Catching Babies Blog Series: Refusal, Rights and Balance

This is an entry in the Catching Babies Blog Series, a conversation with medical economist and author J.D. Kleinke about his new novel, which focuses on ob/gyn residents at the end of residency and the beginning of private practice.

Hilary: Hi J.D.,

I am a medical student who is currently on her obstetrics and gynecology (ob/gyn) rotation. I hope to be an ob/gyn resident in just over a year, and after that, a private practitioner, hopefully in an academic practice.

When I first heard about your book, I thought it would be more like Peggy Vincent’s Baby Catcher: Chronicles of a Modern Midwife than Grey’s Anatomy. But, as I read it, I was reminded of life in the call room, listening to the residents at my core rotation site talking about their engagements, their breakups, their exercise routines and their more difficult patients, in that order.

I was enthralled and moved by the dramatic medical and ethical issues in the beginning of the book: a resident so tired he is hallucinating, a vaginal birth after cesarean (VBAC ) patient with a ruptured uterus bleeding out in a snowstorm, and a twin to twin transfusion vaginal delivery with head entrapment. At first I thought, well, these are all extremes. But, the easy births don’t make good literature. And, the easy births don’t form residents’ practice patterns for years to come.

When I was doing my research on labor and delivery interventions, I asked an obstetrician in his late 60’s about VBAC. He said he saw a traumatic uterine rupture during his residency, and he would never let that happen to one of his patients. This same physician said he thought breech deliveries were fine, as long as they met certain conditions. He had never had a case of head entrapment, obviously, so his attitude and practice patterns reflected this.

How do you feel, as a medical economist and as a patient, about physicians practicing based on clinical experience and attitude as opposed to evidence? As much as I try to base my attitudes toward my future clinical decision making on evidence, I have a constant barrage from everyone around me, telling me I will only have one license and thousands of births, that obstetricians have to be “right” all of the time, that I need to protect my lifestyle as much as I need to advocate for my patients, and evidence is flawed, anyway.

This doesn’t even take into consideration the emotional and physical strain the particular practitioner is experiencing on that particular day. If a physician is practicing late on a Friday night, after not eating since breakfast, has already had two gynecological procedures go badly that day, hasn’t seen his family and has a chance to make it home just before bedtime, and will have to pay his weekend coverage physician for any births that he leaves behind, how does that factor into his decision making toward the women he has admitted in labor, if at all? We do hold physicians to much higher standards. We are not supposed to make any mistakes, ever, at all, and we are not supposed to let hunger, sadness, exhaustion, or pain affect our skills and our judgment. But they do. How can we balance this?

I am happy that there are new work hour rules in effect as of July of this year. (Link to new rules) Residents can still work 24 hours straight, and can still work up to 80 hours in one week. But, there are more limits on unsupervised practice and excessive work loads on first year residents. Catching Babies focused on graduating residents, who are presumably ready to practice on their own. Some people, mostly older physicians who walked uphill both ways during their residencies, criticize limits on resident work hours as limiting continuity of care and preventing residents from being trained adequately for private practice. As someone who once worked more than 100 hours in a so-called “Hell Week” at my midwifery training, I can tell you that you don’t learn very well once you are hallucinating, and your patients don’t have good continuity of care at that point, either.

I would also like to touch on the part of the book that dealt with anti-abortion protestors. I am glad you chose a religious resident who was struggling with his perspective on abortion as the victim of this violence. The real abortion debate is not black and white. It is very, very gray. As a co-president of our local Medical Students for Choice chapter, I found that most medical students who had qualms about performing abortions due to their religion were not in support of making all abortion illegal, and did not think all future practitioners should not be trained on how to do an abortion. I had many good discussions with them on what it means to be pro-choice, and how practitioners can separate their own values and choices from what they recommend or even force on their patients.

We had a Maternal Fetal Medicine specialist talk to our chapter of the obstetrics and gynecology interest group once. She was Catholic and self identified as “pro-life”. She said she was put in the position of having a mom almost die on her as an attending physician because she had refused to be trained on how to treat a ruptured ectopic pregnancy, which inevitably involves removing the embryo. She told us that she will never be in that position again, and neither should we.

It was very important in Catching Babies for Dan, despite his religious beliefs, to be well trained in second trimester abortion. He paid for it dearly. It’s easy for a fervent protestor to be behind a sign or a brick, and easy for me to walk past their bullhorns and pictures of gruesome products of conception blown up to billboard size with a glare when I attend the American College of Obstetrician and Gynecology Annual Clinical Meeting, but I am not sure how I will feel when I am on my Family Planning rotation when I, like Dan, have to face those very real, very tiny body parts in the stainless steel bowl. Or how I will feel if a brick comes through my window or my family is threatened when I am an abortion provider. I do know that I will never face a teenager who has been date raped, like I was in high school, and tell her that there is nothing I can do. And I will never let a woman die from an ectopic pregnancy because of a philosophical argument.

