Monthly Archives: March 2010

Reply turned post, health care reform style

A Facebook friend posted a link to a news story about how insurance companies still say they will fight to deny coverage of preexisting conditions. I replied that I am sickened (no pun intended) by the people throwing bricks through congressional office windows, spitting on politicians, firing bullets into a congressional office, cutting a gas line at a politician’s family member’s house and calling in death threats, all in the name of defending this horrid status quo.

She asked me in reply “What do you think of all this health care stuff?”

I don’t know how much I have written about it recently, even though I have been following the debate avidly. I got turned off one step at a time with each compromise that was made, when each compromise didn’t earn one single Republican vote. What could have been a progressive reform pretty much got turned into a pretty close copy of the Republican’s answer to the Clinton era Democratic reform proposal. In fact, it uses a lot of ideas from the Republican platform in the 2008 election. We scuttled the public option, contraception coverage, put in extra barriers to abortion, cut the minimum of premiums taken in that had to go to actual medical care, removed end of life counseling, put in mandates, etc. etc. Although I think we have a gutted shell of a reform plan, it is still better than the status quo.

Here is my reply:

I am a big fan of the book “The Healing of America” by T.R. Reid. He looks at health care delivery and payment in several “civilized” countries, including countries like Switzerland that made their transition when we failed during the Clinton era.

It is grossly apparent to anyone who looks, apolitically, at health outcomes, disparities and access that the United States has one of if not the worst health care systems in the industrialized world.

I think we could easily switch over to a single payment system by simply expanding Medicare to pay for all, and then use the best elements from all of the health care systems that already work much better than ours. It’s not like there isn’t ample good examples around. Japan’s cost control and ample access to excellent practitioners and treatments (more visits to physicians per year than the US and best in all outcomes, with a fraction of our cost, and universal coverage), Canada’s self referral system, France’s electronic records card and billing (which would save billions in overhead in offices and hospitals) – for the doctors and business owners, not just the government and patients!), England’s subsidized medical education (in fact, most countries have this), and even Germany’s use of existing private insurance companies to organize the care.

What I don’t like is the knee jerk, angry reaction we have to this kind of reform in our country. In Canada, in Japan, in the UK, this isn’t a left/ right issue. It’s a matter of human rights, and it’s hard to find a politician of any stripe who wants to switch to the US system. In fact, it’s a common insult in the UK in parliament to say that another politician would rather have the US health care chaos, and it’s used by both sides.

As a future practitioner, I would hate to have to turn down a pregnant patient like I was turned down as having a “pre-existing condition” when I was pregnant. Fundamentally, I can’t see why anyone in the health care industry would support the status quo.

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Post at Mothers in Medicine

Mothers in Medicine is having a Q & A topic week. The contributors are all answering questions submitted by readers. I answered a question about having kids before medical school. Check it out!

Also, if you can’t get enough of me bloviating here and at Mothers in Medicine, I have been involved in the continuing conversation about VBAC at KevinMD here and here.

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Reply turned post, Dr. Amy’s “egregious” post on KevinMD style

KevinMD invited Dr. Amy to write a post about offering VBAC, simply entitled “VBAC should not be a woman’s right”. Keep in mind on both my blog and on Academic Ob/Gyn, she has agreed the evidence supports offering VBAC. But, on this post, she mocks people who support offering VBAC, using no evidence or data, but links to blog posts and, of all things, an ad on the site of a medical malpractice firm.

The reply:

Why don’t you link to scientific evidence instead of blogs and websites of malpractice lawyers? Using inflammatory words like “bizarre” and pretending women don’t have the right to be active decision makers in their medical care is doing nothing to improve communication between physicians and their patients.

Here is the evidence report of the NIH conference on VBACs. VBAC activists are not a small group of blog writers. This is a mainstream medical cause.

Also, the pattern of obstetricians not offering VBAC has a lot more to do with the wording of a specific ACOG position statement and less to do with real medicolegal pressures. I am in Miami, which has one of if not the highest cesarean rates in the country, one of the lowest if not the lowest VBAC rates in the country, some of the worst malpractice rates and payouts in obstetrics, some of the highest malpractice insurance premiums, and really revolutionary tort reform, in that obstetricians can and mostly do “go bare”, which means that they don’t carry malpractice insurance, and effectively limit awards $250,000.

