidelines (regardless of your personal feelings) you can find yourself in hot water.

[WestCoastSunRN, MSN, CNS]

Yes, I would certainly be asking about such things in an interview. But these are important questions for me to think about now. Maybe acute care is a better fit for me. I have a lot to think about. Thanks everyone for the responses and helping me process outside of my own head.

[A&OxNone, MSN, RN]

My sister has endometriosis and goes to a gynecologist that suddenly decided to stop prescribing birth control, no matter what the condition. I would also like to clarify that this wasn't part of a religious healthcare system, it was just because of his personal beliefs. My sister is non-medical and liked/trusted him while he offered her "other alternatives" and suffered for so long before (thankfully) having her first child. I just couldn't understand somebody going into that field and not offering such a major service. It still gets under my skin. I felt like it was unethical in a way - like a previous person said, as a provider its your job to lay out all of the options and give your patient the choice if they understand the risks.

If you feel strongly against the CDC vaccine schedule, I would suggest finding a job where that wont be part of your duties. I'm just not sure what your response is if you are ever questioned by a lawyer about why a child died of meningitis or epiglottitis or pneumonia because they were not given the HiB vaccine when indicated, especially if you were following your own schedule and the parent didn't know it wasn't CDC guidelines.

In general, I have a lot of difficulty understanding a provider that puts their personal beliefs ahead of research or patient autonomy. I feels like it crosses a line and makes me feel uncomfortable. I wouldn't want my physician to withhold treatment from me or slant their "speech" about treatment options and leave out certain ones based on personal beliefs. If they disagree because of experience or research, thats totally justifiable. But patients put their faith in you as a provider to guide them. If you have personal beliefs that aren't backed up by evidenced based practice and practice guidelines, I would really just suggest finding a job where those beliefs don't conflict with your job.

All this is said with respect and isn't a personal attack, I promise. It really is just to give you perspective from the other side.

[Julius Seizure]

I am not certain of this, but being that my uni is Catholic -- I may have support in not performing certain procedures such as IUD placement.

I'm sorry OP, but I'm gonna plead ignorance here! I am not catholic, but I did work at a "catholic" hospital, and I never heard that birth control such as IUDs were against "the rules"

Does the catholic faith not agree with birth control?

As for your original question, yes I think you might be right about a specialty practice avoiding some of these concerns - not many IUD placements are done in a pulmonology clinic Otherwise, I think you would just have to be patient and hope to find that "right fit" for you in a family practice job. Wishing you luck, whatever you choose.

[WestCoastSunRN, MSN, CNS]

My sister has endometriosis and goes to a gynecologist that suddenly decided to stop prescribing birth control, no matter what the condition. I would also like to clarify that this wasn't part of a religious healthcare system, it was just because of his personal beliefs. My sister is non-medical and liked/trusted him while he offered her "other alternatives" and suffered for so long before (thankfully) having her first child. I just couldn't understand somebody going into that field and not offering such a major service. It still gets under my skin. I felt like it was unethical in a way - like a previous person said, as a provider its your job to lay out all of the options and give your patient the choice if they understand the risks.

If you feel strongly against the CDC vaccine schedule, I would suggest finding a job where that wont be part of your duties. I'm just not sure what your response is if you are ever questioned by a lawyer about why a child died of meningitis or epiglottitis or pneumonia because they were not given the HiB vaccine when indicated, especially if you were following your own schedule and the parent didn't know it wasn't CDC guidelines.

In general, I have a lot of difficulty understanding a provider that puts their personal beliefs ahead of research or patient autonomy. I feels like it crosses a line and makes me feel uncomfortable. I wouldn't want my physician to withhold treatment from me or slant their "speech" about treatment options and leave out certain ones based on personal beliefs. If they disagree because of experience or research, thats totally justifiable. But patients put their faith in you as a provider to guide them. If you have personal beliefs that aren't backed up by evidenced based practice and practice guidelines, I would really just suggest finding a job where those beliefs don't conflict with your job.

