The [Inclusive] Contraception Project

Interview 3 - A Northern Physician

To start, can you please tell us a little bit about yourself and your background in medicine?

I started off doing public/community health and epidemiology both in Halifax and New Zealand, so my clinical practice tends to be rooted in the broader social determinants of health. Then I studied medicine in Calgary and came to Northern BC to practice family medicine. Right now, I share a practice with three other physicians and, as a group, we provide full-service family practice care which includes inpatient care, hospice, and nursing home care. One of our doctors at the clinic does emergency medicine, the other runs a gender clinic, another works in detox, and I do obstetrics, so together we provide diverse full-service care for patients.

 

My approach to contraception in the office is if women don't want to get pregnant, then I can offer them an informed choice discussion about contraception, or I can offer them termination if they're already pregnant. And if they do want to be or stay pregnant, then I can offer them preconception, prenatal, intrapartum, and postpartum care. I like to think that I can support a woman regardless of what her preferences are, so that her options are open, and not limited by my skills or community resources.

 

From your experience, what barriers are patients experiencing when accessing contraception (especially beyond the financial barriers)?

 

The financial barrier is a big one. A lot of women don't have the hundreds of dollars to buy a Mirena (IUD) [intrauterine device] up front, so they choose a less effective, but immediately cheaper, option.

 

The other large barrier has to do with physician education. No matter where women present seeking contraception – virtually, walk-in clinics, family physician, or emergency – they should be given accurate information about options.

 

Part of my role is teaching Year 2 medical students about contraception with the goal of trying to get accurate information out there, regardless of whether the students become an orthopedic surgeon or family physician. Contraception is part of wholistic care and can affect other areas of health and care planning. The second part of physician education (beyond knowledge) has to do with skills training. Physicians must have the procedural skills to perform an IUD insertion or implant, and certainly in smaller centres where there might be fewer physicians this can limit access to contraception for patients. There are some physicians who are also uncomfortable discussing or examining anything related to female reproduction, and that can be a huge barrier. So really, those non-financial barriers come down to education. This might mean addressing knowledge, skills, and attitudes towards reproduction in medical school and residency curriculums. When I think back to my training, contraception was taught like everything else and was primarily lecture-based, but we were also taught sensitive interviewing techniques for sexual/reproductive issues and conducting safe pelvic physical exams for male and female anatomy.

 

There is also the issue of geography. Quite simply, something as simple as bad roads in the winter can limit access to contraception. In addition, a smaller center may have fewer physicians serving a larger community. The fewer physicians you have access to, the harder it will be to find someone to talk to, and the more difficult it may be to access them due to geography or scheduling. And that doesn’t even address the issue of whether or not the physician is skilled enough to walk you through an informed-choice discussion of the options, and then the issue of actually accessing contraception in your community depending on availability. So, I’ve certainly assisted medical terminations for unwanted pregnancies from [nearby towns] where people just don’t have options for contraception, and I think one of the benefits of COVID-19 has been the explosion of virtual medicine that has really opened up women’s options for reproductive healthcare even outside of their home communities.

In terms of COVID-19 and contraception access, I think in the early days we had people who were more reluctant to come in. Thankfully, for people with the Mirena IUD, a fantastic and official SOGC statement came out that said it was shown to be effective up to 7 years even though it is licensed for only 5 years. This meant that patients could leave their IUD in during the pandemic, which was reassuring for many, plus it was substantiated in research. So, in the early days we did take advantage of things like that and delay IUD replacement because people were hesitant to come into the office. Other than that, I haven’t seen COVID-19 result in harm. I continue to care for wanted and unwanted pregnancies, but I can’t say if any unwanted pregnancies were occurring due to the pandemic and lack of access to contraception.

 

For women from communities where there isn’t a knowledgeable or skilled physician, how do they manage their reproductive health?

