MMI- pregnancy and drinking

[wizzed101]

A pregnant woman enters your practice to have some checkups. You learned that she often drank to reduce stress. She acknowledged that drinking can cause serious harms to the fetus, but in her words: "I can't help it. If I don't have occasional drinks, I don't think I can go through this." From her contact information, you learned that she was from a neighboring state where it is a felony to drink during pregnancy. The woman probably came to your practice because there is no such law here.

What should you do in this situation?

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[ifnotnowwren]

A pregnant woman enters your practice to have some checkups. You learned that she often drank to reduce stress. She acknowledged that drinking can cause serious harms to the fetus, but in her words: "I can't help it. If I don't have occasional drinks, I don't think I can go through this." From her contact information, you learned that she was from a neighboring state where it is a felony to drink during pregnancy. The woman probably came to your practice because there is no such law here.

What should you do in this situation?

Start us off with what you think. I think these MMI questions are really stimulating but if you are trying to practice, it's going to help for you to start off the discussion with your thoughts. People may challenge them or introduce new variables, as your interviewer might. Developing the skill of reasoning through these problems and finding your own initial footing is going to be way more helpful than reading what other people think.

 

[freak7]

What should you do in this situation?

You're asking a "should" question about an ethical dilemma. That's the whole point of the dilemma.

 

[wizzed101]

Start us off with what you think. I think these MMI questions are really stimulating but if you are trying to practice, it's going to help for you to start off the discussion with your thoughts. People may challenge them or introduce new variables, as your interviewer might. Developing the skill of reasoning through these problems and finding your own initial footing is going to be way more helpful than reading what other people think.

I just made that question up. I think it is quite risky because it can lead to a debate about whether a fetus is a life.

Regardless, my mother came to me for a checkup so she obviously cared about the baby. I would do my best to keep it healthy as that was her wish. First, I would advise her to seek help for her drinking problem. Maybe there is a depressant that does not harm the fetus. If that failed, I might employ some scare tactics to better inform her of the consequences of drinking during pregnancy- she might be very knowledgeable on the subject, but as we all have our bias, she might have subconsciously downplayed it a bit. On the other hand, if she might decide to abort the baby if not provided relief.

I don't know if it is appropriate or even feasible to venture into tackling the root cause of her stress: maybe it was her job, her partner, etc...

 

[Psai]

Why do medical schools do this to people?

 

[Pinocytosis]

Why do medical schools do this to people?

The admissions office enjoys watching neurotic and anxious pre-meds squirm in their seat as they try to solve impossibly-difficult ethical scenarios.

 

[Ismet]

Why do medical schools do this to people?

I had one MMI interview setup for residency too. Safe to say that program was at the bottom of my ROL (other things I didn't like too).

 

[Catalystik]

A pregnant woman enters your practice to have some checkups. You learned that she often drank to reduce stress. She acknowledged that drinking can cause serious harms to the fetus, but in her words: "I can't help it. If I don't have occasional drinks, I don't think I can go through this." From her contact information, you learned that she was from a neighboring state where it is a felony to drink during pregnancy. The woman probably came to your practice because there is no such law here.

What should you do in this situation?

Let's add another parameter for consideration: Even if this behavior isn't a felony in your state, do you have a legal obligation to report child abuse. What if she were instead a heroin user?

 

[CognitiveSci]

I think the answer is quite simple; report it as child abuse. If she wants to harm herself, that's fine, but to harm her child isn't ok. Yes, she cares for her child, but the fact that she went to a different state where what she's doing isn't illegal shows that she is manipulative and is putting her interest before her child's needs and health

 

[WheezyBaby]

I think the answer is quite simple; report it as child abuse. If she wants to harm herself, that's fine, but to harm her child isn't ok. Yes, she cares for her child, but the fact that she went to a different state where what she's doing isn't illegal shows that she is manipulative and is putting her interest before her child's needs and health

Seeking care somewhere she can be honest about her health without fear of imprisonment is manipulative?

