By Rob Stein
Washington Post Staff Writer
Thursday, August 31, 2006
Sandwiched between a swimming pool store and a spice shop on Lee Highway in Fairfax, the Tepeyac Family Center looks like any other suburban doctor's office. But it isn't.
The practice combines "the best of modern medicine with the healing presence of Jesus Christ," a brochure at the reception desk announces. An image of the Madonna greets every patient. Doctors, nurses and staff members gather to pray each day before the first appointments.
The center is one of a small but growing number of practices around the country that tailor the care they provide to the religious beliefs of their doctors, shunning birth-control and morning-after pills, IUDs and other contraceptive devices, sterilizations, and abortions, as well as in vitro fertilization. Instead, doctors offer "natural family planning" -- teaching couples to monitor a woman's temperature and other bodily signals to time intercourse.
Proponents say the practices allow doctors to avoid conflicts with patients who want services the practitioners find objectionable, as well as to provide care that conforms with many patients' own values. The approach, they say, provides an alternative to mainstream medicine's reliance on drugs and devices that, they argue, carry side effects and negatively affect couples' relationships.
"I want to practice my faith," said John T. Bruchalski, the obstetrician-gynecologist who started Tepeyac. "I'm not interested in pushing it on other people. But this allows me to practice medicine without having to do something that I wouldn't see as positive or healthy."
Critics, however, worry that the practices are segregating medicine along religious lines and may be providing inadequate care by failing to fully inform patients about their options. The critics are especially alarmed about the consequences in poor or rural areas with few alternatives.
"Welcome to the era of balkanized medicine," said R. Alta Charo, a bioethicist at the University of Wisconsin at Madison. "We've had this for years with religious hospitals. What's happening now is it's drifting down to the level of individual practitioners and small group practices. It essentially creates a parallel world of medicine."
The American College of Obstetricians and Gynecologists has no formal position on such practices, but its officials say the approach can offer a way for religious doctors to work and serve religious patients as long as they are upfront about their limitations.
"If women know before selecting them, then it's quite a legitimate thing to do and might meet the needs of many women and doctors," said Anita L. Nelson of the University of California at Los Angeles, speaking for the organization. "But if you hang out your shingle that says 'All-purpose OB-GYN' and don't offer certain services, that's false advertising."
The phenomenon is another manifestation of the tensions arising between religion and medicine with the rise of religious expression in the United States and medical advances that create moral dilemmas for some. Natural family planning, or NFP, practices are seen as a way of sidestepping confrontations over abortion, the morning-after pill and other types of care that some religious health workers refuse to provide, asserting a "right of conscience."
"This is a way that some of us have found to practice medicine that is consistent with our beliefs," said Kathleen M. Raviele of the Catholic Medical Association, which, along with groups such as the American Association of Pro Life Obstetricians and Gynecologists, promotes natural family planning.
"It's definitely a new trend, and it's a refreshing trend," said Theresa Notare of the U.S. Conference of Catholic Bishops, which has workers in at least half its dioceses trying to enlist more doctors to open such practices. "This is a trend that we should be excited to see grow."
The number of "NFP-only" practices is unknown, but an Ohio-based Web site promoting them has a registry of nearly 500 doctors who have pledged to practice this way. Most are obstetrician-gynecologists and family practitioners.
"We're trying to get doctors to see that contraception is not good medical practice," said Steve Koob, who runs the One More Soul site ( http://www.omsoul.com ). "Natural family planning for couples that need to space their children is as effective, and it builds a marriage."
Doctors on the registry say they converted their practices after struggling to reconcile their beliefs with their medical responsibilities, often after years of being penalized or shunned by colleagues.
"I've encountered a lot of resistance to how I practice over the years," said Lorna L. Cvetkovich, an obstetrician-gynecologist in Ann Arbor, Mich. "For one thing, contraception and sterilizations bring in a lot of revenue. But I finally found partners who feel the way I do, and we're scraping by."