 

It's a good question, and I don't know if I can adequately answer it because I don't often see those patients. I imagine many of them seek care in another town or must drive to [my city] because it’s a bigger city. In the internet era, I imagine many women turn to Google for information and options. For instance, I’ve certainly had patients who search my name directly or go to the health unit and then are sent to me that way. I also think women talk amongst themselves – they’ll ask their friends, groups on Facebook etc.

 

I do remember having one woman who drove for 1 hour to see me specifically because there wasn’t anyone locally who could put in an implant for her. So, when you think about it, she had to plan for childcare, take a day off work, and manage road conditions. It comes down to time and money. Unfortunately, the burden of contraception falls disproportionately on women.

 

Which patients do you think are falling through the cracks in terms of access? How can the health system better serve these people?

 

In terms of cultural safety, many Indigenous people feel unsafe in our healthcare system. It is our responsibility as physicians to meet people where they choose to access care, where they feel safe and not judged, and using a trauma-informed approach. Because of ongoing and past wrongs that have resulted in a mistrust of the health care system, anytime there is a sensitive physical exam or a discussion around sexual abuse it’s going to be difficult for the patient. As physicians, we always need to look at the patient needs, not just what services we historically have provided. We should always question how we provide care and be willing to change how we do things to better suit patient needs. Indigenous people are more likely to live in more remote areas, which may limit access as well. Substance use often related to intergenerational trauma is more prevalent in Indigenous people, and may further affect access to contraception.

 

That’s the nice thing about the implant – it goes in your arm (less sensitive exam compared to vaginal insertion of an IUD) and we can perform this procedure in settings outside of a physician’s office. For example, I don’t need a clinical room with a clinical bed that has foot supports. I can insert an implant literally anywhere and meet the patient where she is in her home community or on the street. This brings down a lot of barriers to contraception. As far as I know, the implant is not yet covered by MSP and this is an area that needs to be addressed.

 

As a physician, do you jump through any extra hoops to help provide access to care for patients?

 

For me, it can be a scheduling issue where I try to make myself and my clinic available at times patients can come in for an appointment. Quite often, patients can only come in on certain days (work, school, or life) so we try to provide access when patients are available. Providing flexibility in the schedule is a really big factor here. So sometimes I call them at eight o’clock in the morning before clinic starts or maybe later in the day after clinic hours. I can’t do that regularly for my own self care and healthy boundaries because I also have a family and kids to spend time with. But I can do it on occasion, and it’s no problem if I have to make an exception or there’s extenuating circumstances. I will do that when I can. On occasion, I’ve tried to apply for special authority for Mirena (a hormonal intrauterine device) through Pharmacare as a way to get people funded for an IUD, but this is often declined.

What would you want people to know about access to contraception?

 

For the general public, I believe that people have a right to know their options. They also should have a right to timely and geographically appropriate access to contraceptive care. This isn’t always feasible, for many different areas of medicine, but I especially want politicians to know that providing publicly funded, long-acting reversible contraception (LARC) has a substantial cost-savings to our health system. In the long-term, providing funded LARCs is a cheaper option than oral contraceptive pills (OCPs), for example, due to fewer visits to physicians for refills which means less MSP billing for physician services. There are also fewer accidental or unintended pregnancies which means fewer medical and surgical terminations which, overall, are more costly than covering universal contraception. I really think it’s a no-brainer to provide publicly funded LARC in terms of overall costs to the system as well as from a human reproductive rights standpoint.

If you could create your dream contraception policy in BC, what would it look like? 

 

First, opening the age range of Options for Sexual Health (OPT) would be helpful. The current age cap at 25 years is limiting. If people are uncomfortable with the information that their primary care provider is offering, then they have an option of somewhere else to go and that could even be done virtually. This addresses some of the geographical and training challenges that we have in BC. It’s important that women have access to a skilled provider when they want it.

