Tag Archives: Cesarean Section

Reply turned post, I reject your reality! style

OK for Mythbusters, not for health advocacy

I have been participating in the Facebook group VBAC Facts Community for a little while now, ever since meeting the wonderful community founder Jen Kamel at the VBAC Summit last year. It is a supportive group, and Jen runs the site well with the help of moderators and a good foundation of evidence.

This group, at times, can be a good example at how distorted internet microcosms can make uncommon opinions seem much more accepted. In this community, using midwives and having a home birth comes up in almost every thread, it seems. I have seen using a midwife treated like a hipster fashion choice recently on Jezebel and other sites. However, midwife attended births still make up less than 10% of births in the United States. Hardly a huge trend. Midwives are underutilized here compared to many other countries with better maternity and neonatal outcomes than we have. But, depending on your source, midwife attended and/or out of hospital births may seem to be common or even a glorified standard. However, in the circles I travel in my daily grind as a physician, choosing out of hospital birth is fringe, reckless behavior.

So, it’s like entering a portal in another world when I participate on a thread in the VBAC group, and the commenters have a heated argument about epidurals, and many participants did not get one. On our labor and delivery floor, it is a rare to never occurrence that someone wouldn’t get one. Because out of hospital birth, choosing not to have an epidural even if you deliver in a hospital, and VBAC are such rarely available, rarely supported choices, I am usually on the side of defending people who advocate for such choices as underdogs, not the holier than thou bullies that many paint them to be.

It’s also a really strange place for me to be in when I gently try to correct medical inaccuracies, and I sometimes get painted as a brainwashed surgico-technocrat physician. I correct fellow physicians when they say all VBAC is dangerous. For real, even my attending physicians. I also have corrected fellow physicians who state episiotomies are preferable to tearing. But, I also correct women in the VBAC group who state things that are medically inaccurate, like that worsening hypertension in pregnancy is not serious and does not warrant an induction or cesarean unless the fetus is in distress, or that leaving the hospital midlabor is a reasonable course of action if one is faced with unwanted interventions (in one particular thread in which I was painted as a typical brainwashed South Florida cesarean happy physician, the intervention that warranted attempting to leave midlabor was continuous external monitoring).

These are not the majority opinions even in this microcosm. But, they are often aggressively defended positions. One that has come up repeatedly, recently, is an insistence that tubal ligation is linked to “post tubal ligation syndrome”, which leads, according to some posters, to the majority of women needing hormonal interventions to control heavy menstrual bleeding, and / or hysterectomy to control intractable post procedure pain.

I think these communities are incredibly valuable, not just because of the sharing of strictly evidence based facts. I think a lot, even the majority of the benefit is the support and stories from other women who have experienced similar choices and situations, or share similar priorities and stories. I think in the VBAC community, and in pregnancy and mothering as a whole, there is so much value to support, empathy and stories. However, there is a big difference between asnwering an original poster who says “what was your experience with tubal ligation?” and someone answering “geez, I had pain and menstrual irregularity after” and an original poster saying “I am planning on a tubal ligation” and a slew of commenters saying “NO! This is PROVEN to cause a, b and c horrible side effects to the majority of women who get it!” and usually a touch of “Have you considered Natural Family Planning?”

Sigh.

I have reluctantly been the heavy in many of these conversations, but it is triggering a bunch of pet peeves of mine. 1. Medical inaccuracies masquerading as facts. 2. Ignoring the expressed informed choice and priorities of the woman posting and substituting the commenters’ own priorities and (often faulty or anecdotal at best) information

So, this coalesced into a recent thread, and here is the reply I posted:

“This is the best article I have found on post tubal ligation syndrome:

http://www.nejm.org/doi/full/10.1056/nejm200012073432303#t=articleResults

It is a good article because it compares women who have had tubals with women whose partners have had vasectomies. It is also a good study because it has an N number of over 9,000 subjects who had the tubal ligation. It is also authored by a group from the Centers of Disease Control (the CDC). There is no economic conflict, and the New England Journal of Medicine is about as high quality a publication as it gets. Here are the results:

“The original concern about sterilization involved the risk of heavy bleeding and intermenstrual bleeding, but we found no evidence of either problem. Furthermore, we found that women who underwent sterilization were likely to have decreases in the amount of bleeding, the number of days of bleeding, and the amount of menstrual pain and an increase in cycle irregularity. We know of no biologic explanation for these changes, most of which were beneficial, in women after tubal ligation.”

