Reply turned post, do I have a Kick me! sign style?

So, considering the last few days and weeks I have had, I shouldn’t be surprised that I was the recipient of a flurry of referrals from Dr.Amy’s blog to mine. She apparently didn’t have enough sarcastic and dismissive things to say about this post I wrote giving what I thought was non controversial, balanced advice to my cousin Susan, who is pregnant for the first time, about things to ask a potential obstetric provider. So, she wrote a whole post about it, how I am “obsessed” with birth, thinks everyone else should be, and how wrongity wrong I was to supposedly ignore “skill level” of the provider in my list of interview questions.

I am sure I am not doing much for my image posting my reply on here, but I am really starting to wonder what is going on. I do honestly try to avoid conflict in most areas, and usually only object to what I think is truly objectionable. I seem to be very unpopular this week with the online medical establishment. I hope this doesn’t seal my reputation as a trouble maker. I am really making an effort to walk the high road when I reply, but I do refuse to stand by silently when I am linked to or talked about. I don’t have higher standards for myself than I do the other people who are engaged in these discussions. I sometimes feel like they do for me, but, oh well.

Here is my reply on her site:

Dr. Amy, you don’t say how to measure this skill level. I asked you several times. How about avoiding complications of a vaginal delivery, since you mention avoiding complications? OK, what would those be? Well, a common one would be a third or fourth degree tear. What is the greatest risk factor for that? Well, an episiotomy.

I am glad more people are going to my blog and reading the whole post than are commenting on here, based on my referral numbers. I don’t see a lot of consent here, either. Even in the cherry picked statements, I think I don’t look all that bad. But hey, Dr. Amy readers, I link to an entire task force position statement on labor and delivery interventions(pdf), among other things, in the original post.

I also must object, again, to your sarcastic and dismissive tone. I am not “obsessed” with the birth process – I am researching obstetrics at medical school, and plan to be an obstetrician. Is Dr. Fogelson “obsessed” with the birth process when he leads off an article about evidence based delivery interventions with a paragraph on episiotomy, and how it should be unthinkable to recently trained physicians?

Evidence based care is the only way I can think of to judge practitioners, and I gave many specific examples of how to ask your practitioner about evidence based practices. Evidence based care comes from researchers like me being interested, not “obsessed”, with birth. Using evidence based standards would be the best way to prevent complications, don’t you think?

Also, I very clearly mention several times that each woman should determine her own priorities when interviewing a practitioner. I, in no way, suggest they need to share my “obsession” priorities. I have been to many vaginal deliveries (probably more than you have in the past decade, anyway) and currently research birth full time. I can tell you what the worst sequalae of these deliveries are – complications due to iatrogenic unnecessary interventions. As for skill, I have seen a recently graduated midwife handle shoulder dystocias with calm skill, and have seen a seasoned ob/gyn handle it like a first year medical student.

Here are your questions:

HOW should a newly pregnant mother rate a physician based on his or her skill? HOW does she find this information? What SPECIFIC parameters should she use?

Mortality rates are obviously not good, even if they are available, for reasons your commenters have already pointed out. Patient characteristics, along with physicians characteristics, can contribute to mortality rates. Also, in our developed country, mortality rates are not good indicators, since maternal and infant mortality is very rare, and is usually indicative of an underlying pathology or birth defect, not poor skill of the practitioner.

I gave many examples of specific evidence based standards as examples, and some practical and yes, atmospheric issues (like, can my partner spend the night in the post partum room. May be atmospheric, but a first time mom might not even know to ask and probably cares a lot), and made it clear the priorities of the person interviewing were obviously personalized and flexible.

Also, one more question, which I have asked before. What is SPECIFICALLY wrong with using the interventions I suggest as a guide to the practitioner’s adherence to evidence based care? Is that really such a horrid way to judge a practitioner that you need to scold me on my blog and on yours? Just scoffing and calling me naive is not answering this question.

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36 Comments

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36 responses to “Reply turned post, do I have a Kick me! sign style?

  1. infamousqbert

    NO QUESTIONS! KNEEL AND OBEY BEFORE THE MIGHTY DOCTOR!!!