 

[LizzyM]

I won't give you the answers but I'll ask some questions:


Hmmm....does she meet the definition of alcohol use disorder?
http://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/basics/definition/con-20020866

how often is she drinking and how much?
While there is no level of drinking during pregnancy that is known to be "safe", there is a difference between having one drink one night per week and having six drinks every night.
What are the sources of stress in her life?
What other resources does she have to deal with stress?
Who is in her social support network?
Are there any non-drinkers in her support network?
Does she want help to deal with her dependence on alcohol?
Are there alternative ways to deal with stress that would be safe for her to employ during pregnancy?


@CognitiveSci Do you believe that alcohol use disorder (alcoholism) is a disease or a moral failing?
As a physician will you treat people with diseases or will you call the government authorities and have them arrested for breaking the law?

 

[Psai]

I had one MMI interview setup for residency too. Safe to say that program was at the bottom of my ROL (other things I didn't like too).

LOL I'd get up on the spot and leave. If they're going to put me through nonsense during the interview, I can only imagine how bad it would be as a resident

 

[DingoPingo]

as someone who knows nothing, I would direct her to a psychiatrist who can help treat her stress and provide external contacts for support for other areas of her life and offer to contact them with her so she can stop drinking during her prefnancy

 

[LizzyM]

as someone who knows nothing, I would direct her to a psychiatrist who can help treat her stress and provide external contacts for support for other areas of her life and offer to contact them with her so she can stop drinking during her prefnancy

As an OB or family medicine specialist, you would have been trained to provide this basic level of care to a patient with this problem without a referral to a psychiatric specialist but your heart is in the right place. Self-help through groups such as AA are also a powerful ally in helping people who want to stop drinking.

 

[freak7]

Let's add another parameter for consideration: Even if this behavior isn't a felony in your state, do you have a legal obligation to report child abuse. What if she were instead a heroin user?

I think the answer is quite simple; report it as child abuse. If she wants to harm herself, that's fine, but to harm her child isn't ok. Yes, she cares for her child, but the fact that she went to a different state where what she's doing isn't illegal shows that she is manipulative and is putting her interest before her child's needs and health

By this logic, an abortion would be considered child abuse/murder and I don't imagine many physicians would report every single potential mother requesting an abortion to the authorities.

Edit: I feel like you guys just walked into the trap line of questioning that the adcoms would pursue

 

[Matthew9Thirtyfive]

By this logic, an abortion would be considered child abuse/murder and I don't imagine many physicians would report every single potential mother requesting an abortion to the authorities.

Edit: I feel like you guys just walked into the trap line of questioning that the adcoms would pursue

Additionally, CPS often can't do very much for children that have been born, so what do you expect them to do for a fetus? Have someone watch her 24/7 and arrest her if she drinks?

 

[Matthew9Thirtyfive]

http://mobile.nytimes.com/redirect?...ant-women-alcohol-new-york-city-says.amp.html

Wow. Another example of NY trying to fix a problem and going way too far.

 

[Dr. Jan Itor]

I think the answer is quite simple; report it as child abuse. If she wants to harm herself, that's fine, but to harm her child isn't ok. Yes, she cares for her child, but the fact that she went to a different state where what she's doing isn't illegal shows that she is manipulative and is putting her interest before her child's needs and health

Manipulative? Ouch.

I'm highly educated with three kids and didn't know that there were states where having a drink while pregnant is a felony. (In fact, Google isn't exactly helpful in finding a list of such states.) I'd guess that this woman isn't aware of any legislation and isn't trying to get away with something. It's more likely that she lives near a state border and picking this particular doctor isn't part of some grand scheme.

I mean, if she knows it's illegal and really wanted to put her interests ahead of the baby, why get a check-up in the first place?

The scenario doesn't exactly make it sound like she's an addict. A glass of wine here and there to relax is a lot different than pounding a fifth every night and shutting down the bar.



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[Matthew9Thirtyfive]

Manipulative? Ouch.

I'm highly educated with three kids and didn't know that there were states where having a drink while pregnant is a felony. (In fact, Google isn't exactly helpful in finding a list of such states.) I'd guess that this woman isn't aware of any legislation and isn't trying to get away with something. It's more likely that she lives near a state border and picking this particular doctor isn't part of some grand scheme.

I mean, if she knows it's illegal and really wanted to put her interests ahead of the baby, why get a check-up in the first place?