I don’t think there’s any evidence of widespread issues post tubal. In fact, this high quality study seems to indicate the opposite. I am not saying a tubal ligation is right for everybody, but I do think it is inappropriate for every thread on here in which tubal ligation is mentioned to devolve into a pronouncement that tubals are PROVEN to cause these problems, often with alarming figures like half of all women who get tubals end up with hysterectomies, etc.

As I have also said, it is inappropriate at best and borderline bullying at worst for women on here to disregard a woman’s stated informed choice and substitute their own priorities, especially if they are coming from a place of anecdote and questionable information. It is also inappropriate to ignore a woman’s expressed desire for a highly effective form of birth control (like a tubal or IUD) and to tell them to try NFP* instead, when it has a typical failure rate much higher. I hold a woman’s right to make informed decisions about her reproduction to include highly effective birth control if desired as well as safe options for trial of labor after cesarean.

I am not a surgery lovin’ medicoindustrial defending brainwashed doctor. I trained as a midwife, had both of my kids unmedicated** with midwives, and have never used hormonal birth control myself due to my own priorities and reasons. I support low intervention birth and VBAC for two main reasons which may seem contradictory, but are wonderfully not. 1. It’s a woman-centered approach and 2. It is an evidence based approach. Bullying women into avoiding their choice of safe contraception is neither.”

*I love this site for comparison of contraceptive methods: http://www.birth-control-comparison.info/
**The first labor was augmented with pitocin without my informed consent, but was otherwise unmedicated

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Breaking the silence

I am happily coming down off the high of presenting at the Medical Students for Choice annual conference – I was part of a fantastic panel on Protecting Choice in Birth. I felt honored to be sharing the table with some brilliant people – two wonderful ob/gyns, two reproductive justice lawyers, and little old me. We talked about the legal and ethical underpinnings of patients’ rights and choice in birth: site of birth (e.g. out of hospital birth), VBAC, even use of a doula or refusal of certain interventions.

It was a wonderful experience. The director of MS4C told us the response was so overwhelming that the conference was buzzing about our panel, and we are definitely invited to return. I learned a lot from my co-panelists, and loved the enthusiastic response from the audience. One sweet medical student literally had his jaw agape when Farah Diaz-Tello, from the National Association for Pregnant Women, described a woman who had her baby taken away and put in foster care for simply wanting to postpone signing a blanket consent for any intervention or procedure during her labor and delivery. She had a healthy, spontaneous vaginal delivery with no complications during her SECOND psych consult (after the first psychiatrist deemed she was clearly mentally competent and allowed to refuse consenting to an unnecessary hypothetical cesarean), and apparently her six year old is still not in her care due to the red tape surrounding her case. Jaw dropping, indeed.

I talked about my journey, including being a patient, mother, midwifery student, doula and research fellow before becoming a doctor. I discussed the hostile-to-patient-autonomy atmosphere in South Florida, my fellowship research on labor interventions, and how to present risk to patients.

I almost burst into tears when my co-panelist, the lovely and dynamic Dr. Hanson, showed pictures of twins and breech births she has delivered all over the world. I did end up tearing up during lunch, not just because birth is moving and emotional, but because I am slowly accepting that I will most likely never be doing these difficult deliveries, and my wonderful copanelists innocently asked me about my residency plans. I may not be doing deliveries at all.

