Advice to a mom-to-be, on caffeine and from home style

OK, I am home today with a not-so-sick five year old and my new 12 cup French Press coffee maker. So, sorry about the overabundance of posts today. I have super caffeinated typey fingeritis.

I wrote some more advice to my mom-to-be cousin Susan:

There are a few questions you can ask practitioners when you interview them. I would pick a few things you are particularly concerned about and use them to judge your practitioner choice (along with your gut feeling about your rapport with them, of course). It’s really up to you what these things are but here are a few examples:

1. Episiotomy: Do you employ them? Routinely? Under what circumstances?

It is up to you, but this would be my main litmus test. Episiotomy is not evidence based, at all, and there is a HUGE effort to restrict and/or end their use. It causes lasting harm to the mother, and the practitioner should at least show some hesitation, and boast about a low to non existent rate. In my opinion, the only time an episiotomy should be used would be if forceps had to be applied, and it facilitated that. And, forceps are rarely applied.

2. Cesarean section: What is your cesarean section rate? Under what circumstances do you do them? (Specifics, like…how long would someone have to be stalled in labor? 4 hours? 12? 24? What if my water breaks? How would you define a non reassuring fetus during labor?)

3. Induction: Do you do elective inductions on your first time moms? What percentage of your first time moms do you induce? Is it at their request, or is it the routine practice to do them at a certain gestational age? What are your guidelines for doing them? What are your guidelines of letting a pregnancy run past its estimated due date?

Again, your priorities in this situation are up to you, but I wouldn’t recommend an elective induction unless your Bishop score was 10 or more, which is a score of how ready your cervix and the fetus are for delivery. Inducing someone who is post dates is more understandable, but most guidelines say not to do so until at least a week post dates, even two if the fetus has reassuring status. Many practices starting pushing inductions at 39 weeks with an unfavorable Bishop’s score.

Those are the big three. Now, there are other points you may want to discuss, based on your own priorities.

During labor, can I eat and/or drink? Can I have access to a tub for labor, or a shower, or walking, or a birth ball, or my own clothing, or (fill in the blank)? Can I bring a doula to my labor? How many support people can I have, and what are the visitation rules in general? Can my support person spend the night with me in labor and after the baby is born? Do you require an I.V.? Do you require continuous external monitoring? Can I get intermittent monitoring if I am low risk and in early labor? Do you routinely do an artificial rupture of membranes in early active labor? What are your guidelines for ruptured membranes, do you have a time limit for how long they can be ruptured before you move to cesareans section, if everything else seems low risk? Do you routinely administer pitocin to strengthen contractions, or do you have a guideline for stalled labor before you use it? Can I have (whatever accommodation you may need, such as a vegetarian meal, or a kosher meal, or a disability accommodation, or religious accommodation)? Can I have access to an epidural at any time, or only during certain hours? What other pain relief options do you offer, and how are they offered? Are you supportive of patients not wanting to use epidural pain relief or IV pain medication? When do you show up to a labor? Who will show up to my labor? (It may depend, if it’s a large practice). What sorts of situations would you show up to the hospital for, and what ones do you expect the nurses to handle? For example, if I thought I was in labor, do you want me to come by the office? If I was admitted to the labor floor, do you do show up in early labor? (Most docs in this area don’t, but some do in other areas. As for the other complications and issues, you’d be surprised. I would love to hear this question asked. I wouldn’t dare when I was pregnant, but hey, why not throw it out there? I would hope that I’d be happy to ask that when I am an ob/gyn).

I could go on and on. Pretty much, ask them the questionnaire I am doing for my research project.

I would also see how they respond to being asked these questions. Hopefully, they will support your right to want to know the answers, and take the time to answer them. And, I think it needs to be done before a traditional birth plan is written, generally in the third trimester. That will be as important as what the answers are.

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44 responses to “Advice to a mom-to-be, on caffeine and from home style

  1. This post is a perfect example of the “natural” childbirth obsession with process as opposed to outcome.

    The most important thing to know about an obstetrician is his or her level of skill, not the atmospherics like whether or not you can eat in labor.

    Similarly, this post speaks to the naive belief of “natural” childbirth advocates that “of course my baby is going to be healthy and nothing could go wrong” so what I really need to worry about is whether or not I have an episiotomy.