The scenario doesn't exactly make it sound like she's an addict. A glass of wine here and there to relax is a lot different than pounding a fifth every night and shutting down the bar.



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Agreed. Sounds like she has significant stressors and no good coping mechanisms, but drinks to relieve stress prior to getting pregnant and is relying on that because it's all she knows. She may say she needs to have an occasional drink to deal with it, but that's where you have to come in and educate her and provide alternatives. If she didn't give two ****s about the baby, she wouldn't be in for a prenatal visit.

 

[LizzyM]

http://mobile.nytimes.com/redirect?...ant-women-alcohol-new-york-city-says.amp.html

Wow. Another example of NY trying to fix a problem and going way too far.

How so @Matthew9Thirtyfive ? NYC says bartenders can't refuse to serve a pregnant woman. Who is to decide who is or isn't pregnant? Are you going to have bouncers asking to see IDs -- and a urine specimen --on the way into the clubs?

 

[Matthew9Thirtyfive]

How so @Matthew9Thirtyfive ? NYC says bartenders can't refuse to serve a pregnant woman. Who is to decide who is or isn't pregnant? Are you going to have bouncers asking to see IDs -- and a urine specimen --on the way into the clubs?

So bartenders now are not allowed to refuse service to a particular class of people. Seems like the government reaching into small business. If a cake shop can refuse to sell cakes to gays, why can't a bar refuse to serve alcohol to a pregnant woman?

And no, I don't think they should refuse to let pregnant women in. My wife went to a few concerts while pregnant with both our kids. It just seems like they are trying to protect pregnant women at the expense of business owner autonomy.

For the record, I feel like they have good intentions, and fixing the discrimination women and pregnant women face in areas like the workplace is definitely a good thing.

 

[Dr. Jan Itor]

What would be the requirement for refusing to serve a pregnant woman, though? Visible bump? Some women don't shown until the third trimester (if even then.) Some women have a bump after eating a sandwich when they're non pregnant.

Seems like there would be a lot of room for litigation the first time a bartender refuses to serve someone and they're not pregnant. Or if they serve someone who doesn't look pregnant and the baby winds up with FAS.


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[Matthew9Thirtyfive]

Because sex is one of the federally recognized protected classes

https://en.m.wikipedia.org/wiki/Protected_class

Yes, I get that. My point is that I think it's a bit absurd that you can refuse to serve a cake to a gay couple (something that arguably has a significantly lesser chance of causing harm), but not alcohol to a pregnant woman. Just seems like a misguided attempt at anti-discrimination.

 

[LizzyM]

Yes, I get that. My point is that I think it's a bit absurd that you can refuse to serve a cake to a gay couple (something that arguably has a significantly lesser chance of causing harm), but not alcohol to a pregnant woman. Just seems like a misguided attempt at anti-discrimination.

I suppose if someone had a religious objection to serving booze to a pregnant woman, they could do so in Mississippi or Kentucky or wherever else there are those religious exemption from civil rights law... New York is not the Bible Belt (duh) and New Yorkers are pretty liberal when it comes to human rights.

 

[Matthew9Thirtyfive]

I suppose if someone had a religious objection to serving booze to a pregnant woman, they could do so in Mississippi or Kentucky or wherever else there are those religious exemption from civil rights law... New York is not the Bible Belt (duh) and New Yorkers are pretty liberal when it comes to human rights.

But not so liberal that they'll protect a fetus against fetal alcohol syndrome.

 

[Tenk]

All you can do is recommend. If they don't listen to you that's on them. It won't take you long to realize you will not be some omnipotent all knowing all wise physician that everyone will listen to like you are preaching the gospel. Instead you will be a talking head in an endless sea of google searches, webmds, and well my boyfriend's aunt's dog is a nurse and they said xy and z. Once you realize this then you are truly free.

 

[LizzyM]

But not so liberal that they'll protect a fetus against fetal alcohol syndrome.

Liberals never put the interests of a fetus ahead of the rights of the mother.

 

[gyngyn]

Liberals never put the interests of a fetus ahead of the rights of the mother.

Almost never.

 

[Matthew9Thirtyfive]

Liberals never put the interests of a fetus ahead of the rights of the mother.