I got a decent amount of invitations to obstetrics residency programs. I am slowly canceling them, one by one. I simply cannot justify moving my two boys to a city where I don’t know anybody, then disappearing to work my ass off 80 hours a week at all times of day or night. I also don’t want to put them in public schools in the Deep South. When I got divorced during my third year of medical school I knew that would mean facing residency as a single mom. The divorce was worth it, but now that I have experienced the reality of how hard internship is, even with significant family support in my home town, I had to reconsider my options.

I will most likely be pursuing a family practice residency at a local residency program, probably at the hospital where I am doing my internship. Yes, obstetrics can fall under the family practice umbrella, but I would be the first family practitioner to get hospital privileges in the greater Miami area in recent or remote history. In other words, the chances of that happening falls between not likely and impossible. Yes, not even if I do an obstetrics fellowship, which would involve leaving town for a year. It’s just not the standard of care here, even if it’s normal in other parts of the country. And my custody arrangement stipulates that I practice here after training. So, even if I move for residency, I would have to uproot again and come back.

I can still do women’s health. I can still do prenatals. I can do lactation medicine, including the pediatrics portion. I can even be the medical director of a local freestanding birth center, just not their backup surgeon. Which, honestly, was never a huge draw for me. I want to be at the normal pregnancies, not a back up for the ones that go wrong. I can do family planning. I can still do academics, including medical ethics, which is an interest of mine.

So, most of the time I am ok with this. Most of the time. I have a lot to be happy about. I have great kids, good family support, a supportive director of my residency program, relatively good health, friends, a cute little house, a fuzzy loyal dog, and a blossoming (very tentative!) new relationship with a nice guy. And I’m a doctor, for Chrissakes. With a job in a shitty economy.

So, anyway, another permutation on the journey. Let’s see how it plays out.

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Preventing primary cesarean

Hi! Internship has been keeping me busy. So has getting together my presentation for this year’s VBAC summit. I had an hour and fifteen minutes to talk. I went over, and I still didn’t cover half of what I wanted to say.

The First Cut is the Deepest. (I can’t figure out how to embed the viewer.)

You can find the mp3 to hear me speaking to go along with the presentation. I explain. A lot. I also tell funny stories, horrible jokes, and pass out chocolates. Sorry, the chocolates are not available through the internet.

MP3 of me: https://www.wepay.com/stores/vbac-summit/item/preventing-primary-c-sections-what-you-need-to-kno-717302
MP3s of all of the presentations: https://www.wepay.com/stores/vbac-summit

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Reply turned post, from abortion to homebirth style

Hello! Hey, I’m a doctor!

Please go read this excellent article at RH Reality Check: Why Birthing Rights Matter to the Pro-Choice Movement.

Here is a great quote from the author Laura Guy, who is a doula (yay!) and a certified lactation consultant (IBCLC) (double yay!):

But let’s be clear about something. Reproductive justice means that everyone has complete control over if, when, where, how, and with whom they bring a child into the world. It means that people have accurate, unbiased access to information regarding all facets of their reproductive lives, from contraception to pregnancy options, from practices surrounding birth to parental rights. It means that our choices are not constrained by politics, financial barriers, or social pressure. In other words, how can the right to give birth at home – safely and legally – not be on a reproductive justice advocate’s radar?

As I commented on the article, I was thrilled when, during the keynote address at my first Medical Students for Choice meeting, the speaker mentioned out of hospital birth. Reproductive rights are full spectrum. They start before sexual activity begins – bodily autonomy begins with birth, stretches through childhood with protection from oversexualization, extends through accurate sexual education, includes contraception and freedom to choose when and how to become sexually active, and definitely doesn’t end once one decides to carry a pregnancy to term. The ability (or lack thereof) of women to choose the site and mode of their delivery, among other important issues of autonomy during pregnancy, are key ways that women’s rights are challenged daily in this country. Pregnant women are not human incubators.