  2. Awww, don’t feel so bad! Being lucky enough to be featured on The Good Doctor’s blog is a blessing in disguise, trust me. Not only does your traffic triple in volume, but you get lots of new friends. As much as Amy claims to detest “birth advocates”, she sure has a knack for bringing us together. :)

    Your post here is great, but I’m afraid it’s going to fall on deaf ears over there. None of your well-thought-out questions, research, and experience will matter, because you don’t agree with her. You could tell her that the sky is blue and she won’t believe you because you’re one of those “birth-obsessed” nutjobs.

    Frankly, I’m glad to see an OB who is “obsessed” with birth joining the field. Much nicer than some OBs that seem more obsessed with their pocketbooks….or demeaning and subjugating women, for that matter.

  3. Skill seems to be such a strange thing to measure or even require of an obstetrical care provider. For your average pregnancy and delivery, in a mother that isn’t coming into the pregnancy with an underlying condition, and in a pregnancy that is proceeding normally, why NOT ask about things that are more comfort based? Why on earth would you want to know about their skill at providing interventions when chances are good, in a normal pregnancy, they won’t be required anyway. Seems to me that asking this information is rather like hiring a plumber based on his ability to remodel your bathroom, when all you need is a leaky tap fixed.

    Sure it’s great if your OB has the suture skills of a plastic surgeon, but you are less likely to need or appreciate those skills than the skill of an approachable demeanor. It seems to me, if you are a “garden variety” pregnant woman, you would get more mileage in looking for a provider who has delivered more than X number of babies, and delivers babies on a fairly regular basis.

    If you are high risk than yes, I would be looking very closely at skill, at outcomes, at training.

    As someone who comes from a high risk background as a patient, I think that mortality and morbidity rates are perhaps not the greatest questions, but I certainly would encourage anyone to ask an obstetrical care provider about high risk situations and how they are handled – I’ve seen both OB’s and Midwives spectacularly drop the ball on high risk pregnancy situations, with disastrous and tragic outcomes for mother and baby.

    • Great plumber analogy. Of course, it’s actually good to know your plumber’s skill at remodeling a bathroom if in the course of fixing the leaky tap, he typically causes various problems that culminate in a remodel…..

  4. emjaybee

    In Texas, we call this sort of thing “pissing into the wind”. Excuse my crudity. But there are people who confuse “trying to shout the other person down” with actual debate. I believe your referrer is in this camp.

    You are not required to engage with someone who refuses to argue in good faith, or accept actual facts. Her strategy is the classic high-school debate strategem of ignoring inconvenient facts and attacking on insignificant points by pretending they are weaknesses. And then repeating things that have already been disproven earlier, in hopes the audience will not notice.

    Since there are no debate judges to penalize ad hominem attacks, contradictory remarks, and so forth on the internet, the only way to win is not to play along.

    Unless you just enjoy stirring her up for fun!

    • MomTFH

      I think it is so funny (well, not funny ha ha, but anyway) that you mention high school debate. I was a competitive debater in high school and college. While people love to make fun of that, and pretend that makes me more combative (no, I have had enough arguing in my life, thanks!), it actually makes me more frustrated when someone gets angry during an argument, uses logical fallacies or just turns it into a war rather than a constructive discussion.

      Dr. Amy tried to challenge me to a debate on this blog, and I repeatedly said I would agree to debate her, if we agreed to some competitive debate style ground rules (including general civility! no one wins a debate round by being a big jerk) with a position statement to debate, and using a moderator / judge to decide if the rules were followed, if the evidence supplied was applied fairly and in context, and who presented the most effective arguments and who answered her opponents arguments the most effectively.

      I am sure you can guess she didn’t want to agree to that.

      • mommymichael

        Which is HYSTERICAL! She’s constantly putting out there “some body debate me!!” “Ricki lake debate me!!” “I said I would go to such and such convention if they would have someone debate me and noooooo one would debate me! so I’m not going!”

        Now here we have someone (you) willing and she doesn’t want to play along because there’s rules to follow??? Talk about high and mighty.

  5. Paige

    What I can’t help but wonder is why a person who is a self-described OB is NOT interested in birth. I have to say that far above and beyond all other criteria, I would not choose a provider who is not interested in the birth process. Seems sort of important in the delivery room, no?