All this is said with respect and isn't a personal attack, I promise. It really is just to give you perspective from the other side.

I am sorry to hear of what your sister has gone through. I can also understand your frustration. For what it's worth -- most of my issues with oral contraception is that I think they can cause more trouble than than they are worth. I think there are valid reasons to question putting synthetic hormones in our bodies. I also think there is evidence for an alternate vaccination schedule from what the CDC recommends. I don't think these things because of religious reasons, actually -- though my faith does inform what I think and do. How can it not? But I do study these things. And I trust sources more educated than myself including my own PCP and my children's pediatrician. These are thinking practitioners who understand the science is always changing. We see this with changes in CDC recommendations as well -- they change. What is the only constant in healthcare? Change.

Regardless, I think there is compelling science with regard to vaccines and synthetic hormones. These, among other medications need to be respected for the full weight of what they can do -- both intended and non-intended consequences. I didn't intend to go into so much detail about why I have a problem with how some conventional medicine is practiced. It is true I would not perform an abortion or want to prescribe an abortifacient medication or treatment. This is one reason I am not specializing in women's health --- but also why I pose questions about women's health because FNPs in family practice DO practice women's health. But truly, most of my concerns are those listed above. And in both cases, it is not to put my own beliefs ahead of the patient. It is, rather, to give the very best and safest care to the patient.

I would never willy nilly come up with my own super special way of practicing medicine. I'm not smart enough to be inventive in that way. But I'm smart enough to pay attention to red flags and question whether there is a better way.

I know you were not attacking me. I appreciate all you said. But obviously I needed to share more about where I'm coming from.

As for your sister --- I'm sure hormone therapy in the way of BC pills, etc. is a first line treatment for her endometriosis. Other treatments are invasive and come with risks. But since BC pills come with risks it is something she has to think about and weigh her options. It would be great, I think, if she could NOT have to take BC, obviously. But that might not be an option. Endometrosis is horrible -- and it's not super well understood, from my understanding. I hope she will be able to get effective treatment. I'm sure as long as her risk factors for the most dangerous side effects are low ---that I, were I her provider, would also treat (at least initially) with BC. That is based on what I know right now about it -- am not a provider, so there could be better first line treatments available now.

I hope I don't sound defensive... I really appreciate you taking the time to respond. It is giving me a chance to be a little bit more clear -- but also hear another side to the issue. Thank you!

[WestCoastSunRN, MSN, CNS]

I'm sorry OP, but I'm gonna plead ignorance here! I am not catholic, but I did work at a "catholic" hospital, and I never heard that birth control such as IUDs were against "the rules"

Does the catholic faith not agree with birth control?

As for your original question, yes I think you might be right about a specialty practice avoiding some of these concerns - not many IUD placements are done in a pulmonology clinic Otherwise, I think you would just have to be patient and hope to find that "right fit" for you in a family practice job. Wishing you luck, whatever you choose.

I'm not Catholic either. :)

But I think they are only against abortifacient meds? But the official position of the Catholic Church, as I understand it, is that BC in not permitted except in cases where it is not being used as birth control (such as PCOS, or endometriosis).

Thanks for the response and encouragement.

[FolksBtrippin, BSN, RN]

I think you should be unemployable in womens health if you would refuse to prescribe the IUD or plan B. Don't sign on to do a job you don't want to do.

As far as vaccination schedules, you need to go with the guidelines, unless you are accommodating a parent who otherwise won't vaccinate or some other valid reason to go against the guidelines.

[WestCoastSunRN, MSN, CNS]

Thanks everyone, for the fruitful discussion. Several of you brought up some really great points and thoughtful responses.

As I said at the onset (or somewhere in this thread), I have no plans to go into women's health. Thus I heartily agree with those who suggest I don't! I know I have some alternative views regarding vaxing, which are certainly not random or non-researched, not anti-vax, and not even that controversial and becoming less and less unique, as well. What I gained from this thread is encouragement and confirmation that it is essential to find a right fit for actual practice. And this may require persistence and patience.