    Picking your obstetrician by how he or she handles the process without bothering to do even minimal research on skill level and outcomes makes as much sense as picking your obstetrician based on the color scheme of the office.

    • MomTFH

      Dr. Tuteur, I don’t appreciate (yet I am not surprised) you taking a reasonable and evidence based post and pretending it is a “natural” birth obsession? I even mention availability of epidurals! Could you at least read the posts before you start to rant?

      Why can’t you discuss something with a respectful tone, instead of dismissing my points (which are supported by evidence), comparing them to choosing a physician and practice based on a color scheme?

      No, Dr. Tuteur. Most deliveries should be physiologically normal. Whether or not a physician follows evidence based medicine and believes in informed consent, which is all I discuss, is a good indicator what the physician’s practice patterns will be like. Skill levels cannot be ascertained in an interview. And, who cares if your physician is skilled at cesareans if you are going to get one even if it’s not indicated and not what you want? Who cares if they can repair a fourth degree tear really well if it’s caused by an episiotomy which should never have been performed?

      Please tell me specifics to my post that are not supporting best outcomes. Or that are outside the realm of reasonable obstetrics practice. Don’t just trash my post with no specifics.

      Please tell me why you are so against patients having informed consent for elective interventions during a physiologically normal delivery.

    • MomTFH

      Oh, and being allowed to eat or drink during labor is not an “atmospheric” issue. You cherry picked one of the minor points I made, and you still didn’t pick a good one. I was at my cousin Susan’s four day long elective 39 week induction lately (She had a Bishop score of two and no risk factors. Did you see the main points? That would have been one of them) and they seriously were intending to keep her NPO (no food or drink by mouth) for all four days, and they didn’t even have glucose in her IV bag. Lactated ringers only. I questioned the nurse, 36 hours into the induction, and she said 1. NPO, non negotiable (and she was at 1 cm with no fetal distress. When was this crash section coming?) 2. We don’t put in any glucose unless the patient starts showing symptoms of hypoglycemia. My response was “She is complaining of “feeling woozy”. How about some glucose in the next bag?”

      How low does this patient’s blood sugar have to go before she starts showing signs of altered consciousness? (And how will that affect the fetus? I know hypoglycemic newborns are a problem.) Is this “atmospheric” to you?

    • infamousqbert

      here, i’ll do what we all really want to.

      AMY! SHUT THE FUCK UP! you’re a giant asshole who can’t bother to give proper backup for ANY of her claims, even when asked directly! leave the thinking to the rest of us!

      doctor amy’s new slogan

  2. mommymichael

    It was the first high risk doctor that I had spoken with who reassured me and made me feel as though he would support me in my want for a natural birth. Until we needed to worry about low fluids at 35 weeks and then suddenly it was all about getting the baby out asap, and talk of a c-section (for low fluids…. when baby was doing just fine.)

    we induced instead.

    It was another doctor in the practice (out of 15, with several other fellows), who I didn’t get to meet until I was already at the hospital, that kept things calm and easy. Letting me labor how I wished. Speaking to me straight in regards to his concerns, and how he could work with me on things and not on others. Giving me the choice, but because he talked it over with me and explained things without trying to scare me *purposely*.. I made the decision to try the path he felt was better.

    The first one strung me along. The second one respected me.

    • MomTFH

      It’s really hard to tell during an early prenatal how a practitioner is going to act in different scenarios. What I think is key is the level of respect and proper informed consent the second physician prioritized.

  3. I agree with all your recommendations, in theory. In reality I find that it is a rare patient (blog readers!) who actually question their doctors, about anything. There seems to be an intimidation factor there. Have you ever heard the old adage that when a doctor enters a patients room to explain a procedure and then asks if they have any questions, the patients always say no…..until the doctor leaves and the nurse enters, then the stream of questions start. I have seen and been exposed to this many, many times.
    Tell your patient to talk to a nurse :)

    As far as picking an OB based on “skill level”, this is a hard one for me. Just what do we mean by skill? For an oncologist you can assess survival rates, for a cardiac surgeon you can assess number of procedures and complications. But what do you assess for in an OB as far as skills? Birth weights? Use of forceps or vacuum? Complications of these? NICU admissions? Infection rates? Number of lawsuits? Admissions to an ICU? Percent of OB hemorrhages? Length of stay? I am being serious. How do you assess skill?

