How do you think Dr. Ingram will respond to Carla’s question? As physicians, we are trained to be in control and to know the answers. We feel uncomfortable with uncertainty, ambiguity and lack of knowledge. Perhaps this is why Dr. Ingram focuses on concrete questions e.g., medications, list of surgeries ─ he is comfortable and confident there. Carla has given him lots of information about herself, yet he has avoided pursuing any of it. Have you experienced a similar situation in your practice?
We might not want to admit to it, but physicians have feelings and beliefs that can negatively impact their behaviour with patients. Maybe Dr. Ingram was raised in a homophobic environment. Perhaps he is confused about his own sexuality. We do not know.
Whatever the case, our professional guidelines require us to be aware of our emotions and how they can unconsciously influence or bias the care we provide to a patient.
So, what does Dr. Ingram say? As a professional, a physician must be honest about what they know and what they do not know. Saying otherwise is lying. As well as being unethical, lying destroys trust between a physician and a patient. Patients, for the most part, do not expect physicians to know everything.
So Dr. Ingram says: “No, I haven’t had a transgender patient before.”
Having admitted being unaware of transgender health, how does Dr. Ingram respond to Carla’s request for care?
- “I can’t help you. You need to see someone else.”
- “I don’t know much about this, but I’ll look it up, and talk to some experts.”
- “I would need your complete medical record before doing anything.”
A physician might be uncomfortable with each of these responses. It can happen that a physician feels uncomfortable with a patient. A physician needs to be aware of their discomfort and acknowledge that it could have a negative impact on the decisions they make.
Is it ethical for a physician, having met a patient once, to refuse further care? The physician has a fiduciary responsibility to provide care to the patient and cannot refuse care because of their views.
If the reason for refusal of care is the physician’s lack of experience and expertise, the following options can be considered:
- Self-education. “I’ll look it up”.
- Consultation for help in care. “I’ll talk to some experts.” The “Communicating with adolescents” module discusses this process in considerable detail.
- Consultation with request for transfer of care.
- Asking for previous records is necessary, but should not lead to inappropriate delays in the patient’s care.
There are a number of resources physicians can consult to become educated, informed and able to properly provide healthcare to transgender people. One source is the series on transgender health published in The Lancet. You can also read the following: “Serving transgender people: clinical care considerations and service delivery models in transgender health.”
Some physicians might feel they are unable to provide care for patients in certain situations due to incompatible moral or ethical values. Regulatory authorities and the courts have been clear that refusing to care for patients “based on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status constitutes discrimination.” (Canadian Medical Protection Association, March 2010, revised June 2016.) Physicians are encouraged to review the CMPA policies. In these instances the physician must either provide the needed care or secure transfer to another physician.
There are a limited number of situations, such as abortion and physician-assisted dying, where a physician’s decision to not participate in care of a patient on the basis of their cultural, religious, moral, or personal beliefs might be supported. In such situations, “colleges have adopted guidelines which generally state that physicians are expected to provide sufficient information and resources to enable patients to make their own informed choice and to access options for care, or to provide an effective referral to another physician or resource.” (Canadian Medical Protective Association, March 2010, revised June 2016.)