Anyway, I guess I am commenting on the amorphous line where the private life of the practitioner ends and the needs and rights of the patient begins. I think work hour rules, oversight, some sort of protection against frivolous lawsuits and consideration of the physician as a human being is important. But I also think the autonomy and informed consent of the patient, along with the practice of evidence based medicine, is just as important. I am wondering how you think this interplay can be balanced.

J.D. Kleinke: Thanks for your comments, Hilary.

These are great observations and important questions. If I am teasing out your questions properly, I’ll respond as follows.

The recent movement across all medical residency programs toward reduced work hours is decades overdue. There is no clinical rationale for the brutality, on providers or patients, of any OB/GYN shift lasting longer than 12, let alone 16, 18 or 20 hours. 24 hours is a reform? You want someone cutting past YOUR uterine artery in hour 23? Into a uterus holding your baby? Around your bladder or clitoris? I wouldn’t want them cutting my bagel at that point, for fear of what they could do to themselves with the knife, let alone me. The OB/GYN residency, like most residency programs, is hazing, plain and simple, more frat house than boot camp – because boot camp is actually a workplace-relevant culling – and it is incredibly dangerous. It is also an incomprehensibly stupid way to compensate for the dysfunctional economics of federal residency funding, academic medicine generally, and our operation of a major part of the safety net we have woven over the years to care for the poor and uninsured and lost. As a gruesome physical, psychological and emotional endurance race, OB/GYN residency selects for and rewards physicians based less on sheer clinical skill and commitment, but on irrelevant criteria like stamina and the ability to think without sleep. It probably weeds out, before match or during residency, God knows how many gifted physicians who do not have these characteristics, or do not want to endure their mobilization. Not only does this bizarre gauntlet-based acculturation process NOT yield for society the best of all possible OB/GYN workforce – it probably yields a subset of people with a special capacity for detachment, indifference, masochism, self-denial, and/or dissociation. Is this who we want to deliver our babies? Is this who we want making emotionally gut-wrenching decisions about medically indicated termination, oopherectomy, hysterectomy? People chronically overstimulated from adrenaline, exhaustion and stress? When they themselves are so compromised, they have lost all sense of wonder, joy, and pathos? Let’s speak plainly: sleep deprivation is a method of torture. And it’s a great one for a secretive regime, because it leaves no visible marks. But prolonged sleep deprivation is how you break people, get them to compromise their most deeply held beliefs, sell out their own friends and families. Is this really how we want to acculturate those attending our childbirths?

Medical evidence and clinical experience are equally valid and equally important. This is not an either/or question, though the loudest voices on both sides of this debate make it sound like it is. All medical fields need more and better data, data-driven protocols, richer informatics at the point of care, and real feedback loops. But we also need human beings at the helm. And we need human beings – both OBs and midwives – who are willing to answer AND follow through on the toughest, most frequent, most important question that patients ask: if this were you, or if this were your wife, what would YOU do? As with that VBAC-averse veteran OB, when one provider’s negative experience with a difficult case diverges with the best known evidence on that case, they have a profound ethical responsibility to turf the case to somebody, anybody. Because no human being can be expected to repress their own terror about a clinical pathway that, even though they know the numbers and the evidence in support of that pathway, they can no longer go down it for their patient. That’s their right as a provider, and as a patient, I’d much rather be warned about it and turfed. And if that weren’t possible, and the potential divergence in outcomes were not that great, I might also prefer the less evidence-backed approach, if my provider were completely comfortable with that pathway and terrified of the evidence-backed pathway. This is the damnable reality of evidence – it works for the study group, but study groups are made up of thousands of little clinical realities, each of which are multi-factorial and, at rock bottom, ultimately human, not machine. Medical evidence is like snow, and every patient is a snowflake.

Much of the clinical practice of abortion is indeed gray, despite deeply held beliefs in this country that abortion is a black-and-white issue. This is why the book takes the abortion problem head-on, as it rears it hydra-headed self in residency, no matter what the protesters out in front of the clinic want to believe. The clinical case I chose in Catching Babies runs right down the middle of the line, for both the devoutly Catholic OB and the desperately ill teenager he is trying to help. All OB/GYNs, no matter how deeply held their views against abortion, run up against these ugly, clinically ambiguous realities in their training, and they have to decide, often with heartbreaking angst, how they are going to navigate them. Ectopic pregnancies do rupture, women do miscarry and need D&Cs, fetuses do develop fatal in utero anomalies in the middle of the pregnancy that will erupt and kill the woman if they are not terminated. These are the gruesome facts of nature, no matter how many laws we pass, providers we harrass, or patients we terrorize outside clinics. All OB/GYNs need to be trained adequately to deal with these clinical situations. And with equal force, I’ll say that all OB/GYNs need to have complete freedom to decide for themselves what they are willing to do, and under what circumstances. Most importantly, they need to be honest with themselves and their patients. Finally, all women and their families need to understand that their OB/GYNs are also human beings, people with hopes, dreams, frustrations, beliefs, fears and political agendas, who are bringing their own souls into every exam room, labor deck, and OR. This is probably the key impulse for my writing the book. I wanted people to understand how the culture of the OB/GYN is formed, informed, mal-formed, and where it can and should be re-formed.

