Am I Mom or Doc (or Both)?

Last week I took Daughter, age 16,  to see her pediatrician about a couple of minor problems. She needed a recheck of her mild acne and wanted to discuss possible remedies for the irregular periods that drive her crazy in light of her sports and activity-filled life (yes, she’s given the OK for me to write about this, and thankfully her friends aren’t MamasOnCall regulars).

I try not to diagnose or treat my own family. It’s bad medicine and it’s frowned upon by the profession; the idea being that you can’t be objective about those you love and are likely to miss something and make mistakes. So we headed off to my colleague, who we’ll call Dr. C.

Dr. C. is an excellent clinician. She’s well-trained and thorough, and tends to be somewhat more conservative than I am in her approach. I’ve appreciated the contrast, since, as an out-of-the-box type, it’s good to have the counsel of someone who follows the directions more closely.

While I did my best not to butt in, she made quick work of the refills on acne meds, did a review of D.’s immunization record (up-to-date), and moved on to the discussion about those annoying periods. She was sympathetic and advised patience. After confirming that the situation has improved slightly and is likely to continue in the right direction, she made it clear that, in her view, no further action was needed.

Now D. is a well-read, fairly sophisticated daughter of a physician with lots of fairly sophisticated 16-year-old girlfriends. So she said (with some embarrassment), “What about birth control pills? I’ve heard that if you take them for a short time they can regulate your periods. I’m not sexually active or anything, but it would be really nice to know when to expect my period so I can be prepared.”

Dr. C. looked at me and I looked back, as if to say, “You’re the doctor here. She makes a good point.” After a brief and uncomfortable pause she answered, “I don’t like to put teenagers on birth control pills for … lots of reasons. The most important is that they can cause blood clots and all kinds of other serious side effects. If you’d like, I can refer you to the adolescent OB/GYN, but I would prefer not to prescribe them.”

I was truly surprised as we thanked her and left the office. It was clear that D.’s request made her uncomfortable, and I was pretty sure it had nothing to do with blood clots.

We got to the car and D. turned to me and said, “What was that about? Is that stuff even true? It sounded like she thinks I’m going to run out and have sex if I’m on birth control pills! She didn’t even want to talk about it.”

There’s nothing like putting a mom/doctor on the spot. I had a million thoughts going through my head. Starting with … very insightful, daughter of mine.

Call me naive, but I know my child, and I know she’s not having sex (not yet, anyway), since I’ve done a stellar job of convincing her that boys — with the exception of her dad and brothers — are immature lower life forms. I know she’s driven nuts by random periods, and that’s why she risked embarrassment to raise the question. I know Dr. C. has her own personal judgements about teen sexual activity, maybe based on her religious beliefs, maybe not, but I didn’t know they intruded into the exam room. D.’s request should have led to more questions, and probably the suggestion that I leave the room so they could talk privately.

I also know the risks of oral contraceptives, and they’re not exactly as Dr. C. described them. Yes, the risk of blood clots exists, but it’s exceedingly small in young women on low-dose pills for a short time, especially if they’re non-smokers. They can be very effective at regulating periods pretty quickly — in as little as three months. I prescribed them myself when I was in practice. Not very often, and with close supervision and lots of counseling, because you want to be sure of the purpose. Teens who are sexually active need much more than birth control pills, which don’t protect against sexually transmitted disease or the emotional fallout of early sexuality.

AND I’m thinking I don’t want to trash D.’s respect for Dr. C., who’s a good doctor (even though it’s becoming clear we’ve outgrown her). So I take a deep breath and try to explain …

“Different doctors have different opinions. Dr. C. believes strongly that kids your age shouldn’t be having sex, and that she can impact that by not enabling it, which is how she sees prescribing birth control pills. While you know I agree it’s best to postpone sex until you’re ready for a committed relationship (and that’s another discussion altogether), I DON’T believe that taking birth control pills makes anyone have sex, and I wouldn’t exaggerate the medical side-effects to make the point. So she and I have different approaches. Looks like maybe it’s time to find you a new doctor …”

But afterwards the whole ordeal left me with questions about roles and responsibilities. What does it mean to be a teen’s doctor? Where do your opinions end and theirs begin? How much influence should I have as the mother/doctor? I’ve deliberately taken a back seat, but when do I step in as my child’s advocate? And what if I wasn’t a doctor? Would I accept the professional’s advice without question? How many other teens and mothers are caught in this quandary? And isn’t this a central issue in all doctor/patient relationships?

OK, so this isn’t news. It’s the gray zone between what your doctor knows and what she believes. Between education and opinion. It’s just most starkly outlined when you’re dealing with teens who are in that netherworld between childhood and adulthood. They often don’t get to choose, so we choose for them. But are we truly informed when we make these choices, or are we depending on what our doctor believes? Where does the choice lie? Where should it?

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Rachel Zahn, MD is a pediatrician turned health writer who had three kids during medical school and pediatric training—crazy, huh?

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5 responses to “Am I Mom or Doc (or Both)?”

  1. Katie Malinski

    Thanks for the thought-provoking post.
    I find myself less forgiving of the doctor’s actions. Providers must always tread very carefully when their personal ‘stuff’ influences their professional role. Balancing power/influence with good boundaries, with professional use of self, with respecting a client/patient’s right to self-determination… it’s really hard to do, yes… But, I think this doctor–perhaps mostly because of her dissembling–clearly crossed the line.

  2. Just a reader

    I believe YOU as the mother should have taken your daughter to an OB/GYN, not a pediatrician. The ped’s office wasn’t the place for your daughter for that type of GYN problem, and the pediatrician certainly is not the person your daughter needs to see for GYN problems.

    Stop trying to blame a fellow doctor for your goof.

  3. Sarah

    I was put on birth control pills when I was 11, due to irregular periods. Maybe a little tmi here, but when it DID turn up, it would go on for weeks, making me anemic. Possibly due to my age, my mother and OB/GYN had no issues prescribing them to me. I didn’t even know about sex at the time! Possibly other doctors would have been horrified at the mere mention of this solution! However, taking those birth control pills got my system to regulate, and I’ve had no problems, not even one. I find it ridiculous that a doctor is allowed to put their own beliefs before the rights of their patients. I certainly support your daughter’s choice, but you should have probably consulted an OB/GYN instead for a much more useful opinion.

  4. "Doctor Richard"

    I don’t agree with “Just a Reader”. The primary care physician’s job is to do what’s right for the patient. As a family doctor, I have put teens on oral contraceptives both for regulating menstrual periods and also when they say they are planning to have sexual intercourse. In both cases they get enough counseling from me about the (limited) risks of the medication itself and the (significant) risks of early, especially unplanned, sexual activity. I do this with the parent out of the room, at first, and invite the adolescent to ask the mom or dad into the room if/when they are comfortable having the parent present for the discussion. I trust adolescents to tell me the truth about their sexual activities and plans. I discuss this information with the parents only with the teens’ permission, unless there is a significant safety issue which must be addressed by the parent (or, rarely, child protection services). I encourage all teens who are or are thinking about sexual activity to discuss this with one or both parents or another trusted adult, for example a teacher or school counselor, older (adult) sibling, or other relative.

    I do refer to an expert on adolescent OB/Gyn for smokers, patients with family history of clotting disorders, and cases where I am concerned about the safety of the teen. In cases where the teen might be involved in an abusive relationship, or have questions I don’t have enough time for counseling (primary care is too busy for as much counseling as I would like), I refer to a nearby expert in adolescent medicine where they have both professional and peer counseling.

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