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?

*********
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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23 Comments

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

  1. Oh, excellent, excellent! clapping hands! now going to share on fb!

  2. Rebecca S

    Confusing bioethics and women’s rights with medical malpractice is incomprehensible. Not that it surprises me, considering the source. The comments when this was posted on her blog a few weeks ago are priceless.

  3. Oh, this post definitely deserves a standing ovation. Bravo, Mom’s TFH! Bra-vo!

  4. Just Saying

    that rocks!!!!

    Can you explain something to me as I’m confused. I am trying to figure out the whole malpractice thing.
    You write: 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.

    How can Fl have the works payouts in ob and award limits of $250,000. I’m confused. thanks

    • MomTFH

      Not every obstetrician goes bare. The academic institutions, community based practices, and some other groups (like hospitalist groups) pay for malpractice coverage for their employees.

      Also, these physicians who “go bare” put a sign up in their office saying they are allowed to limit their vulnerable assets to a minimum of $250,000. That is not to say all physicians are savvy enough accountants to keep all of their vulnerable assets down to $250,000, or that all jury awards are limited to that amount.

  5. I have a question about all this. Let me lay out what I understand to be true and then others can tell me if I’m getting it wrong.

    1) Individuals have the right to refuse any medical procedure (yes, the NIH conference was a little wishy-washy on this but let’s go with it for now).

    2) Doctors have the right to refuse to provide medical care. I can ask a doctor to oversee my VBAC, do my elective c-section, get rid of this annoying hangnail, etc. and they can say “I’m sorry, I don’t do that. You’ll have to find another doctor.”

    This would seem to favor the doctor’s ability to refuse VACs EXCEPT for my understanding that EMTALA requires hospitals to provide medical care in labor. So someone can walk into L&D and refuse anything they want, but not be kicked out. I have read doctor blogs expressing frustration with this exact phenomenon. To me this would seem to set up the right to VBAC. Y/n?

    • MomTFH

      This is pretty complicated. In this case, as in other cases of bioethics, some rights seem to compete with others.

      First of all, I want to clarify that I don’t agree that obstetricians necessarily have a right to refuse to allow a VBAC. I am a strong believer in conscience clauses, and they don’t all have to be applied to performing abortions or prescribing / administering contraception. For example, I am hoping to refuse to ever perform any elective genital mutilation, such as male or female circumcision or rejuvenation procedures.

      But, this right of refusal has some caveats. Usually this involves the right to refuse to perform a procedure or an intervention. Allowing a trial of labor for a woman who you have already agreed to treat as an obstetrician is not performing an intervention. It’s the opposite. An elective repeat cesarean is an elective intervention, and the more the evidence piles up, the more it looks like it is not just reasonable but clearly in the best interest of the mother’s health to let her attempt a VBAC as long as she is a good candidate.

      So, it’s similar to looking at the difference between doing an elective induction early (intervention) and refusing to do one (allowing physiological pregnancy to continue).

      But, it’s not that simple. Let’s say, a woman goes into preterm labor early. Can a physician suddenly decide they don’t want to interfere with God’s plan, and refuse to administer tocolytics and steroids? Well, depends on how absolute one thinks the right of refusal goes. I think an obstetrician would have a seriously hard time defending that.

      There are situations every day in hospitals and private clinics in which nurses, physicians, and other medical personnel refuse to perform certain procedures. In some situations, it’s not a huge problem. In some, it can seriously affect the patient involved in a particular situation, and in some situations, it can change the way care is delivered in an entire hospital or geographic area.

      For example, in some hospitals, they easily shuffle around a few nurses and physicians who don’t want to perform elective abortions. There was a post about this on RH Reality Check by a doctor, but I can’t find it by a simple search right now.

      Also, in some L & D floors, certain nurses will volunteer to handle a fetal demise. (I think At Your Cervix just wrote about this) Someone who is pregnant, or has a history of a loss may not feel emotionally equipped to handle that sort of situation well. It is usually, as far as I have heard, not an issue. But, if there is no one who steps forward eagerly, the woman still goes through the physiological process, and the staff most likely will still treat her. The alternative is almost unthinkable.

      I wrote once about an attending physician at a large public hospital who told us she was so “pro-life” that she, at one, point, refused to learn how to handle an ectopic pregnancy. Well, when she was the only OB attending on with untrained residents, and a woman was hemorrhaging from her ruptured ectopic. When she had to call the backup on-call attending to drive in and save her life, she felt horrible. She felt bad enough about it to tell a group of medical students she would never, ever put herself in that situation again. I can only imagine if that woman died, which luckily, she didn’t, it would have been very difficult for her and the parent institution to defend. If she was in a private practice, it wouldn’t have been a problem.

      Just like there’s a problem when an entire institution decide they are no longer going to provide emergency contraception to rape victims. Or entire institutions decide they will not train their residents in any abortion procedures, or will not perform any tubal ligations. I had a cousin Susan who worked at a Catholic institution that TWICE refused to perform a procedure on her to remove a septic anencephalic fetus with no heartbeat. (Poor thing, it happened in two subsequent pregnancies). That’s not ethical medicine, and she could have died.