@gyngyn beat me to it.

 

[wizzed101]

I won't give you the answers but I'll ask some questions:


Hmmm....does she meet the definition of alcohol use disorder?
http://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/basics/definition/con-20020866

how often is she drinking and how much?
While there is no level of drinking during pregnancy that is known to be "safe", there is a difference between having one drink one night per week and having six drinks every night.
What are the sources of stress in her life?
What other resources does she have to deal with stress?
Who is in her social support network?
Are there any non-drinkers in her support network?
Does she want help to deal with her dependence on alcohol?
Are there alternative ways to deal with stress that would be safe for her to employ during pregnancy?


@CognitiveSci Do you believe that alcohol use disorder (alcoholism) is a disease or a moral failing?
As a physician will you treat people with diseases or will you call the government authorities and have them arrested for breaking the law?

I favor the former coz I knew some people with uhm...30+ background. But anyhow, what if the state mandated me to report? Will the answer always be "yes"? In issue as controversial as this, I can see activists doing sting operation.

In the original scenario, the physician's state of residence had no jurisdiction over the neighboring state. How far can we go to report cases like this? Do we abide by only local laws?

Say you have a pregnant 16 year-old, which is the age of the consent in your state, visits your clinics with her 20+ something boyfriend, but in her state of residence the age of consent is 18. What to do?

 

[Donald Juan]

Say you have a pregnant 16 year-old, which is the age of the consent in your state, visits your clinics with her 20+ something boyfriend, but in her state of residence the age of consent is 18. What to do?

You use your state laws. People from Colorado don't get to smoke pot in other states just because it is legal in their state of residence. It's not up to us to learn all 50 laws and enforce them based on what is on people's drivers license.

 

[CognitiveSci]

Manipulative? Ouch.

I'm highly educated with three kids and didn't know that there were states where having a drink while pregnant is a felony. (In fact, Google isn't exactly helpful in finding a list of such states.) I'd guess that this woman isn't aware of any legislation and isn't trying to get away with something. It's more likely that she lives near a state border and picking this particular doctor isn't part of some grand scheme.

I mean, if she knows it's illegal and really wanted to put her interests ahead of the baby, why get a check-up in the first place?

The scenario doesn't exactly make it sound like she's an addict. A glass of wine here and there to relax is a lot different than pounding a fifth every night and shutting down the bar.



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The OP specifically says she went to the neighboring state because there is no such legislation there. She was intentional with her actions

A pregnant woman enters your practice to have some checkups. You learned that she often drank to reduce stress. She acknowledged that drinking can cause serious harms to the fetus, but in her words: "I can't help it. If I don't have occasional drinks, I don't think I can go through this." From her contact information, you learned that she was from a neighboring state where it is a felony to drink during pregnancy. The woman probably came to your practice because there is no such law here.

What should you do in this situation?

 

[futuremdforme]

The OP specifically says she went to the neighboring state because there is no such legislation there. She was intentional with her actions

So what? If anything that would be a good sign, that she has a sense that what she is doing is wrong and might be more open to intervention. Colorado's tourism is up, and so are applications to university there. That's intentional, but not criminal.

 

[Dr. Jan Itor]

The OP specifically says she went to the neighboring state because there is no such legislation there. She was intentional with her actions

That's not at all what is says.

It says that she is from a neighboring state where it is illegal. It doesn't say that *she* knows it's illegal, but it's inferred that the *doctor* knows it's illegal. Hence the question about whether he should report it.

And to play devil's advocate - Let's say the women DOES know it is illegal. Why would she volunteer that she drinks? Why would she risk herself and seek out prenatal care if she was wanted to put herself above the baby?

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[Goro]

We like seeing if you can think, how you can think, if you can think on your feet, AND display grace under pressure.

Why do medical schools do this to people?

 

[CyrilFiggis]

This is the BS of these questions, they want an answer without the ability to actually follow up and interact with the patient. There are a ton of things to ask first, "You said you don't think you could go through with this? Can you explain what you mean by that?" Is this the pregnancy? Being a mother? Is that pointing towards suicidal ideations? "Is your parter still involved? Have you spoken to him/her about this?" "Do you have a regular OB/Gyn?" "Can you tell me about your drinking habits? Frequency? Amount?"