The approach also provides a haven for women who have had a hard time finding a doctor who understands their beliefs.
"What happens is a patient says to her doctor, 'I don't want an abortion. I don't want to go on birth-control pills. I don't want to create 10 embryos and kill eight of them to have a baby,' " said Thomas W. Hilgers, who started the Pope Paul VI Institute for the Study of Human Reproduction in Omaha to do research in this area, offer patients alternatives and train doctors. "They end up getting ridiculed or told they are stupid."
Some of these doctors have solo practices. Some belong to groups where they are the only ones offering the approach. Others have formed group practices that are NFP-only. Often they carefully screen out prospective patients who might want care they do not provide. Some refer such patients elsewhere. But others feel uncomfortable doing even that, saying it would make them complicit in care they consider immoral.
"If you refer a patient, it makes you as responsible as the one who does the procedure," said Cynthia Jones-Nosacek, a family practitioner in Milwaukee.
Some women, however, report being dismayed after stumbling into one of these practices without realizing what they were.
"It never crossed my mind that it would be an issue," said Katie Green, 26, who was refused a birth-control prescription by Jones-Nosacek. "I was really irritated. It just rubbed me the wrong way."
"It caught me completely off guard," said Elizabeth Dotts, 25, who had a similar experience in Birmingham. "I felt like he was judging me and putting pressure on me. . . . I am the patient. I am the client. It should have been about me -- what I needed. Not what he needed or believed."
Some experts say such practices are providing substandard care if they do not fully inform patients about all options.
"It's not enough for someone to advertise 'We provide natural family planning' or have a sign up in the waiting room that says 'Only natural family planning available here,' " said Jeffrey L. Ecker, an obstetrician-gynecologist at Harvard Medical School. "The assumption shouldn't be that patients understand exactly what that means. The doctor has an obligation to fully explain all options to their patients."
Some experts also criticize doctors who represent natural family planning as being as effective as birth-control pills, patches and other medical approaches.
"To suggest they are equivalent to modern methods is simply incorrect," said David A. Grimes of the University of North Carolina School of Medicine in Chapel Hill. "These methods do not compare favorably in terms of effectiveness, acceptability and continuation rates."
And many doctors and advocates argue it is wrong to imply that pills and other contraceptive devices are equivalent to abortion.
"By saying they won't offer pills because 'I'm a good Christian and don't believe in abortion' basically is saying the pill causes abortion, and that's not accurate," Nelson said.
Tepeyac, named after a shrine in Mexico City that inspired Bruchalski, is one of the largest NFP-only practices in the country, with three full-time obstetricians in Fairfax and an office in Silver Spring, serving about 15,000 patients.
The practice makes it clear what services it offers, and Bruchalski said doctors fully explain all options, including natural family planning.
"I think the approach rests on its own," Bruchalski said. "I believe it promotes excellent communication and understanding between the husband and wife, and the woman knows she's not putting something plastic or hormonal into her body."
Many patients who come to the practice are religious, drawn to it because the care conforms to Roman Catholic teaching but also because it is a nonprofit clinic that takes uninsured patients.
"I really like their whole approach," said JoEllen Murphy, 37, of Falls Church, who started going to Tepeyac after she got fed up with her previous doctor repeatedly asking her what kind of contraception she was using.
"It got annoying, so I decided to switch to Tepeyac," said Murphy, who is Catholic. "They share the same beliefs. You go there and know no one is going to try to talk me into something that I'm not morally comfortable with. I feel understood and not judged for my views."
While the doctors routinely pray for and with patients, the practice serves women of any faith, and some women seek it out not for religious reasons but because they like the doctors' natural and comprehensive approach.
"We approach the person from a very holistic perspective -- body, soul and spirit," Bruchalski said. "We tell patients you have to take care of your body. You have to be able to communicate and develop a relationship. You have to meditate and pray to God or a higher power. We bring this to people of all backgrounds."