So, the only thing these docs have in common with obs throughout the country is the rocketing trend to refuse VBAC since the ACOG position statement change in 1999. They have their tort reform. They have their low VBAC rates. Their malpractice premiums haven’t gone down. Their malpractice awards and frequency of being sued hasn’t gone down. Our maternal mortality is horrendous. I can provide citations for any of that, by the way. ACOG does a yearly survey on malpractice, and they print numbers for Florida every year.

Here are two scholarly articles one and two that indicate that refusing VBAC isn’t the key to malpractice. It’s proper documentation (including during VBAC, yes I have read the first article, so don’t try to misrepresent what it says about VBAC) and evidence based standards of care. And, the AHRQ statement out of the NIH conference is the most recent, comprehensive evidence review on VBAC.

There is already good literature on risk and decision making during pregnancy if you want to talk about the rights of the pregnant patient. It reads: “These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.” The section on VBAC is enlightening, and calls your type of scare tactics unethical. Do you have a similarly well documented discussion published in an equally reputable journal written by practicing obstetricians that takes your point of view, that women don’t have the right to refuse elective repeat cesarean, when the most recent evidence review calls it perfectly reasonable?

I think we all know you don’t, because I have been linking to the Lyerly et al article for about a year now, and you have yet to come up with anything other than your own writing to support your point of view. Why don’t you use well established bioethical principles, and quote ACOG committee opinions on balancing the rights of women to refuse surgeries? Because they support the fundamental bioethical principles of non-malfeasance, beneficence, and autonomy of the patient. I don’t remember seeing CYA listed as a bioethical principle on weighing the rights of patients.

Calling people who are consistent with ACOG bioethics teams and the NIH “irrelevant”, “bizarre”, “Inane”, “egregious” and and “committed to resentment” is, well, bizarre, egregious, inane and committed to resentment. And, it completely ignores the basic fact that a repeat cesarean IS a procedure, and a trial of labor is the REFUSAL of a procedure. That basic inarguable “semantic” fact is the center of why women DO have the right to refuse an elective repeat cesarean. Using inflammatory insulting words doesn’t make your reasoning right NOR ethical, and when discussing rights, that is what is key.

The NIH report concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Why don’t you work with activists AND the medical establishment to get the ACOG position statement on this, and the presentation of risks, both TO obstetricians about malpractice and TO patients about all risks in pregnancy and delivery in line with evidence and bioethics?

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Commenting policy: I am committed to keeping my comment sections civil. If I criticize Dr. Amy for using verbally abusive, inflammatory tactics, I cannot ethically abide by people using the same in my comments. I am also not interested in people insulting people living with mental health diagnoses by using “crazy” or “forgot to take her meds” as insults for anyone, including me and Dr. Amy.

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The match is scary

This is going to be a becoming a physician, technicalities about training post. So, if you’re just here for the birthy stuff, it may be a bit wah wah wah to you.

I am freaked out about the match. In a nutshell, the match is when 30,000 applicants compete for 24,000 spot at residencies, all on the same day. There’s a lot of lead up with interviews, rank lists, and the like, and it’s pretty complicated, especially if you throw in the curve ball that I am an osteopathic medical student, so I can compete in either (but not both) match system.

I am sure there is hyperbole and drama every year, but this year, word on the street is that the MD match was very competitive (pdf of advanced data). Obstetrics and gynecology only had 5 open spots left over; out of 1,187 slots, 1,182 were filled by the match. That left 5 slots left over for every unmatched applicant to scramble to fill. There were 1,777 U.S. Seniors who were applicants for those slots. That doesn’t include foreign medical graduates or graduates from previous years. 77.1% of them matched. The other 22.9% had 5 slots to fight over.

I am trying not to look at this as some sort of estimate that if I am in the top 77% of applicants on paper, I will be getting a position. There is a lot more to it than that, including away rotations, interviews, number of places ranked, etc. But, those numbers, combined with people I know with similar experience and scores not matching in obstetrics this year (vomit!), is making me really nervous. I am starting to rethink my list. I am going to expand it and include a lot more community programs, and cities in which I don’t know anyone. And, ulp, I may reconsider the osteopathic match.

I wouldn’t mind living in the New York / New Jersey area. I do have family up there and friends up there. My phys ed coach husband really wants me to try to get a residency at a place with a moderate climate. But, I could live in Brooklyn. Easily. There are lots of MD and DO programs. Maybe I could even live in Ohio.

Sigh.

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Conversations after the survey

I have been doing a recruitment push for obstetricians to take my survey. I originally planned on doing qualitative interviews with some of the physicians, and using them in the discussion. Although I eventually decided to only do quantitative research, I still get to have some really thought provoking conversations with the physicians once they complete the survey.