      So, I think there are cases when even refusing to perform a procedure are difficult to defend ethically. So, the VBAC situation? I think, if you are one doctor in a large group who would prefer not to do them, it may be arguably OK. But, when the VBAC rate plunges to 8%, entire hospitals and malpractice insurance companies are banning them, woman are being forced to drive hours away from their homes to deliver, etc etc, this is not a case of one individual doctor’s right to refuse to perform a procedure. This is a systemic problem in obstetrics that is seriously adversely affecting women’s access to evidence based care, and is ending in adverse outcomes.

      There is more to consider than whose right to refuse is more of a right. When those rights collide, they cannot both stand, and neither is absolute. There are other issues in bioethics (non malfeasance, beneficence, autonomy of the patient, non paternalism, etc) and scientific issues like the evidence supporting the decision that also come into play, and as the Lyerly et al article describes well.

      I think forcing women to go against medical advice an show up in labor is an undue burden. It is a last resort, sure, but an undue burden. And, my other cousin Susan requested a VBAC, her doctor refused, and she showed up in labor and got sectioned anyway!

      The majority of women with a prior cesarean should not have to fight for evidence based care. Once it gets to be a systemic problem, it gets taken out of the hands of the individual practitioners. It is time for ACOG, and the NIH to take action, or we need an Office of Maternal Health.

      • Folks want to act like the right to refuse repeat section and the right to refuse to attend a VBAC must be mutually exclusive. They are not. Patients and physicians are independent free beings. Outside of contractual obligation, physicians have no legal obligation to provide care to anyone.

        The problem is that both rights _do exist_, but they conflict with one another. This is hardly the first time this has been the case. The solution is not to deny either party their right. The solution is to find a solution that meets the needs of both parties.

        • MomTFH

          They aren’t mutually exclusive and they aren’t the only considerations in a complicated picture.

        • .

          “Outside of contractual obligation, physicians have no legal obligation to provide care to anyone.”

          And when they contract to be on call for the hospital they must follow its rules and state and federal law.

          Refusing VBAC may not be an option. If you want to take it off your list of capabilities, be my guest. But, then don’t whine if you loose call and hospital privileges.

        • doctorjen

          Speaking as another rural phsycian, I was surprised to read on the other comment thread that another rural hospital uses transfer as an option for a VBAC in labor. My referral tertiary care hospital in our perinatal network won’t generally accept transfers in active labor, even in clear cut cases where the baby would be better off born there because of the risk of delivery in route (we are a level 2 nursery – a 26 weeker for example, should really be born there with the neonatologist available if at all possible.) If the only consideration was appropriate care for the patient (and I acknowledge that with all the liability concerns, this is often not the only consideration) surely it’s better to labor in a hospital equipped to do a cesarean within a reasonable amount of time, than in an ambulance! (Our perinatal center is about 1 hour 15 minutes away by ambulance, about 20 min by helicopter, but with all the issues of weather, availability of helicopter, etc, it’s frequently not an option or is delayed much longer than the 20 min, especially because the helicopter usually has to travel to us first.)
          I remain unconvinced as Dr. Tuteur continues to state, that the proximate cause of restricted VBAC access is women consenting and then claiming they didn’t understand the risks. My malpractice carrier offers CME on risk management and includes a session on VBAC. The material includes a review of the litigation cases in our state, and the most common reason for suit was failure to perform a timely cesarean section (some of these cases are truly scary to read – physician notified of patient in labor with previous cesarean section and complaining of abdominal pain, and the physician orders pitocin! Emergency cesarean delayed 80 minutes. Patient’s mother informing staff of omninous changes in fetal heart rate tracing hours before it was acknowledged by hospital staff.) Not that ideal medical practice can ever completely eliminate litigation – but I don’t think the cause of decrease in VBAC access can be adequately attributed to patients who gave informed consent and then sued later. I would definitely like to see liabilty for lack of informed consent reduced if physicians utilize a VBAC specific consent form.
          We have just resumed offering VBAC after a couple years of an unofficial ban because we have a new anesthesia group who doesn’t mind sleeping in house if there is a VBAC in labor overnight, and they are in house in the day time anyway. Even when we had the ban in place, we had a few VBACs because patients refused repeat cesarean and our hospital culture is not comfortable with coercing/forcing someone to have a surgery they don’t want. We documented informed consent thoroughly in those cases (many were patients who had already had a successful VBAC,) and we tried to stay as ready as possible for an emergency, keeping anesthesia in house, etc.
          In a small hospital, especially a rural setting, getting another physician or another hospital is just not always an option, so having some sort of contingency/emergency plan is vital – just as it is to be ready to deal with other catastrophes such as severe peripartum hemorrhage, a sudden abruption, a cord prolapse – or non-obstetric catastrophes such as ruptured aortic aneurysm, severe traumas, acute MI with shock. Of course we don’t always see those things coming, while we do already know about the increased risk of VBAC, but it seems odd to me to have the whole plan depend on either being able to transfer or force someone to consent to unwanted surgery.

          • MomTFH

            Thanks for weighing in.

