The state of Florida provides an excellent example of the increasing hurdles that physicians face as we try to treat patients. Consider Florida’s 2018 law on the prescribing of controlled substances. As a family physician, prescribing these types of medications is already one of my least-favorite activities. My prescriptions generally come only after I’ve interrogated the patient on previously tried and failed treatments, followed by attempts at every other safer alternative I can think of. I accompany these discussions with long-winded lectures on the dangers of controlled substances. Not uncommonly, I say ‘no’ to requests for controlled medications when I believe that the risks outweigh the benefits, facing the disappointment and occasional ire of patients. This isn’t easy. Frankly, it’s exhausting and can even be demoralizing to physicians when patients respond with frustration, desperation, and sometimes even anger.
In some respects, Florida’s 2018 statute limiting opiate prescriptions served a benefit to doctors. The state’s controlled substance database was beefed up, making it easier for physicians to ensure that patients weren’t getting medications from multiple prescribers and pharmacies. It also made it a bit easier for doctors to use the law as a scapegoat when refusing to prescribe controlled substances: “Kidney stones again? Sorry, I’m only allowed to give you a 3-day supply of pain medication.” On the other hand, the law, described as “one of the most restrictive in the country,” led some physicians to stop prescribing opioids completely, instead recommending acetaminophen or ibuprofen for broken bones and postoperative pain.Now Florida legislators have added an additional step for doctors to follow: the requirement to provide patients with a written brochure entitled “Information on Nonopioid Alternatives for the Treatment of Pain.” The handout encourages patients to consider modalities like ice, heat, and yoga, as well as complementary therapies like acupuncture or chiropractic treatment. While the brochure provides helpful information, it is an additional barrier that may encourage physicians already on-the-fence to give up narcotic prescribing entirely.
In their urgency to pass a strict opioid law, legislators failed to consider areas like hospice medicine, which often require emergency dosing of narcotics to patients for end-of-life pain and dyspnea.The law required hospice physicians to log into Florida’s controlled substance database with every prescription for patients in need of medication to ease the dying process.As a moonlighting physician covering weekends for a large hospice organization, this mandate significantly increased my workload, requiring constant interruptions in my day as well as middle-of-the night computer sessions. Ultimately, I found the burden of following the new law so great that I resigned my position, despite my strong desire to care for hospice patients.It took a year and a half for the Florida legislature to finally provide an exemption from the law for hospice patients.
Florida’s latest administrative hurdle for physicians is the requirement that doctors obtain written informed consent for patients prior to performing a pelvic examination. The law, which was signed on June 18, 2020, was intended to prevent patients from receiving examinations while under anesthesia without their consent. According to legislative experts, the law was amended at the last minute during the legislative session, changing the wording to require that physicians obtain written informed consent from patients prior to a pelvic exam at any time.
This week, one of my patients came in to see me, requesting a pap test. After checking her records, I advised her that she didn’t need one yet, as her last pap had been normal without evidence of human papilloma virus. The patient hung her head. “I didn’t want to tell you this, but I need you to check to make sure I didn’t leave a tampon in. I scheduled a pap just so you could look.” After assuring her that she never needed to wait for an “annual” to have something she was worried about checked, I performed the necessary pelvic examination and was able to reassure her that there was no evidence of any foreign body. It was only after she left that I realized that I hadn’t obtained the patient’s written consent—for an examination that she expressly came in for. Oops.
I’ve been told by political lobbyists that the legislature plans to revise the wording in this law in the next legislative session. I’ve also been assured “off the record” that the Florida Board of Medicine has no plans to sanction doctors as long as they are following the principles of informed consent when examining patients. But why is this something that hard-working doctors even have to worry about? And why enact any law that creates barriers for patients to get the care that they need?
I’ve also noticed that when writing laws overseeing medical care, legislators often show evidence of a powerful cognitive dissonance. They are often quick to write laws that require strict accountability for physicians, yet simultaneously pass bills that allow non-physicians with far less education and training to provide medical care to patients.
For example, California recently became the first state to require that physicians complete three years of residency training after medical school to receive a license to practice medicine. Most other states allow U.S.-trained physicians to practice after one or two years of residency. By the time they graduate and before residency, medical students have already received 6,000 hours of clinical experience.Yet legislators in the very same state are pushing California bill AB-890, a law that would grant nurse practitioners the right to treat patients independently after three years—just 4,600 hours—of practice, in addition to the 500 minimum hours that nurse practitioners must complete during training.
Other examples of the dichotomy between laws affecting physicians and non-physician practitioners abound. Federal law requires that any payments made to physicians are reported and available to the public. However, no such law applies to nurse practitioners or physician assistants, even though legislation was introduced to expand the requirement to non-physicians in May 2018. The 2010 Affordable Care act expanded funding to nurse practitioner and physician assistant training programs, but did not increase residency training for physicians, which has been frozen since 1997. Rural health clinics are required to staff facilities with at least 50% nurse practitioners or physician assistants, even if physician candidates are available and willing to work.
Studies show that a robust physician workforce decreases mortality. Rather than making it more difficult for doctors to treat patients, politicians would better serve their constituents by removing barriers to physician practice.