I'm the "lets read the fine print on the insert" kind of gal. I don't think this will make me a less-than provider. As is the hope for all of us on AN, I have IRL mentors and counselors in both nursing and medicine who are also helping me frame what my future advanced practice can look like.

[A&OxNone, MSN, RN]

Two points I think I was trying to make in my last post that I didn't do a very good job being clear - and this is me under the assumption you want to go back to school and haven't started yet or are fairly early in your training as an APP - First is that as a provider, its a different relationship that you have with your patients than as a nurse. Until you experience it and see it, you can't quite understand the trust people put into you until you realize that there are people that just trust you to tell them what to do because they don't know. Can you really have enough faith in what you believe thats against the CDC (or whatever the guideline) to guide every patient down that path? Because they will trust you.

Which brings me to my second point, is that a lot of your practice is, and SHOULD BE, very guideline driven. How to work up, rule out, and treat disorders. So when you stray from those guidelines, you have to have a really good reason and research to back you up incase something happens. (For instance, I know Keppra is the drug of choice for this seizure disorder but the patient has a history of aggressive behavior and I know keppra can intensify that, so I will pick a less desirable medication). I'm not saying everything is black and white and you don't use your brain (def not), but when you go against whats recommended in all the medical literature because you are a "read the fine print on the insert" kinda girl, well, that goes back to my last post that your job to lay out the fine print and present it to the patient and let them decide what risks they are willing to take.

For example, "For the HPV vaccine, it prevents you from several viruses that could cause you to develop cancer. Like with most vaccines, there is a risk of pain at the injection site or muscle pain, fever, fainting, or in some cases, a severe allergic reaction does happen and it can be serous. This is the information about the vaccine and after you do some research on your own, you can let me know if its something you are interested in for next time". DONE.

[WestCoastSunRN, MSN, CNS]

Two points I think I was trying to make in my last post that I didn't do a very good job being clear - and this is me under the assumption you want to go back to school and haven't started yet or are fairly early in your training as an APP - First is that as a provider, its a different relationship that you have with your patients than as a nurse. Until you experience it and see it, you can't quite understand the trust people put into you until you realize that there are people that just trust you to tell them what to do because they don't know. Can you really have enough faith in what you believe thats against the CDC (or whatever the guideline) to guide every patient down that path? Because they will trust you.

Which brings me to my second point, is that a lot of your practice is, and SHOULD BE, very guideline driven. How to work up, rule out, and treat disorders. So when you stray from those guidelines, you have to have a really good reason and research to back you up incase something happens. (For instance, I know Keppra is the drug of choice for this seizure disorder but the patient has a history of aggressive behavior and I know keppra can intensify that, so I will pick a less desirable medication). I'm not saying everything is black and white and you don't use your brain (def not), but when you go against whats recommended in all the medical literature because you are a "read the fine print on the insert" kinda girl, well, that goes back to my last post that your job to lay out the fine print and present it to the patient and let them decide what risks they are willing to take.

For example, "For the HPV vaccine, it prevents you from several viruses that could cause you to develop cancer. Like with most vaccines, there is a risk of pain at the injection site or muscle pain, fever, fainting, or in some cases, a severe allergic reaction does happen and it can be serous. This is the information about the vaccine and after you do some research on your own, you can let me know if its something you are interested in for next time". DONE.

I think you did a fine job expressing yourself. But I find myself thinking the same thing in this thread -- that maybe I'm doing a poor job asking my questions and conveying my thoughts. I do get it. I think, actually, we are on the same page. And you said it very well. Evidence based practice should be our guide except when it is insufficient or until it has reached its limit -- the Keppra example is a good one.

EBP can only be a part of the equation. Clinical acumen and expertise must be the other part. And aside from both of those things we should always be asking "why" and is there a better way? Because often, 10-20 years after asking such questions we find that there is, indeed, a better way.

But you are also correct in pointing out that I am not yet a provider. I have MUCH to learn, and it is from that humble reality that I ask for feedback on these types of questions and scenarios.