    Just one more prop for nurses, and then I’m gone. For those of us who have worked in hospitals for a long time, you will see the pregnant nurses usually all seeing the same MD or CNM group at the hospitals they work in. They have inside information, and have seen these practitioners in action. I did they same thing. I saw a group of CNM’s with great OB back up. Did I look at there “skill?” I looked at there C/S rate, VBAC success rate (I was a VBAC), and I knew what they were like and how they managed patients in the DR. Valuable inside information! So again, find a nurse who works in the hospital you are delivering in and ask them their opinion on different practices. :)

    • MomTFH

      Yeah, I’m not so sure what the skill level thing is about. I am afraid Dr. Amy thinks there are unskilled obstetricians out there we need to weed out. I haven’t heard any such things from the natural birth community, but she must know something I don’t. Maybe we should check Angie’s List.

      Otherwise, practice patterns tend to determine intervention rates, which vary widely from practitioner to practitioner.

      I have told people who get to meet nurses at childbirth classes or tours of the hospital to ask about the doctors. They definitely know what goes on.

      • Well, we can gather from the comment that the measure of skill would not be anything to do with process, since that’s merely a pathological obsession. You apparently have to look purely at outcomes to determine “skill” of an obstetrician.

        • MomTFH

          Dr. Amy thinks that women who want to have any input on their perinatal care have a pathological obsession.

          She is a primo example of why I am asking to physicians about informed consent and patient autonomy in my survey. So far, (VERY preliminary data, so don’t draw any conclusions) most of the small group (just over two dozen, mixed demographics and practice types) of physicians I have polled so far seem to agree or strongly agree with patients having the right to refuse interventions such as episiotomies.

      • mommymichael

        have you seen that angie’s list commercial about induction turned c-section? i was surprised to see it. your comment reminded me

  4. From a patient’s perspective, there really is no formal way to access information on “skill level,” is there? The Birth Survey and other online rating sites are a start but those are mostly indicators of patient satisfaction. ICAN chapters have their finger on local vaginal birth friendly providers.

    • MomTFH

      Yes, and online doctor sites in which random internet users can leave comments usually selects for disgruntled input. I have used those sites to try and find contact info for obstetricians in my area for my research, and the comments I have stumbled on can be very nasty. None mentioned skill level specifically, but they sure mention bedside manner a lot. That would go back to the rapport thing I mentioned in the original post.

      • I agree about the problem assessing skill level. I can’t think of a single readily accessible way for patients to do that. Even “find a nurse to talk to” may be beyond the ability of many people for various reasons. Although I don’t love the existing online doctor sites, I’ve read about some practices making patients agree not to rate their doctors online, so even that may be out. Regular people can probably find out where a physician did their training (through the right combination of internet access and knowing that a state database probably exists to provide this and discipline information), but even that is not going to readily translate to a reliable “skill level” of a provider.

        • MomTFH

          I know. I think, especially based on her continued silence, that she wanted to come on here and be sarcastic, but really didn’t have a valid alternative way to compare obstetricians otherwise, so she came up with “skill level”. She didn’t read the original post, and didn’t think through her response very well.

          I mean, if I was going to get a complicated and rarely performed procedure done, I would probably want to ask my surgeon about hir experience and skill level – how many of these procedures have you done, and what were the outcomes? But, with a relatively common, non technical event, like a physiologically normal vaginal delivery, I think practice patterns for common interventions, informed consent, and basic practical questions (can my partner spend the night in the post partum room?) make much more sense.

          (Sorry, keep editing and adding to this comment)
          No ob/gyn can finish a residency without doing a serious number of deliveries, vaginal and cesarean. I don’t think skill level is a big issue there.

          • “I think, especially based on her continued silence”

            I made my point and I didn’t think I had to pound anyone over the head with the obvious. Obviously skill level is more important than process. Just because it’s more difficult to find out, doesn’t mean that you can simply pretend it doesn’t matter.

            How can anyone claim to be “educated” about childbirth when they don’t even know how their provider compares to other providers?

            I wouldn’t go to any medical professional who did not have strong training, lots of experience, and a history of good outcomes in difficult cases.

            “No ob/gyn can finish a residency without doing a serious number of deliveries, vaginal and cesarean. I don’t think skill level is a big issue there.”

            Hilary, you live in the world of the terminally idealistic and naive. Get back to me when you have had to take responsibility for someone’s life and after you have observed dozens of practitioners and have some clinical (not ideological) basis to compare providers.

