Need some advice here - being asked to sign religious directives

[Call Me Dr.]

Okay SDNers, I'm hoping that you can share any experiences you might have with the US Conference of Catholic Bishop's Ethical and Religious Directives for Catholic Health Care Services.

I'm finishing up a Peds EM fellowship and accepted a faculty position at a non-Catholic academic institution. Peds EM docs work primarily at the children's hospital but also staff 2 satellite EDs. One is a satellite location of the children's hospital, the other is a community hospital that was just acquired by Catholic Health Initiatives (CHI).

As a consequence of the acquisition, CHI is requiring all physicians to be re-credentialed. The only difference between the old credentialing packet and the new is a logo and the inclusion of an "Acknowledgment and Certification" form to sign stating that we adhere to CHI's Our Values and Ethics at Work Reference Guide. The form also states that I will report violations and participate in investigations of violations. The actual Reference Guide wasn't included but I requested and obtained a copy of it. Within the Reference Guide, the only religious language is on a single page and vague. However, it does state on that page that the US Conference of Catholic Bishop's Ethical and Religious Directives for Catholic Health Care Services must be adhered to.

I downloaded a copy of that document from the internet* and I really don't agree with many of the directives in that document. Most of what I don't agree with doesn't directly impact my provision of medical care as a PEM doc, but I feel does violate the rights of women and my ability to provide medical care in the best interests of patients. Specifically relevant to my practice, the directives would prohibit counseling about condoms or other contraception that I routinely do for adolescent patients as part of STI prevention, as well as referrals for patients interested in contraception. It would also prohibit adherence to advance directive requests for terminally ill children. I made a brief inquiry with my future boss who essentially e-mailed me back to just sign it.

I really don't feel good about signing this document. I feel even worse about the possibility of signing the document and then having my privileges revoked later for violating it. Thoughts? Experiences? Any advice would be appreciated.

*it's available at http://www.usccb.org/issues-and-act...c-Health-Care-Services-fifth-edition-2009.pdf

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[VentJockey]

Wow, that document is a real piece of crap. I would not be willing to sign it personally. After reading that, I think I will never be willing to work in a hospital that is affiliated with the catholic church. Honestly, the catholic church is a toxic entity in health care. An organization that believes HIV is bad, but not quite as bad as condoms, has no business running a hospital. If they try, we as doctors really ought to not engage with them.

Christopher Hitchens has a wonderful 6 minute speech on the misdeeds of the catholic church, both past and current:

 

[Droperidol]

I would inquire and insist on not being scheduled or credentialed at that hospital. I hope your contract does not state which hospitals you are required to work for or credential at.


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[Call Me Dr.]

It's not clear to me after reviewing my contract whether I am required per the terms of the contract to be credentialed at that particular site. I think it could be interpreted to require me to be credentialed there, though, because it obligates me to be credentialed in accordance with the payment services groups' contractual obligations.

Any physicians with experience working at a hospital that follows the ERDs?

 

[Old_Mil]

I downloaded a copy of that document from the internet* and I really don't agree with many of the directives in that document. Most of what I don't agree with doesn't directly impact my provision of medical care as a PEM doc, but I feel does violate the rights of women and my ability to provide medical care in the best interests of patients. Specifically relevant to my practice, the directives would prohibit counseling about condoms or other contraception that I routinely do for adolescent patients as part of STI prevention, as well as referrals for patients interested in contraception.

You're a pediatric emergency med doc, not a pediatrician. Condom counseling, STI prevention, contraception referral isn't your sandbox. You're right it doesn't affect your provision of medical care as a PEM doc. But this sounds like a philosophical issue for you, in which case find a non catholic hospital to work in....

 

[WilcoWorld]

You just finished a Peds EM fellowship. That makes you a very desirable hire. Use that power as you see fit.

Refusing to sign this document may be the most potent political statement you ever have the chance to make.

 

[Call Me Dr.]

You're a pediatric emergency med doc, not a pediatrician. Condom counseling, STI prevention, contraception referral isn't your sandbox. You're right it doesn't affect your provision of medical care as a PEM doc. But this sounds like a philosophical issue for you, in which case find a non catholic hospital to work in....

Great points, and precisely why I'm struggling with this. The directives will rarely impact my care as a PEM doc. However, I absolutely do discuss condoms and STI prevention with kids who are at risk or who present with STIs. I also respect advance directives for terminally ill patients. I think those are the 2 situations that would violate the religious directives.
As for finding a non-Catholic hospital to work in . . . I'm not working for a Catholic hospital. It's a satellite practice site that was recently acquired by a Catholic health system. I would not knowingly seek employment with a Catholic hospital that follows these directives.

 

[Call Me Dr.]