    And don’t you know tin foil doesn’t exist anymore? ;)

    • Maureen

      So true! Would someone want a dentist who wasn’t interested in oral health? Or a cardiothoracic surgeon who was really more interested in his Harley than their heart?

  6. K

    There is pretty much no way I am ever going to find an OB with the skill level required to handle me if I get pregnant & the time comes to give birth. I don’t even know how I would measure that… I mean really now, how many nulliparous women do you know with a surgically altered perineum?

    But it’s probably gona happen sooner or later anyway – me getting pregnant I mean – hopefully – never tried it before… so I probably wouldn’t pick a newbie OB – no I definitely wouldn’t pick a newbie. But on the other hand isn’t medical school training set up so that even if you are a newbie when you’re out on your own, you’ve already had hands-on experience anyway?

    So yeah I’m sure that whichever doc I pick, will be skilled and experienced and all, but isn’t it better to be skilled, experienced AND receptive to the kind of birth experience the client wants? That way you’re ready for anything!

    Is this like that whole medicalization of pregnancy thing I keep reading about?
    And having read that Salon.com article about moms developing PTSD after giving birth due to traumatic birth experiences – ones in which medical interventions were explicitly mentioned – I don’t know man, seems like having someone is inclined to avoid interventions you don’t want where possible seems pretty important long term.

  7. Maureen

    Frankly, Dr. Amy is a crackpot, and I don’t think that it is a good use of your time and energy to worry about what she says about you.

  8. Maureen

    And another thing, I think that it is a weird thing to say that women should choose a provider based on skill. If all women knew how to accurately judge the skills of providers, we wouldn’t need providers because we’d all be extremely highly skilled MDs or midwives. Also, what is a provider going to say when a woman says, “how skilled are you at …”? They are of course going to say that they have the skills! So how are we to judge as clients? We obviously can’t watch them, and would we know what to look for if we did? We simply cannot have enough information to judge medical professionals on skill in any objective way. That’s why licensing boards and accredited education exist – to take a bit of the guess work out. That’s why it is important to be educated about evidence-based practices, and make sure you have a provider who adheres to them.

  9. Ashley

    Dr. Amy is so far off the deep end in every place I’ve ever seen her comments that I’ve started to suspect that she’s actually poe–of obstetrics, instead of Fundamentalism. (http://www.urbandictionary.com/define.php?term=poe) Once you start drawing the parallels between her rambling arguments and your typical logic-is-no-good-in-these-parts Fundamentalist argument, well…you just can’t take the lady seriously at all. If anyone ever did in the first place.

  10. mommymichael

    One extra thought that just occurred to me.. from this last birth of mine, a foley catheter was placed to dilate my cervix. In talking with the doctor on call (who i loved!), he said he was going to have his best resident come in to do it. I asked “why can’t you do it?” not wanting tons of rotating residents coming in and out and touching me. He replied “do you know the last time I’ve done one of those??? you don’t want me doing that.”

    so there you have it.. a conversation about skill level. but I doubt that I could just go in to my appointments each time asking about skill level, know what I’m talking about and what a “good” skill level should be.. AND as someone mentioned about – Get a honest answer. Or rather I suppose I should say, if you’re interviewing someone based on skill level.. they’re going to say they’re the best.

    btw he chose a foley cath queen for the insertion!

    • MomTFH

      Great story. Yes, I can see an appropriate conversation like that happening in regards to a particular procedure. And, what a great doctor to admit that someone with more recent practice in a possibly tricky procedure would be preferable.

      On a separate note, people keep on bringing up foley catheters for cervical ripening / induction to me recently. It’s an interesting technique.

      • mommymichael

        for me, i felt it was the better choice compared to cytotec use, and AROM.

        I ended up having a BM that I pushed with – which then made the foley cath fall out. I dilated only 1cm. I suppose i could have had them replace it, as it wasn’t uncomfortable (for me at least) to have it done. But hindsight is 20/20 right?

        • MomTFH

          Yes, I am intrigued by it as an induction method. It is less systemic than pit, less permanent than AROM (and doesn’t start a clock ticking), less risky than cytotec and prostaglandins. I was wondering about how difficult and / or uncomfortable it would be to place, compared to cervidil. I have seen cervidil placed in an unfavorable (closed, hard and posterior) cervix before, and it seemed to be incredibly uncomfortable. I would think that both a foley and the cervidil would be more comfortable in a more favorable cervix. Not sure how to compare them head to head, since pain is relative and cervices vary.