So, seems like a bunch of mutual appreciation society activity here. Where is the angst that usually prompts the reply-turned-post? Well, on the RH Reality Check link of Facebook, one commenter says: “This is great and it’s also important for women to have the right to medical interventions (like elective C-sections) they feel are right for them.”

Here is my reply:

‎@Kathleen – within reason. Feeling something is right is one thing, but unnecessary medical intervention is not a “right” per se.

It’s a very nuanced issue that may not fit well in the comments section on Facebook. For example, evidence and expert position statements warn against early induction. Feeling like an induction is right is not enough of a reason to get one. Take it from someone who has been in the paper gown, sick of being pregnant, and in the white coat – many women feel like an induction before the end of pregnancy.

Also, someone who is a really poor candidate for vaginal delivery (placenta previa, for example), may feel like they want a vaginal delivery, but it is not medically advisable. Same goes for women who are poor candidates for homebirth. I think homebirth is an excellent option for good candidates. Not all. There is a role for practitioners to play here, too.

As a physician and most likely a future ob/gyn, I will be one of many practitioners who need to constantly work that balance between respecting a patient’s autonomy, providing good informed consent, and practicing good medicine with a good conscience. Medicine is more than ordering off a menu.

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Reply turned post, midwives are hacks style

When I signed onto Facebook this morning, a link showed up on my feed from a page that I don’t remember “liking”, but, as it is called “Nurtured Moms”, I can see it being a possibility.

The link was to an article by OB Management examining collaboration between ob/gyns, nurse midwives, and CPMs / lay midwives. The original article is actually not that bad, and does encourage collaboration with midwives (mostly with CNMs) and higher standards and licensing for CPMs, which I support. It didn’t accurately give the background on the Flexner Report, the purpose of which was to weed out inferior MEDICAL SCHOOLS, not midwives. But, I didn’t bring that up because I thought it wasn’t fully relevant to the discussion.

The posting on the Facebook page included the caption:

Exactly. In fact, it is even worse than the article suggests.

It states, “The North American Registry of Midwives’ Portfolio Evaluation Process requires midwives to be the primary care provider during 50 home births and to have 3 years’ experience. The average ObGyn resident gets this much experience in 1 month.”

However, this is not the requirement one needs to meet to become a CPM; this is the requirement to be a PRECEPTOR of CPMs — to pass your “knowledge” on to others!! In fact, to become a CPM, you only have to attend 20 births as a primary care provider. Also, just this year, they added the requirement for a high school diploma. For the last 15 years, you didn’t even need one to become a CPM. The most recent requirements are here: http://narm.org/req-updates/

The first commenter said this:

People need to understand that high standards do not limit choice for mothers. It boggles my mind when I hear lay midwifery apologists insist that making CNM the standard would “limit mothers’ choices.” Limit *what* choice, exactly? Oh right, clearly they want women to be able to “choose” substandard care (CPM) even though the very best (CNM and OBGYN) is readily available to everyone. It’s disgraceful that in America we allow uneducated hacks to practice medicine on the most vulnerable citizens. The ACOG is right not to “collaborate” with lay midwives.

I posted this:

The requirements for direct entry midwives are higher than that in Florida. Also, ob/gyn residents are already licensed doctors by the time they get that experience. There is no requirement for any specific clinical experiences first, although most medical students do at least observe a certain number of births.

Also, ob/gyn residents are not on labor & delivery every month. It depends on the training program, but most involve less than 100 vaginal deliveries a year.

Don’t get me wrong. I am a supporter of adequate training for CPMs/DEMs/LMs. I am also a supporter of accuracy.

Commenter #1 replied:

Accuracy? Lay midwives’ “education” pales in comparison to that of legitimate medical professionals. That’s accurate. Split all the hairs about med school that you like– lay midwives are still substandard, full stop.