*******

Other posts in the Catching Babies Blog Series:

Consider the Source: A new voice for maternity care reform
Tolerating Risk in the U.S. Maternity Care System
Catching Babies Blog Series: Fear, Faith and Perverse Incentives

13 Comments

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13 responses to “Catching Babies Blog Series: Refusal, Rights and Balance

  1. I just got this for my kindle after following the whole series of blog posts here, at Unnecesarean, at BBI, at Birthsense, etc. I am really looking forward to reading it, though I am a little scared it will be emotionally wrenching for me!

  2. I just started the book myself, so I’m still forming thoughts, but had to remark on this: “Not only does this bizarre gauntlet-based acculturation process NOT yield for society the best of all possible OB/GYN workforce – it probably yields a subset of people with a special capacity for detachment, indifference, masochism, self-denial, and/or dissociation. Is this who we want to deliver our babies? Is this who we want making emotionally gut-wrenching decisions about medically indicated termination, oopherectomy, hysterectomy? People chronically overstimulated from adrenaline, exhaustion and stress? When they themselves are so compromised, they have lost all sense of wonder, joy, and pathos?”

    Powerfully put. I earnestly hope the structure of residency is changed as you and others in favor of reform hope.

  3. jacqueline

    beautiful, JD, thank you.

  4. Pingback: Birthing Beautiful Ideas | Catching Babies Blog Series: Tolerating Risk in the U.S. Maternity Care System

  5. Doesn’t all this simply beg the question “why should we as a society continue to utilize OBs for low-risk vaginal births?” The education of OB/GYN residents is appropriate for dealing with high-risk and accepting referrals, while the education and temperament of most midwives is appropriate for labor-sitting with low risk clients. What we need is fewer OB residents and way more midwives, to get to a 70/30 or 80/20 midwife-to-obstetric-consultant ratio. This is how maternal health education money should be apportioned.

  6. HelenS

    It occurs to me to wonder whether training programs for other jobs that require alertness in emergency situations where one might not have gotten enough sleep are anything like this. Do firefighters or soldiers have to be on such long hours of duty during training? (Non-rhetorical: I don’t actually know.)

    • MomTFH

      I know there is that type of training in the military.

      • Yes, soldiers absolutely do, but given the nature of the job expected (I served in the Canadian military in the 80s), that training is appropriate and expected. Soldiers will, in time of war, have limited sleep for long periods, and be expected to function at high efficiency levels anyway.

        The comment: It probably weeds out, before match or during residency, God knows how many gifted physicians who do not have these characteristics, or do not want to endure their mobilization.

        …this is me. I knew already as a teen that I was capable of being a doctor, or a lawyer, but found myself balking at the idea of being tortured in exactly that way, for the life of, say, a GP, or a dermatologist, or who knows what. I knew I wouldn’t be willing to keep at it, because it was obvious it was just for hazing, that it was done because “that’s how we’ve always done it!”, and that it would mean I’d spend my days among colleagues who were the sort to take such hazing in stride. I did make it through basic training, and the various other training regimes I went through in the military, because of the relevance of much of it to the life ahead. Irrelevant hazing? No way.

        Sorry for the paleocomment, here, just reveling in having my Toobz back, and wandering through my blog roll. :)

  7. emjaybee

    THANK you for being honest about sleep deprivation in health care practitioners.

    It can be crazy-making, as someone who advocates for reform in healthcare, to read about sleep deprivation used as torture, or stories about how driving while sleep deprived is worse than driving drunk, or stories about how sleep deprivation increases your risk of heart attack, etc. etc, and then…

    …to bring this up to a doctor and have them tell you , very seriously, that residents at hospitals, people with dangerous drugs and scalpels in their hands and innocent patients in their care, *don’t* suffer or lose performance ability when sleep deprived, and that I “just don’t understand” as a non-doctor, how *necessary* it is for residents to learn this way, the only way they’ll ever see enough patients/be able to see enough patients through a given situation.

    It’s as though this basic logic:

    1. Sleep deprivation in human beings leads to poor performance
    2. Doctors are human beings.
    3. Therefore, sleep deprivation in doctors leads to poor performance.

    …is magically transcended by…well no one can say why residents or doctors (or nurses doing double shifts) can magically transcend the limitations the rest of humanity is subject to. They just can, is why!

    We have strict rules on how much sleep truck drivers can get, and the worst they can do is a kill a few people in a wreck or lose a cargo. But doctors? Nah, we’re good.

    • MomTFH

      Thanks, emjaybee. I have found that most of the physicians who defend such sleep deprivation went through it themselves, and I think they think other new physicians should go through it because it was the way things have always been done. Most professional physician and medical education organizations are more supportive of restricting sleep deprivation.

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