I have gotten great responses from the obstetricians. Of course, I wait until they have completed it to discuss it, and let them lead the conversation. I don’t want them to think I have enormously strong opinions in any direction. I discuss methodology, survey validation, and sometimes share anecdotes, but don’t make any soap box speeches.

One physician took the survey today, and said he thought it showed a slant toward midwifery. I found this interesting, since there is no mention of midwifery in any of the questions. I asked him what he meant, and he said that the questions about upright positioning and doulas were the sorts of things that midwives would do.

Now don’t get me wrong, I loved talking to this physician. He showed a genuine concern for autonomy of the patient, was not at all interested in forcing procedures on anyone, and thought “we should be humans first and physicians second” when dealing with patients, especially during pregnancy. I told him “In the same vein, we should treat our pregnant patients like mothers first and patients second.” He said he thought the ideal model for maternity care was the cooperative midwifery based model of care in the United Kingdom.

He also said the most important thing to consider is: the mother is leaving and taking her baby home, regardless of the mode of delivery. She lives with the the birth the rest of her life, not the obstetrician. He said yes, you can get sued for 18 years, but he knows, as do most obstetricians, that most cases don’t end up winning if you didn’t screw up. He thinks the litigation issue is an exaggerated scare story, and he has been sued. He said it’s about doing a job well, not an investigation of the essence of your soul, which is how he sees many obstetricians react.

But, as I complained in this post, those exact practices, upright positioning and using a doula, are more evidence based, according to the non-midwifery based United States Preventative Services Task Force, than the other interventions I ask about (continuous external fetal monitoring, routine artificial rupture of membranes in active labor, episiotomy, etc). But, somehow, simply including them in this survey, with no mention of the word midwife once, makes my survey somehow biased toward midwifery.

He didn’t mention the word “bias”, but another physician did mention the word “bias” after taking the study. (The responses have been overwhelmingly positive. Neither of these two physicians found the amount of alleged bias very problematic). I just think it’s strange. The USPSTF, Cochrane reviews, etc. examined the body of literature and then concluded there are evidence based benefits of doulas and upright positioning, but even asking about that seems questionable to some practitioners.

Well, I was setting out to examine the disconnect between evidence and knowledge and attitudes of practitioners. I guess I have found it.

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Sorry about the silence

My kids are in baseball right now. It seems like every day involves a game or a practice. I have an awful raccoon sunburn. Coach Stu says it makes me look like a super hero. I think it makes me look like a dork. My older son S’s birthday is coming up, I am doing a recruiting push for my research project, and I am freaking out about preparing for rotations and residency.

We had our preclinical oreintation at school, and I received all the books for my school’s version of shelf exams. I found out you have to get a 95 or higher on the shelf exam to pass with honors on that rotation. Ulp. I started doing Rosetta Stone, Latin American Spanish to prepare for my rotations in lovely Hialeah, Florida. I have a weak lifelong exposure to Spanish.

As for residency thoughts, I have been adding to this post, and I started a spreadsheet with info on each site. I am really starting to worry about arranging away rotations and interviews. Considering there is only one ob/gyn residency within driving distance of my house, I am going to have to plan on traveling. I am interested in three sites in NC and one in SC. If I could do my away rotations in the summer or during spring break, I could be near my family for some of that time. But no, they are usually done in the winter. I am dreading the idea of spending months or more away from my family my fourth year. I suppose I can minimize that, and do a bunch of rotations around here, but that is really futzing around with valuable rotation time. I really want to consider two programs in the Pacific Northwest, also. Maybe I can just do long weekends in November or December, and make that my vacation month.

Ugh. Vomit. I wish I could just put my family (and pets) in a deep freezer to hibernate for a year, so I could fly around and get the dream residency, then move them to the beautiful new city, thaw them out, and continue life as a family.

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Amnesty International takes on maternal mortality in the U.S.

Amnesty International just released a report on maternal mortality (and near misses) in the United States, treating it like a human rights issue. It’s often asserted, including in this report, that infant and maternity mortality are key indicators in the health and social justice of a country.

I need to finish reading the 154 page report (ulp!) so I can get my thoughts together to be a coordinator for local lobbying. I like their proposal to ask Representatives and Senators to call on President Obama and Health and Human Services Secretary Kathleen Sebelius to create an Office of Maternal Health at DHHS, and to improve collection of data on perinatal mortality and morbidity on a state by state level.

Then, I’ll report back, and hopefully get to my cousin Susan’s birth story and the NIH VBAC conference.

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