Cynicism, with consequences.

On a recent evening, while working in a children's hospital emergency department as a pediatric emergency medicine physician, I picked up the chart of yet another patient without a true emergency: a sixteen-year-old with vaginal discharge. After reviewing her chart, her nurse and I spoke with her in her room. Her story was all too familiar. She was sexually active. She did not use contraception. She had also been treated for pelvic inflammatory disease three times before, but luckily, she had not yet been pregnant. And like many adolescents, she did not have a primary care physician, so the emergency department was her primary care clinic. I informed her that she would need a pelvic exam and a pregnancy test. I also asked if she had had unprotected intercourse in the last five days. She said yes. I gave her my standard sex talk for adolescents, which covers condoms, safe sex, and emergency contraception, also known as Plan B. Before I could finish, the nurse huffed out of the room. Back at the nursing station, I asked the nurse to gather the supplies I would need to do a pelvic exam and pregnancy test. I also told her that the patient wanted Plan B. The nurse rolled her eyes. "I can't stand it when girls like this are having sex but can't accept the consequences," she said. "And this girl is obviously having sex with multiple partners." She shook her head. "I refuse to give her Plan B. You can get it yourself." Trying to figure out her reasoning, I asked her why, exactly, she was refusing to get the Plan B. She told me, "This patient is not being responsible, and I don't believe in abortion." I tried to explain that emergency contraception doesn't cause abortions. In fact, scientific evidence shows that the main mechanism is to prevent ovulation, not implantation, and that it won't affect an already fertilized or implanted embryo. She didn't seem to care. I was torn. Part of me wanted to tell her that, if she was going to work in my ED, she was going to have to give patients the medications that I ordered, while part of me wanted to respect her beliefs. But I had a nagging suspicion that her response had nothing to do with her beliefs--that she just thought this irresponsible adolescent did not deserve our help. Every day on the front lines of health care, treatment decisions like this one are made. What factors influence them and ultimately determine what care a particular patient receives? In the real world, it is clear that treatments do not solely depend on what is medically indicated for the disease at hand. Should the decision to provide emergency contraception depend on the situation? For example, suppose this sixteen-year-old was in a monogamous relationship and using a condom, but it broke. Would we have felt the same? Does (or should) her socioeconomic status play a role in how we treat her? How about her race? What if she were a rape victim? While a particular treatment may be legal or medically indicated, that doesn't mean it will always be discussed with or provided to patients; much depends on the attitudes of the health care providers, and those attitudes are often based on the context they perceive to be relevant. Studies have shown the majority of emergency contraception prescriptions in the ED are given in situations involving nonconsensual intercourse or sexual assault. Consensual unprotected intercourse, though, can be a different story. Over the years, I have known both physicians and nurses who, like the nurse above, refuse to prescribe emergency contraception in this situation. In order to assess the attitudes, beliefs, and experiences that influence health care providers' decisions about emergency contraception in pediatric emergency departments, Melissa Miller and I, along with several colleagues, recently conducted a multicenter study to examine this issue. We interviewed focus groups of nurses and physicians to elicit their thoughts and experiences regarding emergency contraception in the pediatric emergency department. …