          • doctorjen

            Cervidil isn’t placed in the cervix, it’s placed in the posterior fornix. If placement is uncomfortable, it’s usually because the cervix is posterior (a fairly normal thing at the end of pregnancy before significant dilation/effacement) and the provider is trying to stuff it way back behind the cervix. Generally, placing a cervidil should be no more uncomfortable than a cervical exam, or maybe even less since you don’t have to actually get through the cervix. Technically, since it releases prostaglandin through the mucus membrane of the vagina, it can probably go anywhere in there – we know misoprostil (another prostaglandin) works wherever it is, including rectally.

            The foley catheter is placed through the cervix, usually by speculum exam. (I have seen one provider who claimed to be able to guide it through the cervix with his fingers – but a foley catheter is pretty floppy and that seems unnecessarily difficult.) The catheter is placed all the way through the cervix, and then the balloon is inflated. It varies in comfort, but most folks feel cramping and pressure as you go through the cervix, and the same once it is in place. I’ve found it to be somewhat more uncomfortable for clients than placing a cervidil, but I’ve also found it to work better, so it’s usually a fair trade off. I can usually get it in even a closed cervix, because generally at term, the cervix is easier to dilate than it is when non-pregnant, so even the relatively soft catheter can usually be pushed through.

            Neither are techniques that are particularly appropriate for favorable for induction cervices – they are cervical ripening techniques. Yes, it’s probably easier to get a foley through a 3 cm cervix than a close one, but there isn’t as much of a point. Cervidil shouldn’t really be any more uncomfortable regardless of favorability, but again, it’s a ripening agent so it isn’t needed if the cervix is favorable.

          • MomTFH

            Thanks for the explanation and clarifications.

  11. Pingback: Desperately needed comic relief « Mom’s Tinfoil Hat

  12. MomTFH

    I found out about the National Practitioner Data Bank today, but the general public does not have access to the information it holds. It lists malpractice reports, licensure, clinical privileges and society membership reports, and Medicare and Medicaid exclusion reports, which would be more informative, IMO, than simple mortality numbers. But, you can only do queries that don’t tell you about individual practitioners.

    In fact, even if you were a pregnant practitioner, you only have access for “self-query”. So, for example, if Dr. Amy was pregnant and wanted to look up a practitioner, she would only be able to look up herself, if she was still practicing. Which she supposedly hasn’t done for a while.

    It is established for medical boards and the like to keep tabs on practitioners who have been censured.

  13. jen

    Don’t take it personally, she’s just upset about her departure from science based medicine:

    http://www.sciencebasedmedicine.org/?p=3969

  14. How funny that while trying to “teach” us *birth obsessed* crazies about “the way”, Dr. Amy has brought me to your wonderful blog :) I actually posted a reply on her post to one of her comments…

    “Those hospitals with the lowest c-section rates probably do have the lowest mortality rates”

    Just like the countries with the lowest c-section rates have the lowest mortality rates? Oh, wait, they have the HIGHEST mortality rates. So much for that kind of reasoning.

    My reply

    First of all, I HAVE to say that I am SOOOOO glad that you do NOT practice obstetrics in my area. I will also say that I am SURE (not sarcastic either) that you are a wonderful doctor, and have a low mortality rate, but what about your morbidity rate???

    I would love to see where you got your info on countries with the lowest c section rates having the highest mortality rates… are you talking about industrialized countries or countries where emergency care, and skilled obstetricians are not available…?

    Did you know that the US has the HIGHEST infant and maternal mortality and morbidity rates of industrialized countries? AND, to go along with it, the highest C-section rates aswell….? My hospital has a level 1 NICU, and has a 40% c-section rate!!! AND the OB practice I used with both of my pregnancies, has a CNM on staff, and when she fought with and got the hospital to approve my use of a homebirth birthing tub AT the hospital, the Dr’s in the practice actually told me that babies born underwater DIE! Which is COMPLETELY untrue.