Refusing to sign this document may be the most potent political statement you ever have the chance to make.

Yes, but does dying on my sword promote change? I support the ACLU's legal battles against this document, I wish that physicians at my future institution had collectively refused to sign this document as has occurred at other places, and I think these religious directives undermine the patient-physician relationship and patient autonomy. The question is what my options are if signing it is a condition of my employment.

 

[touchpause13]

CHI is a horrible institution (worked for one of their nursing homes as a CNA)

I know nothing about nothing, but if I were you I wouldn't sign, especially since you do talk to kids about contraceptives.

 

[DeadCactus]

Condom counseling, STI prevention, contraception referral isn't your sandbox.

So a 15 year old tells you she has multiple partners and rarely uses condoms and you just march on to "Any fever or chills?"

 

[Droperidol]

Old Mil, I absolutely think sti counseling is in our purview. Do you really want a teen with pid to get mpl infections and then have to deal with her ectopic? I bet for patients that come in with asx htn you recommend they take their bp once or twice daily and keep a log of it for their pcp. You probably do the same for uncontrolled diabetes. Why not for sti? Just because we work in the ed doesn't mean we can't take 20 seconds to educate on basic disease prevention. I have had a teen tell me after a quick discussion of contraceptives that she couldn't have done so because she was raped. I wouldn't have gotten that information without the discussion. I personally feel that's part of our Hippocratic oath and definitely not just in the sandbox of the pcp or ob gyn.


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[VA Hopeful Dr]

Before you get too worked up about this, find out if the particular institution who bought the site really buys into this thing.

Every Catholic hospital system has to say they follow this, but they don't all actually care equally. I worked for a Catholic hospital my first year out of residency and literally the only part they really cared about was abortions.

I wrote OCPs regularly, and didn't even hide why - I didn't diagnose everyone wanting OCPs with menorrhagia, for example.

Ask around to see how much this will actually matter... unless this is a principled stance, in which case definitely make an issue about it.

 

[Promethean]

Yes, but does dying on my sword promote change? I support the ACLU's legal battles against this document, I wish that physicians at my future institution had collectively refused to sign this document as has occurred at other places, and I think these religious directives undermine the patient-physician relationship and patient autonomy. The question is what my options are if signing it is a condition of my employment.

Doesn't that question answer itself? You can either sign it and abide by it, sign it and abide by your conscience, or not sign it and risk consequences, which could possibly include not being employed there. I'm not being a smart a**, I just don't see that there are other options.

Collective action still requires someone to be the first to step up. Maybe you are among the first to really look so deeply into what it is that you are signing. Maybe everyone did look at it and just figured that it wasn't really going to impact their practice, so why fall on their sword over it? Probably, you aren't remotely the only person who feels this way. Can you contact others who are being asked to sign this same document, or even who may have signed it, so that you aren't just one crackpot making trouble, but a member of a concerned group?

It is possible that you could refuse to sign it in its current form, or that you could insist that if you sign it, a waiver is also included which specifically protects those aspects of your practice that matter to you. Anything that requires you to sign and be bound by it is an agreement, and that means there is at least the possibility to negotiate.

I guess that is a 4th option. You could draw up a formal waiver, or try to do one as stealthily as they have tried to impose these restrictions upon you. I have seen instances of people handwriting their own clauses on documents of this sort and signing them. Even if the employer fails to notice the amendment, if they accept it then it becomes binding on them in turn. If you want to go this way, get a lawyer with employment/contract experience. I am not a lawyer, but: My nursing education did not lead to a degree, and I needed one to get into medical school. The fastest, least expensive degree that I could complete was a BS in Business Admin, Human Resources Management. So, I recently had to read a lot of employment contract law. I know just enough to know that a consultation fee and maybe paying to have a document or two prepared would be an excellent investment in protecting yourself and your practice.

 

[GeneralVeers]

I would sign it, and just ignore all of their silly, medieval nonsense and do what I thought was right anyway. I've worked for these kinds of places before and as was stated by VA Hopeful, they only care about abortions.

 

[Birdstrike]

I would sign it, and just ignore all of their silly, medieval nonsense and do what I thought was right anyway. I've worked for these kinds of places before and as was stated by VA Hopeful, they only care about abortions.

Agree. They just put that wording in there so they can look consistent with their mission publicly, knowing they can't enforce crap, and HIPAA prevents them from digging through charts, anyways. With morning-after pills, condoms, etc, being over the counter, and you're certainly not performing abortions in the ED, it shouldn't be that much of an issue. If methotrexate comes up as needed, turf to OB/Gyn. Other than that, what are they going to do, fire you for telling some 18 yr old to "buy some rubbers next time"? Anything you're doing is in an emergency setting for "emergencies," and "you had no choice," but for the interest of patient safety. All that other primary care stuff (lengthy counseling, prevention, etc) can and should be deferred to primary care for time/efficiency reasons, as well as continuity, anyways.