 

Second, I believe all contraception plans should be fully covered for everyone. And that needs to include both men and women because then there is access for transgender patients too. If you limit these policies to women, then you do exclude people who are at risk of pregnancy but do not identify as female. Basically, I think the plans should be for anyone who needs contraception. It’s as simple as that, and the math works in our favour economically.

In terms of OPT clinics, what is access like in BC?

 

In [the city] where I practice, there is an OPT clinic and it offers both in-person and telemedicine appointments, so you don’t need to live in [the city] to access the clinic. The clinic can also tell patients where the nearest provider is for an IUD or an implant, and it can also train local providers if they notice that there are gaps in expertise for more difficult procedures. There are OPT clinics across BC in larger centers.

The first point of contact for patients with reproductive health needs is often a family physician. How do you view the training for future generations of family physicians?

 

Solid family practice training is the most important piece for physician education, and most residency programs do a great job of training people. This doesn’t mean, however, that people will feel comfortable providing the full range of reproductive care after they’re done training so there needs to be an alternate option for patients, just in case, so everyone can receive appropriate care. For example, like OPT clinics.

 

We don’t need to “reinvent the wheel” so to speak, we should use existing infrastructure as a backup. A big determinant of comfort for physicians-in-training is where they spend time training. For example, residents who train at my clinic (being a clinic with a reproductive healthcare focus) are going to be pretty comfortable inserting IUDs and hopefully implants as well. We’ve created an environment where it is very comfortable to discuss reproductive health and this helps the training of future doctors. On the other hand, if a resident is in a practice where the supervising physician doesn’t feel comfortable discussing reproductive medicine or procedures, then the residents will come out of their training with few procedural skills and less confidence. So, the training depends a lot on where the placement is, and sometimes the residents don’t have a choice where they are placed for training.

Why do you think some physicians are uncomfortable providing reproductive healthcare?

It is more common than we think, and more common than we’d like to acknowledge in the health profession. Some doctors just don’t do female pelvic exams or pap smears because they’re uncomfortable with it and they feel it’s not their role. This is more rare but, unfortunately, results in women not receiving care. Sometimes, these women don’t even know their options. This is a disservice. Many physicians do refer these patients to female colleagues, such as myself, but OPT is not an option for women over age 25 or it can take a while to get an appointment. Personally, I have residents always asking me questions and it’s an added incentive to keep up to date on the topics I’m already passionate about. New guidelines for everything come out all the time; it’s hard to stay on top of the latest knowledge in everything so having residents helps.

We hear reports that youth don’t access contraception for fear of their parents finding out (shared insurance plans) – have you found this to be true or not?

 

No, I think if parents have health benefits most kids are pretty comfortable taking advantage of those benefits and, from what I’ve seen, they don’t hide their need for birth control from their parents. I haven’t come across any situations where that’s been an issue. I recently had a lengthy discussion with a teenage girl and her mother on the phone about the girl’s contraception needs. She decided to get an IUD that would be covered under her mother’s health benefits. Fortunately, this hasn’t been an issue from my experience in practice.

Are there any assumptions made around access to contraceptive care in Northern communities?

Yes, I think we all assume that access to contraception is going to be more difficult in the North than in the South, but just because you remove distance doesn’t always mean you improve access. There are some folks here who live far away from [my city] and yet they regularly come into town for their appointments – it’s just part of their life that they adjust for. They choose to live far away from larger centres, so they come in every couple of weeks to complete their errands all at once (including contraception), and that’s acceptable to them. Rural living certainly has its health benefits for wellbeing. I think people in urban centers, although distance might not be as much an issue, face other barriers.

What has your own personal experience with contraception been like?

I’m actually pretty lucky because I’ve always had access to contraception when I’ve needed it. I also always had the money for it, and I felt comfortable asking for it from health professionals. I really haven’t had any barriers. And I think those are really the main elements to accessing contraception – having adequate knowledge to make decisions for yourself, feeling like you have a voice and are being listened to, removing financial barriers, and reducing geographical barriers.