    When I went into labor right after Thanksgiving, my midwife was still out of town, and I was delivered by a Dr, who ignored almost all of my requests, and NOT for medical reasons. For example… I asked that she wait 45 minutes- 1 hour before clamping the umbilical cord, because the cord blood is still pulsating to the baby, and it is healthy. AND there is NO medical reason to do anything before then anyways… she clamped it right away.

    I also asked that I be able to walk around, she said that since my water had already broken I was to be confined to bed… even though this had already been discussed with my CNM and my regular Dr.

    The only thing that was respected was that I not receive IV fluids unless medically necessary, and thats only because my regular OB had written it on a prescription pad for me! I actually had to explain my reason to the nurse and Dr, who apparantly didn’t even KNOW that IV fluids given during labor disrupts your bodies natural ability to produce Oxytocin, which puts a woman at risk of needing pitocin, which lowers the babies oxygen levels by causing unnaturally harsh contractions and in turn increases the risk of a c-section.

    I refuse to give birth again at a hospital unless I see some SERIOUS changes at one of the 3 major hospitals in my area because there is absolutely NO support for a woman like me who wants a natural, intervention free birth WITH the safety net of a hospital and skilled obstetrician near by in case of an emergency or serious complication. I am SOOOO happy that there are OB’s for MANY MANY reasons, and I understand why so many women choose to just sit back and let the Dr tell them what to do, when to do it and how.

    But for me, at this point, I am willing to drive the 2 hours to the closest birth center when I become pregnant with my 3rd child, although I plan on waiting a few years to have another baby in hopes that there will soon be a birth center in my town.

    I am also shocked that you would refer to pregnancy and childbirth as “Inherently Dangerous” I FULLY believe that IF and WHEN, OB’s start treating childbirth as exactly what it is, a natural process that sometimes requires the additional help of an OB, and not a medical condition that must be managed, FAR fewer women will even choose the homebirth route, because the reason we are choosing either homebirth (would be my choice if the hospital 2 minutes away had an OB department) or driving 2-5 hours to a birth center (what I will have to do because I do not live next to a hospital with an OB department, and I am not naive enough to believe that emergencies do not happen, so being right next door to a hospital if not at a hospital supportive of natural birth is the only option) is because we want you there, we desperatly feel that you NEED to be there, but turning something into an emergency that is not (for example, breach babies and twins can be successfully delivered vaginally. And if you want, I can get TONS of research for you that backs that up. ALSO, the use of continuous fetal monitoring increasing the need for a c section, when RESEARCH PROVES that the infant and maternal mortality and morbidity rate is not higher it is LOWER when intermitent fetal monitoring is used instead), or causing something to become an emergency when if left alone it wouldn’t have been one (for example, the use of pitocin GREATLY increases the risk of an emergency c section because it causes stronger than normal contractions that cause the babies heart rate to drop and often stay down longer than normal, and causes the babies oxygen level to drop. It also increases the need for an epidural which often causes a womans blood pressure to drop), scares us a whole lot more than giving birth in our bath tubs.

    AND, after choosing to drive 30 minutes away from my home with my first pregnancy and 20 minutes (we moved, I didn’t change practices) with my second, because I chose the BEST hospital and the BEST OB practice and the BEST pediatrician (based on my research, and not my natural childbirth desires), I then chose which practicioner I wanted from their 5 OB’s and 1 CNM (which turned out to be the CNM) based on who was more ready and willing to work with me (baring any medical complications) and who I was most comfortable with.

    One of my concerns was the episiotomy because I KNOW that MEDICAL RESEARCH PROVES that a perenial tear is WAYYYYY safer than an episiotomy, AND in my personal opinion, a practioner who routinely perfoms episiotmies is more likely to routinely perfom other unnecessary interventions, and less likely to have read or to believe medical research PROVING that those unnecessary routine procedures are unnecessary, and often potentially harmful.

  15. IndianaFran

    you have probably already heard this?

    http://www.sciencebasedmedicine.org/?p=3969

  16. Brittney

    I can’t wait to see her reply post about how I am not a medical professional, and just a *birth obsessed* crazy, lol. I will say that I probably am, lol, but only because I have had 2 births that I feel had FAR too many unnecessary inerventions, leading to pitocin, and epidurals, which is not what I wanted.