Dumb prompt if you're not given follow through.

 

[DokterMom]

So bartenders now are not allowed to refuse service to a particular class of people. Seems like the government reaching into small business. If a cake shop can refuse to sell cakes to gays, why can't a bar refuse to serve alcohol to a pregnant woman?

And no, I don't think they should refuse to let pregnant women in. My wife went to a few concerts while pregnant with both our kids. It just seems like they are trying to protect pregnant women at the expense of business owner autonomy.

For the record, I feel like they have good intentions, and fixing the discrimination women and pregnant women face in areas like the workplace is definitely a good thing.

There's a whole heck of a lot of paternalism when it comes to legislating women's decisions that could impact their fetuses -- abortion, alcohol consumption, smoking, etc. Adult women of reproductive age are able to make their own decisions and to be held accountable for the decisions they make. The government, healthcare establishment and popular press are very vocal about the "No alcohol! No smoking! No coffee! No cola! No raw fish! No non-organic produce! No painkillers! No sleep aids!" -- And the pregnancy Nazis are everywhere - visible, vociferous and judgemental. (I attended a reunion in a bar while visibly pregnant and had a non-alcoholic beer -- the dirty looks I endured!)

The last thing this patient needs is more judgement from her physician. When the world is already way up in your business you need moderate counsel and reliable information from a knowledgeable individual in a position of trust and mutual respect. The whole "One toke of marijuana will turn you into a crazed axe murderer" approach is not helpful and frankly, not credible. Women drank alcohol in moderation and smoked (sometimes heavily) for generations with overwhelmingly minimal results on their babies. We know it's not good -- but extreme positions create their own problems.

There are ways for this mother to reduce her drinking without being turned over to the legal system. I would talk with her to find out when she's drinking (social or alone), how often, how much and come up with workable solutions to improve the situation for her baby. If she believes she has a problem and is open to treatment, great. If she's not quite there but is willing to cut back to a minimal level, that's much better than nothing.

 

[Matthew9Thirtyfive]

That's not at all what is says.

It says that she is from a neighboring state where it is illegal. It doesn't say that *she* knows it's illegal, but that the *doctor* knows it's illegal. Hence the question about whether he should report it.

And to play devil's advocate - Let's say the women DOES know it is illegal. Why would she volunteer that she drinks? Why would she risk herself and seek out prenatal care if she was wanted to put herself above the baby?

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If she does know it's illegal and volunteered the info, I think it's

There's a whole heck of a lot of paternalism when it comes to legislating women's decisions that could impact their fetuses -- abortion, alcohol consumption, smoking, etc. Adult women of reproductive age are able to make their own decisions and to be held accountable for the decisions they make. The government, healthcare establishment and popular press are very vocal about the "No alcohol! No smoking! No coffee! No cola! No raw fish! No non-organic produce! No painkillers! No sleep aids!" -- And the pregnancy Nazis are everywhere - visible, vociferous and judgemental. (I attended a reunion in a bar while visibly pregnant and had a non-alcoholic beer -- the dirty looks I endured!)

As I stated in an earlier post, I agree with this. While I feel that the life of the fetus should be protected to the extent that pregnant women are educated about the dangers and potential consequences of risky behavior, my argument against the law requiring bars to serve pregnant women is actually more about the rights of small business owners.

The last thing this patient needs is more judgement from her physician. When the world is already way up in your business you need moderate counsel and reliable information from a knowledgeable individual in a position of trust and mutual respect. The whole "One toke of marijuana will turn you into a crazed axe murderer" approach is not helpful and frankly, not credible. Women drank alcohol in moderation and smoked (sometimes heavily) for generations with overwhelmingly minimal results on their babies. We know it's not good -- but extreme positions create their own problems.

Not really sure what this has to do with anything I posted. In my last post, I stated that a woman coming to talk to her doctor about drinking is likely looking for help and alternatives to alcohol for stress relief.

There are ways for this mother to reduce her drinking without being turned over to the legal system. I would talk with her to find out when she's drinking (social or alone), how often, how much and come up with workable solutions to improve the situation for her baby. If she believes she has a problem and is open to treatment, great. If she's not quite there but is willing to cut back to a minimal level, that's much better than nothing.