 

[Call Me Dr.]

Thanks for the great discussion. An update:
I sent a more detailed e-mail with the specific language copied from the directives from the ERDs that prohibit counseling about condoms or other contraception that I routinely do for adolescent patients as part of STI prevention, as well as referrals for patients interested in contraception. And also the directives that could prohibit adherence to advance directive requests for terminally ill children. I also highlighted that my specific concern is professional repercussions if I were to be reported for violating the ERDs if I sign the form, given that I can foresee circumstances in which I will knowingly violate them in the best interests of the patient.
Got a more moderate response this time that acknowledged the validity of my concerns. Legal looking into it. To be candid, I'm not sure that anyone had actually read the ERDs given how misleading the signature document is. I can't imagine any of my future colleagues would think it's appropriate to treat the intractable pain of a terminally ill 6 yo cancer patient by helping them "to appreciate the Christian understanding of redemptive suffering."

 

[Birdstrike]

I can't imagine any of my future colleagues would think it's appropriate to treat the intractable pain of a terminally ill 6 yo cancer patient by helping them "to appreciate the Christian understanding of redemptive suffering."

I must be missing something here. Their religious beliefs ban morphine for dying kids?

 

[Siggy]

I must be missing something here. Their religious beliefs ban morphine for dying kids?

I imagine it's more of, "don't honor the DNR of the 6 year old terminal cancer patient" than "don't provide pain relief."

 

[link2swim06]

Well it could be worse, it could be jehovah witnesses owning the hospital.

 

[VentJockey]

I imagine it's more of, "don't honor the DNR of the 6 year old terminal cancer patient" than "don't provide pain relief."

Well, that's pretty damn bad. Oh, the kid is dying, let's break his ribs and shove a tube in his throat. God isn't done with him yet, he could make it a whole three more days in the ICU if we do this right...I'm sure when the kid is on a vent with flail chest from the vigorous CPR, he's going to appreciate his redemptive suffering.

 

[Call Me Dr.]

Directive 59. "The free and informed judgment made by a competent adult patient concerning the use or withdrawal
of life sustaining procedures should always be respected and normally complied with, unless it is
contrary to Catholic moral teaching." Children and their guardians are not considered competent and DNRs for children have been interpreted as contrary to Catholic moral teaching under this directive.
Directive 61. "Patients experiencing suffering that cannot be alleviated should be helped to appreciate the
Christian understanding of redemptive suffering." Again, has been applied to DNRs for children.

 

[VA Hopeful Dr]

Once again, I sincerely doubt that this is something the hospital is going to be strict about.

 

[WilcoWorld]

Well, that's pretty damn bad. Oh, the kid is dying, let's break his ribs and shove a tube in his throat. God isn't done with him yet, he could make it a whole three more days in the ICU if we do this right...I'm sure when the kid is on a vent with flail chest from the vigorous CPR, he's going to appreciate his redemptive suffering.

This is the best of all possible worlds, Dr. Pangloss.

Once again, I sincerely doubt that this is something the hospital is going to be strict about.

But surely you recognize that there are two questions here:

1) Will I get fired for doing what I think i s right?
2) Am I willing to sign something that I find morally objectionable?

I think you are correct that the answer to #1 is "not likely".
The answer to #2 is a personal choice, and the OP has to decide if this is a battle worth picking.

 

[VA Hopeful Dr]

But surely you recognize that there are two questions here:

1) Will I get fired for doing what I think i s right?
2) Am I willing to sign something that I find morally objectionable?

I think you are correct that the answer to #1 is "not likely".
The answer to #2 is a personal choice, and the OP has to decide if this is a battle worth picking.

Yeah, I mentioned point 2 in my first response - if its about principles then definitely fight this. If its about worry over getting fired for talking about condoms, then just sign the thing.

 

[EDParallax]

Directive 59. "The free and informed judgment made by a competent adult patient concerning the use or withdrawal
of life sustaining procedures should always be respected and normally complied with, unless it is
contrary to Catholic moral teaching." Children and their guardians are not considered competent and DNRs for children have been interpreted as contrary to Catholic moral teaching under this directive.
Directive 61. "Patients experiencing suffering that cannot be alleviated should be helped to appreciate the
Christian understanding of redemptive suffering." Again, has been applied to DNRs for children.

Horrific, and a violation of patient centered care. Not to mention autonomy and nonmaleficence. Kudos to you for your strength to question what you're asked to sign. Good luck.

 

[dotcb]

I would not sign it. If you really want the job, I'd request to not be scheduled there. I feel bad for the kids.