    If those interventions had been necessary, I would not be upset, but because they weren’t, I have actually changed OB’s (for my yearly’s and possibly future pregnancies, I see him thurs/today) to one my now long gone CNM refered me to. She got fed up with the Dr’s at the practice (I talked to her on FB, lol) and moved to WV to TEACH MED STUDENTS ABOUT NATURAL CHILDBIRTH!!! Sucks for moms here in SC, great for moms in WV and wherever those docs go to practice :)

    Anyways, sorry for highjacking your post, lol, I just sooooo shocked at Dr Amy’s blog/posts/comments/point of view/her as a person, I had to comment on her post, and while reading your blog, had to show you some love :)

  17. jen

    I think I posted yesterday, but maybe it wasn’t approved or my connection screwed up? Anyway, I wouldn’t take it personally, she’s upset because she just got her ass handed to her on science based medicine.

  18. MomTFH

    Hey everyone. I was at the most wonderful labor and delivery (and then was sleeping it off) the last two days. I was trying to approve all these great comments over my iPhone as fast as I could. (I only have to approve a comment if it’s the first time for that email address.)

    I wish I had time to reply to everybody directly. That last reply I made was supposed to be threaded behind doctorjen’s, but I think there is a limit to levels in threaded replies, and then they get bumped to the bottom of all of the comments.

    I did want to take a second and expand on that thank you. I am still learning about obstetrical interventions. There is some finesse on terminology and technique. Although I read and talk about practices, and observe them when they’re used at labors I attend, I have not gotten to do most of this stuff myself, and don’t know some of the finer points. I’m glad doctorjen wrote that comprehensive explanation, because I was being careless in my terminology and some of my descriptions of techniques.

    While foley catheters and cervadil are both commonly used during labor inductions, neither are technically induction techniques, right? They are considered preparation for the induction, for cervical ripening. When I have seen cervadil used on my cousin Susan, the nurse explained that it could be applied in different places. She said she preferred to try to apply it on the cervix, which was very posterior. It makes total sense that you would only be using these if the cervix was unfavorable, because otherwise, it wouldn’t need ripening.

  19. Eliora

    Mom TFH:
    I agree with the pp- Dr.Amy had her ass for a hat handed to her by SBM- I personally think she is crashing and burning and I am so pleased. I think at some point you cannot separate the principles from the personality. It is hard for me to read her running river of vitriolic crap and say well- this provides for a good debate, or in here she has a point, we can overlook this other glaring defect as many do- to appear respectful of her “validity”. I don’t see the point- I think she is a sick sick lady.

    She never argued with you in good faith on the Unnecesarean despite your attempts to get her to clarify positions with actual data and research and to stop talking out of her ass these simple requests were rebuffed in favor of her own style of debating/brow beating instead of stepping up- plain and simple.

    Her ad hominem style and red herring/straw man got so tired and in her own evolution- she always found women whom she considered unworthy opponents and berated them and wore them down- she met a formidable opponent in you so she wants to TRY to exorcise you from the vortex of internet hamlets she has tried to rule. It is projection pure and simple. You bested her (again, and again and again), she can’t accept it.

    Personally, I think she has sunk really really low and continues to sliiiiiiiiiidddddde- with the lifting of stillbirth and home birth disaster stories from MDC.It is really really a good thing that she no longer practices medicine- she would probably just be the worst to patients. It just shows what kinds of principles she guides herself by. The principles can no longer be separated from the personality. I hope she stays in SOB land.

  20. Eliora

    doctorjen:

    I am hoping that obs are rethinking misoprostil.

    http://www.valuepharmaceuticals.com/public/med_info/cytotec.php

    I am actually hoping that the grass roots movement that is starting to try to get obs to comply with this product’s warning label will filter to the OB community sooner than later. Mothers and babies are dying- we don’t need new, interventions introduced at this time that will hurt laboring mothers.

    • Eliora – your site is quoting the FDA label for miso. Miso has never been FDA approved for the use in pregnancy. FDA labels are about protecting the company from liability then they are about evidence based practice.

      Miso has been extensively studied in pregnancy, and its off-label use is supported by every major governing body in obstetrics. It has never been shown to be associated with adverse outcomes, other than in VBAC. There are some situations where other agents are preferable, but in many situations miso is a very effective and safe induction agent.

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