            I have seen providers who have terrible outcomes who are idolized by their patients because they have good bedside manner. Some doctors are good doctors and some are bad doctors, with poor judgment, sloppy technique and minimal skill. It is unbelievable to me that you can pretend that anyone who finishes a residency is the same as anyone else except for their episiotomy rate.

          • MomTFH

            Dr. Amy,

            First of all, you are (yet again) ignoring all of my original points. And, still being disrespectful.

            Skilled at what? How do you measure or compare this skill? How does this potential patient you mock as being naive enough to think she is “educated” compare this skill (at what?) between practitioners?

            I think comparing adherence to practice bulletins and evidence based standards of care in regards to birth is a reasonable and advisable way to compare practitioners. How is this a bad standard?

            And, are you seriously saying that there are too many obstetricians that complete their residencies without being skilled at vaginal delivery, since you sarcastically mock my statement about this as “terminally idealistic and naive”? That weeding out these providers with terrible outcomes based on their poor skills is really what women need to do?

            On the same post you accuse ME of having a “natural” childbirth obsession?

        • You are right Rachel that finding a nurse, or any insider, is not really accessible for the majority of patients. Skill level of an obstetrician is an extremely difficult thing to quantify. I would be curious to know just how women find/choose their providers. I smell a blog post coming!

          • RR, I think this is the issue here. I can dig up dirt through a bunch of different consumer (for lack of a better word) networks, with friends I can bug for info, case law, informal reports from doulas and nurses, etc. Plus, I’d feel comfortable asking questions about experience, philosophy and how emergencies will be handled. I don’t think this is typical. A lot of things are implied simply by having a choice of provider to start with.

            Personally, I don’t think it would be fair to judge a care provider solely by outcomes or to use that as a measure of their skill. Or at least not without knowing what exactly happened. Even cesarean rate isn’t always a fair indicator of practice or philosophy.

            So I guess we’re supposed to believe that there IS a formal way for patients to find out specifics on each physician’s history of resolving difficult cases with good outcomes, but it’s just more difficult. So WTF is this mysterious fountain of case specific physician data that we can all dip our cups in? Hmmm.

          • MomTFH

            Maybe there is this secret nurse network that rats out unskilled doctors on an anonymous website or something. Dr. Amy must know about it.

  5. Skill level. Hahahaha. That’s cute.

    I so badly want to share a relevant pun about a doctor at our local hospital, but don’t know if it’s kosher to talk about real doctors by name on the interwebs. Ah well.

    • MomTFH

      I know! It doesn’t violate HIPAA to talk about a practitioner. It’s really your call. I tend not to mention any practitioners by name, because I don’t want to seem disrespectful to a field I want to be a member of. Even though I think doctors with issues with evidence based care and informed consent only reflect badly on themselves, not the practice of medicine as a whole.

      Anyway, it’s your call. I wouldn’t delete it or have a problem with it solely because it was a real physician. It would have to be offensive or unethical for other reasons for me to have an issue with it.

      • Well, on the issue of skill level, there is an OB at our hospital that is very skilled at Cesareans…because that’s all she likes to do. Her name is Slusher, but everyone calls her Slasher. Which is both funny and scary at the same time, and women avoid her, or pray she is not on call when their labor starts. At our little parenting group (which comprises of a wide variety of women at different levels of beliefs about birth and parenting in general), when a woman tells her birth story and says that Slasher was there, a collective groan ripples through the group. A doctor can certainly be skilled, but patients will still dread her, especially if the skill she possesses is not one they want.

        Come to think of it, skill level may be VERY appropriate for this discussion. A heavy use of unnecessary interventions will probably mean that a practitioner is NOT that skilled at normal vaginal birth.

        • MomTFH

          Great story, and I don’t see any problem at all with sharing it. You’re right, also, that unnecessary intervention practice patterns are the best way to determine if a practitioner is skilled at normal vaginal birth.

        • zonzevek

          That’s actually a very bad attempt to prove a point through the use of an anecdote. I’d recommend you to avoid such things in the future.