Again, I basically said this in one of my posts on this thread. When you cherry pick one post, you end up arguing against nothing.

 

[DokterMom]

If she does know it's illegal and volunteered the info, I think it's


As I stated in an earlier post, I agree with this. While I feel that the life of the fetus should be protected to the extent that pregnant women are educated about the dangers and potential consequences of risky behavior, my argument against the law requiring bars to serve pregnant women is actually more about the rights of small business owners.



Not really sure what this has to do with anything I posted. In my last post, I stated that a woman coming to talk to her doctor about drinking is likely looking for help and alternatives to alcohol for stress relief.



Again, I basically said this in one of my posts on this thread. When you cherry pick one post, you end up arguing against nothing.

Actually, I was not replying to you directly. Just ranting in general --

 

[CyrilFiggis]

Just ranting in general --

Sounds like you're stressed. Need a drink?

 

[WheezyBaby]

Sounds like you're stressed. Need a drink?

Improper to offer a drink without offering a UPT first, tut tut

 

[DokterMom]

Sounds like you're stressed. Need a drink?

Could use one yes! But still working -- hence the stress. Of course, if I got off SDN, I could get more work done and drink sooner

 

[gyngyn]

Could use one yes! But still working -- hence the stress. Of course, if I got off SDN, I could get more work done and drink sooner

I'm sipping a nice icy negroni.

 

[Matthew9Thirtyfive]

Could use one yes! But still working -- hence the stress. Of course, if I got off SDN, I could get more work done and drink sooner

Just drink at work. That's what vodka and water bottles are for.

 

[freak7]

Sounds like you're stressed. Need a drink?

I'm watching football, if you're going to the fridge, I'll take a cold one

 

[DokterMom]

I'm sipping a nice icy negroni.

A negroni - my favorite!

 

[YeezusRice]

If she can't handle her possible drinking issue now what makes you think she'll be able to handle it when the baby is born and waking her up at 3 am to changer his/her diaper? And isn't there research that suggests AA groups don't really help?


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[LizzyM]

If she can't handle her possible drinking issue now what makes you think she'll be able to handle it when the baby is born and waking her up at 3 am to changer his/her diaper? And isn't there research that suggests AA groups don't really help?

"Not everyone will comply with treatment. But, among those who do, are they made better off? That’s a question worth answering.

"The Humphreys study does so and tells us that A.A. helps alcoholics, apart from the fact that it may attract a more motivated group of individuals. With that established, the next step is to encourage even more to take advantage of its benefits."

http://www.nytimes.com/2015/04/07/u...hallenge-of-evidence-based-medicine.html?_r=0

 

[doctorbob23]

I love these questions because there is no right answer. It's legal so all you can do is educate the patient and wish for the best. But for the interview elaborate and tell them what you think about women drinking during pregnancy.

Ultimately as a physician all you can do is give professional advice and adios.

Non compliant patients are a part of the medical practice you'll have to deal with so start now

The whole purpose of this question is to understand ur thought process so give them that

 

[Vrachika]

I love thinking about ethical questions, and they aren't BS. As physicians we will be faced with lots of ethical dilemmas, so get used to it. These types of questions don't always have right or wrong answers, but I think there are usually better answers or worse answers. I don't know much about the legal issues surrounding this topic, but my two cents:

If there is a legal obligation to report/act in a certain way, follow it (this should be obvious). Don't risk your license/job.

Instead of jumping to the conclusion of reporting her for child abuse, why don't you start by asking the patient what she wants to do? Substance abuse problems are not often solved by taking legal action. She came to you, admitted to drinking while pregnant, and said she understands that there is risk to the fetus. Ask if she wants help figuring out a solution, because it seems to me that if she didn't want to change it, she may not have mentioned it in the first place. If she does, work with her to figure out something that works for her. If not, well, so be it. Not that you can't try to persuade her , but she is the one who ultimately has to make the decision. If your attitude toward her is friendly, accepting, and warm she is more likely to trust you and listen to your advice.

My opinion: I wouldn't report her. She is your patient, do your best to guide her healthcare decisions.