            I was surprised, also, by the comments on the other thread about transfer. I may not have a lot of obstetrics experience compared to someone who has completed an ob/gyn residency, but I have been to a bunch of labors, and at least a few dozen of them have been VBAC labors.

            I find it really hard to believe anyone thinks driving several hours, transferring hospitals without knowing who the practitioner is who is going to deliver your baby, or attempting an unassisted homebirth VBAC are reasonable options for most women or practitioners.

            We had a VBAC specific informed consent (and a physician consult) at the birth center where I trained, and as I said on the thread on KevinMD, they have only been sued for shoulder dystocias, and they did a lot of VBACs.

      • If I were a chairperson, I would immediately fire any faculty member who refused to operate on a bleeding ectopic pregnancy. It is impractical and unjustifiable to provide a coverage schedule for a physician who refuses to provide a core service of our field. The argument that treating an ectopic is an abortion is not adequate.

        • MomTFH

          I wholeheartedly agree. I was surprised she shared the story with us – she is an MFM attending at another academic institution who was visiting at our school. She shared the story as a “lesson learned” with the qualification that she thinks it was a horrible and she doesn’t want to be in that situation again. However, I am curious as to why it was allowed to happen in the first place.

          She can be an MFM with a consultant practice, and not be an attending with coverage in a large institution who would reasonably have to deal with emergent ectopic pregnancies on a fairly regular basis. I am also surprised she wasn’t trained on this as a resident.

          If she knew she had some what consider to be extremely limiting conscience issues, she should have made them known to her colleagues and chain of command before this came up.

          • MomTFH

            Oh, and it also illustrates how complicated these issues can be – it’s more than just informed choice vs. physician refusal.

        • doctorjen

          I practice in a Catholic hospital, and I was surprised to read this, too. Even here, ectopic pregnancy has never been an issue – it’s not like there is any viable option other than getting rid of the ectopic. I know that Catholic organizations do vary in their interpretation of the Catholic directives for care – my hospital wouldn’t have an issue with a physician completing an inevitable abortion for example, but I know some hospitals won’t allow any intervention unless there is no fetal heartbeat. I’ve never heard of any place refusing induction/d&E or whatever for a fetus that already has no heart beat – that must have been so traumatic and unnecessarily added stress for MTH’s “cousin Susan”.

    • .

      It does. A patient must be offered, but nevertheless can refuse transfer. The hospital must tell her the risk of refusing — aka we don’t know how to handle VBAC.

      This is, as of this writing, untested in HHS and the courts.

      I would caution any woman against using it. If you want to VBAC close to home with people who don’t know what they are doing, you could do a freebirth at home. Take the transfer.

      • MomTFH

        Speaking as someone who has participated in at least a dozen VBAC deliveries, they are managed like any other vaginal delivery. Emergent complications, such as cord prolapse, frank bleeding (signs of a possible abruption) or nonreassuring fetal heart tones (which would be the most likely sign of a symptomatic rupture, I think, or many other possible, more common complications, or even more likely, more warning than reality of a serious issue) are transferred to cesarean. The birth center where I trained was five minutes from a hospital and we had a back up physician, with a mandatory evaluation for VBAC candidates.

        That birth center had at least 100 VBACs that I know of. They have been sued twice – for shoulder dystocias. We need to keep the risk of adverse outcomes and litigation in perspective.

  6. Helen

    “two subsequent pregnancies”–I hope you mean two consecutive pregnancies. The thought of anyone having that happen *three* times in a row … once is bad enough, twice is horrific.

  7. “But, when the VBAC rate plunges to 8%, entire hospitals and malpractice insurance companies are banning them, woman are being forced to drive hours away from their homes to deliver, etc etc, this is not a case of one individual doctor’s right to refuse to perform a procedure. This is a systemic problem in obstetrics that is seriously adversely affecting women’s access to evidence based care, and is ending in adverse outcomes.”

    Let’s not forget women who feel driven to birth at home, sometimes with unskilled attendants or alone if they live in a state where midwifery is not legal and therefore not regulated, just to escape repeat surgery, even if it’s not a choice they would have made otherwise. While many unassisted birthers do so because of careful research and personal reasons, many more do it because they feel they have no other option. How many times have I heard women say they’ll just “labor in the parking lot till pushing” and then walk into the ER in order to have a VBAC in an otherwise prohibitive hospital? How is this better than labor with watchful attendants monitoring mom and baby? It’s not. If I hadn’t found my wonderful midwives, I would have been a parking lot laborer myself. This is not an acceptable alternative, but women are desperate to avoid surgery. Why is it better to eliminate the option of a safe VBAC, thinking it will force women to have a “safer” Cesarean, when in fact it pushes the pendulum the other way? A choice made in fear is not a choice at all, whether it’s the choice to have a RCS because it’s the only option, or the choice to give birth alone in your bathtub because you’re so afraid. And this applies to all other forms of birth trauma as well, not just Cesareans. A woman who has been traumatized will do whatever it takes to never suffer that way again.

  8. Pingback: Reply turned post, Cox really showed J.D. this time, zing! « Mom’s Tinfoil Hat

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