          What’s very unfortunate about your example is that you have failed to understand Dr Tuteur’s post. Do notice she did not mention about focusing on skill level related to c-sections but in general. Also, what’s exactly the problem with cesareans? They are by far not the worst case scenario (the worst case scenario would be a death or a permanent injury… I feel very odd for having to actually point this out)

          Dr. Tuteur is right unfortunately, the things mentioned in this blog post are very low priority and something to care about after you actually found many doctors that are capable enough to go through all the possible complications and you need a tie breaker…

          In fact, in my own attempt to show how wrong this post is I’ll point out something that may not be obvious but is actually scary: The perfect candidate according to the selection method is… a layman who has never delivered a baby, probably your husband or even a 10 years old… :

          1-2. Most ten years old have never performed Episiotomies and their cesarean section rate is zero.
          3. Has never done inductions either!
          4. And finally a 10 years old will allow you to do all the things you want like the ones mentioned on that gigantic paragraph about atmosphere.

          • MomTFH

            I find it very amusing that you chose to give someone else recommendations and criticism on their post, when you don’t know the difference between an analogy and an anecdote. She is making an analogy, which is what you are doing in your post with your 10 year old son.

            Maybe you can answer the questions that Dr. Amy cannot: Skill at WHAT? Measured HOW?

            No one said cesareans are the worst case scenario, or that a doctor’s cesarean rate should be zero. It is really easy to make a stupid argument no one is saying sound ridiculous. Did you read what I actually did write about cesarean section?

            “Under what circumstances do you do them? (Specifics, like…how long would someone have to be stalled in labor? 4 hours? 12? 24? What if my water breaks? How would you define a non reassuring fetus during labor?)”

            So, obviously, there are circumstances in which it would be appropriate.

            The interventions listed in my post are not low priority, and every obstetrician should be able to answer those questions AND handle complications, which are less likely than a physiologically normal birth. Are you seriously suggesting there are obstetricians out there that can’t handle complications of labor? (And, I do mention handling complications in the post. But, most obstetricians handle complications similarly It’s the normal deliveries that have huge variation.)

            The US Preventative Services Task Force thought the interventions I listed were important. Have you read the study I linked to? Based on what evidence do you think these are unimportant? Because there are almost 2000 studies in PubMed on episiotomy alone. Should we go tell these authors and journals to knock off all this nonsense and start talking about “general skill level”, gosh darnit?

            As for your example with your 10 yr old son, it’s ridiculous. Read my post. If your ten year old son can explain non reassuring fetal status, explain under which circumstances he would recommend an induction (including a discussion of post dates) including a thorough understanding of the Bishop’s Score, and can discuss under which circumstances he would employ episiotomy (notice I never said any of these things should be ZERO, again, it’s easy to make a stupid argument sound stupid, and I never said that), then we’ll talk.

            And, if he will entertain the priorities of the mother-to-be during what is most likely one of the most important days of her life by considering whatever items in the list at the end that she thinks are important to her, then he has a lot more compassion then you or Dr. Amy seem to. You really think it is unimportant if her partner can spend the night with her after the baby is born? Or if someone with a disability can get an accommodation?

  6. I’m curious on forceps being the only indication for episiotomy. If a baby is crashing on the perineum, wouldn’t that be a reasonable use of the scissor cut? Wouldn’t that get the baby out faster?

    On the subject of skill level….doctors who get sued most are the ones with the worst bedside manner, not the ones with the lowest skill levels. So even when we’ve experienced the skills first hand, we (as in “everyone”, not the “natural birth” subset) don’t seem to be very good at identifying good vs bad!

    Liz.

    • I can see an indication for an episiotomy with a difficult shoulder dystocia.

      • MomTFH

        Shoulder dystocia involves the baby being stuch at the pubic bone, not the perineum. None of the descriptions of the maneuvers or drills I have read or seen have involved an episiotomy. I have heard of doing an entire episioproctotomy, but again, if the baby is stuck under the pubic bone, this doesn’t solve the problem. I have read most if not all of the current literature on episiotomy, and none of it mentions shoulder dystocia as an indication. That being said, I saw an ob cut an episiotomy on my cousin Susan because she was afraid of a shoulder dystocia. The baby was not predicted to be macrosomic, was not macrosomic, and there was no shoulder dystocia, not even for a second. But, she got an episiotomy,(which she had specifically refused prior to the delivery, and then apparently was not necessary) just in case.

