Monday, November 25, 2013

Should This Gynecologist Be Allowed to Examine, Treat Male Patients? Of Course!

Dr. Elizabeth Stier - wants to continue treating the men in her practice.

Dr. Elizabeth Stier isn't asking for much, only that she be allowed to continue examining and treating male patients  at risk for anal cancer. The disease is rare, but it can be fatal and its incidence is increasing, especially among men and women infected with H.I.V. Like cervical cancer, anal cancer is usually caused by the human papillomavirus, or HPV, which is sexually transmitted.  (One of the last major media notices put out about it was a few years ago, when Farrah Fawcett described her ordeal.)

As a New York Tmes piece described Saturday, though most of Dr. Stier's patients are women, (she works at Boston Medical Center), she also treated about 110 men last year, using techniques adapted from those developed to screen women for cervical cancer.  

But in September, the American Board of Obstetrics and Gynecology insisted that its members
treat only women,
with few exceptions, and identified the procedure in which Dr. Stier has expertise as one that gynecologists are not allowed to perform on men. Doctors cannot ignore such directives from a specialty board, because most need certification to keep their jobs.  Doctor Stier expressed shock to learn that she would lose a vital credential, board certification as a gynecologist, unless she gave up this important part of her medical practice and her research: taking care of men at high risk for anal cancer.

Now Dr. Stier’s studies are in limbo, her research colleagues are irate, and her male patients are distraught. Other gynecologists who had translated their skills to help male patients are in similar straits.  Worse, this comes at a time when researchers are about to start a major clinical trial that is aimed at preventing anal cancer (increasing at new, alarming rates), with $5.6 million from the National Cancer Institute. Observers say the Dallas' board’s decision will keep some of the best qualified, most highly skilled doctors in the United States from treating male patients in the study.

Though Dr. Stier and the Director of the planned study asked the Board to reconsider their decision, they remain adamant. According to the Times article, they are convinced such practice amounts to "money making" and is "tarnishing the specialty's image. . But  Dr. Mark H. Einstein, a gynecologic oncologist at Montefiore Medical Center  said, “The board’s approach is to be rather dogmatic and to draw a line in the sand.”

In many ways it reminds me of a fierce debate that erupted in an Astronomy meeting some years ago when one purist decried planetary scientists calling themselves astronomers. "How can they be astronomers? " he asked, "when the very name is based on 'astro' referring to stars, not planets!"  Presumably, if this person could be transported to the present context, he'd argue "gyne" refers to females so can't be applied to males.

But he'd miss the point that many of the techniques are the same and are medically transferable. For example, the technique entails the use of Anoscopy. .  This involves using 4-5 cm long lighted tube (anuscope)  to examine the anal canal which is 4-5 cm long. A high resolution version also adds a magnifier to look for abnormal growths much the same way as is done in a colonoscopy. These growths may be cancers or precancers, with the latter requiring surgery  though doctors can burn off precancers in much the same way gastro-enterologists can excise polyps during a colonoscopy.

The point is that Dr. Stier has been an expert in the high resolution method and her patients - males especially  - have come to depend on her. Though she has been treating men for 10 years, she will now be able to see only women and this worries her.  What most concerns her is what will become of the men she's been treating. As she points out in the NY Times piece, the procedures are embarrassing and uncomfortable for patients, and it takes time for a doctor to gain their trust.  Now, they will have to seek treatments and care at other hospitals, with other medical practitioners with whom that same trust may not be possible. It is possible that they won't even bother.

Dr. Joel Palefsky, a specialist at the UCSF Medical Center in San Francisco(where I had my prostate cancer high dose treatment) said:

"We need as many trained people as possible. The assumption all along has been that many of the gynecologists we trained would participate in the study and would see both men and women.”

Sadly, however, definitional absolutism and semantics has crept into a field which can ill afford it. If we are ever to win the battle against cancer - especially against the "squeamishness-inducing, embarrassing cancers" that make people's skins crawl - we will need all hands on deck and as many different resources and high level skilled professionals as possible!

Bravo to Dr. Liz Stier for trying to do her part!

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