        I don’t know how many fingers a practitioner can get in to attempt to free a shoulder, but based on what I have seen of the mechanics, it’s not the perineum that is the limiting factor. Of course, if a practitioner decides that the perineum is impeding the process of getting to that shoulder, then of course, it could be warranted.

        And, I have seen tears. I have yet to see a baby crash on the perineum, but I have seen quite a few babies and shoulders tear through a perineum. Compared to the rest of the birth process, the perineum is not a significant barrier. But, of course, if it seemed to be the barrier between the baby been born and not, and it wasn’t tearing, then an episiotomy would be warranted.

  7. Gen

    Amy said (elsewhere, Googled)– “It hasn’t proven that Jupiter isn’t made of marshmallow, either. According to the principles of logic, you don’t have to prove a negative. You only have to prove a positive.”

    Amy said (here)– “Just because it’s more difficult to find out, doesn’t mean that you can simply pretend it doesn’t matter.”

    You’re just here to harass Hilary or you’re nostalgic for the days long ago of pulling power trips on the residents and fellows you supervised. Or your kids are too old to put up with power trips. Otherwise, you would back up your claim that there is a way for patients to find out which obstetricians are sub-par.

    While you’re linking or describing this process that will benefit everyone, why don’t you educate everyone with your experience on how an unskilled obstetrician can botch your care. Provide examples.

    Do I hear crickets?

    • MomTFH

      Ha, that sounds more like Dr. Phil than Dr. Amy! Well, the beginning part, anyway.

      I am also pretty boggled by her assertion that there are unskilled obstetricians out there duping moms who think they are “educated” with their charming bedside manners, all while causing nonspecific bad outcomes due to nonspecific poor skills.

  8. “Maybe there is this secret nurse network that rats out unskilled doctors on an anonymous website or something. Dr. Amy must know about it.”

    Oh there is, it’s called: Nurses Rat Out Unskilled Doctors Anonymously.net. No one knows about it because it is a dot-net, and not a dot-com.

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  10. Skill level. I guess I would look to see where the good doctor did their residency. I found that many doctors who went through the Brigham and Womens experience came out of it good doctors. Some did not but most did. So you can see where they went to school.

    Also you could see how long they have been practicing. Bed side manner is not the same as skill. I have found that a few really skilled docs are a$$holes. Too bad but they are. I cannot change that. Also I have known docs who have great bedside manner but if a shoulder dystocia occurs or some other emergency, we will have more trouble. The good news is that when they practice in a hospital, the nursing staff and other docs are watching them. Why? Because we can be found liable if we watch them do stupid stuff and don’t sound the alarm. So we sound the alarm.

    I think if I were in a strange land and about to give birth and wanted a good, hands off, doctor, I would call the birth center closest. Why? Because OB specialist know each other in a small area. So the birth center close to you may have a verbal list of good docs. Can not hurt to try. I know that the birth center close to me has midwives who have worked in and around the area so they would know who to direct you to. Also the midwives may be able to give you some good questions to ask the doc that you may not have heard of.

    • MomTFH

      So, you don’t recommend the secret nurses’ website? Or, are you keeping it a secret? *wink wink*

      That’s a great recommendation, about calling the local birth centers and asking them. I was just in the process of putting up a follow up post to this one, and I will add this recommendation.

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  12. MomTFH

    Speaking of doctors with poor skills (and how hard it is to find that out), here is an interesting post by a maternal fetal medicine fellow.

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  15. MM

    http://healthwise-everythinghealth.blogspot.com/2010/01/do-doctor-and-hospital-ratings-matter.html

    Check this out. :)

    “Where can a patient go to find out the outcomes of a hip replacement? What if I want to know the infection rate and the number of hips that require “re-do”? How can I find out information about my surgeon? How many has he/she done? Do they track outcomes one year after surgery?

    Believe me, you cannot get this information. Period.

    Patients are becoming more savey about health care choices but research suggests that rankings have little influence over those choices. “The primary care physician is still the leading source for patients seeing specialist physicians and the opinions of referring physicians remain the leading factor for an individual patient choosing a hospital”, according to a JAMA perspective article.

    For that reason it is important that patients have a choice and have transparent information on their primary care physician. Selecting a physician is done mainly by “word of mouth” and availability. The consumer websites where patients can rate doctors are imperfect, but without better ways to get information, more patients are looking there as they select a doctor.

    We still don’t know if the 5 star doctors are just nicer or if they are clinically better.”

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