I replied:

I am not splitting hairs. I am giving accurate information. A first year ob/gyn resident on her first labor and delivery rotation may have never caught a baby herself. She is a “legitimate” licensed medical professional.

Again, I am all for adequate training and licensing for CPMs. I do not think it is fair to call them all “hacks” or “substandard”. I also don’t think it is safe for ob/gyns or ACOG to not cooperate with lay midwives, nor is it accurate. ACOG does acknowledge that birth center births have been proven to be as safe as in hospital birth, and they support birth centers as a safe site of birth in their position statement, and most birth centers are run by CPMs or other types of lay midwives.

The best way to make homebirth and other out of hospital birth safe, other than adequate training of midwives, is to ensure seamless cooperation with other “legitimate” medical professionals when necessary. Anything less is unethical and unsafe for mothers.

Full stop.

I am not sure I am going to go back to comment on the thread, but if you follow the link to the new qualifications, 10 + 20 + 20 + 5 = 55 births required, not 20.

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Reply turned post, blame the mom or the system? style

My buddy Jill of The Unnecesarean has launched an awesomely Rad Pitt (inside joke, you’d get it if you were from San Diego or South Beach) new project called CesareanRates.com. She shared a top ten list from my lovely state of Florida on Facebook, which got, as expected, an avalanche of disgusted responses.

It is hard not to see rates of 50, 60% + without choking on your third cup of coffee. OK, maybe I’m the only one on my third cup of coffee. And I didn’t really choke, since I was well aware that some hospitals down here have had rates higher than that, as you can see by Jill and my silly little guerrilla action here, which was when we first became partners in crime.

Well, in the flurry of comments on her Facebook page, many people followed the familiar line of – blame the moms. Blame the women for not educating themselves. Blame them for choosing a hospital birth over a homebirth. Blame them for being all Hispanic (Mexicans and Brazilians in particular were blamed for our cesarean woes) and wanting a cesarean. Blame them and the OBs for creating an atmosphere of fearing birth, and forget about changing that system, because it’s a lost cause. There are plenty of good replies to this, but I am sharing mine here:

OK, diving in. First of all, the Mexican and Brazilian population in Miami and Broward County is pretty low. Cubans are by far the majority of the Hispanic population. Also, research shows that maternal request and ethnicity as factors influencing primary cesarean are both way overblown.(1) In fact, some research indicates that being Hispanic decreases your chance of having a primary cesarean in the United States.(2)(3)

Training as an OB in residency and insurance are not the primary reasons why OBs in South Florida don’t want to do VBACs. My assertion is based on as yet unpublished research from my fellowship project. Residency sites are probably the most consistent place you can get a VBAC in Florida – note that someone on this thread is going to do a VBAC at Jackson, which is the only OB residency in South Florida. Most OBs cite malpractice concerns as their reason for not doing VBACs, and that was very consistent with responses in my research. And, no tort reform is not the answer, because Florida has had some of the most extensive tort reform for OBs in the whole US – OBs here can and often do “go bare”, which means they don’t even have to carry malpractice insurance, and can limit their liability totals in various ways. Jackson has immunity as a public hospital, also.

I have to say, I am not fond of blaming moms, either for their site choice or their cultural backgrounds. I also don’t think it is effective to turn our back on changing the system. As Jill said, almost all women choose to birth in hospitals. Even with out of hospital birth rates increasing, we are still talking rates around 5%. Of course, I have to believe on changing from within, or else my life’s path is a waste of time.

(1)http://www.childbirthconnection.org/article.asp?ck=10372
(2)http://www.ncbi.nlm.nih.gov/pubmed/19788975
(3)http://mchb.hrsa.gov/research/documents/finalreports/declercq_r40_mc_08720_final_report.pdf

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Much more fun than studying

I am cramming for my last exam in medical school tomorrow. Scratch that, I am procrastinating instead of studying. I will be speaking at the VBAC Summit again this year, and had to write a bio. As much as I didn’t want to write about myself, it was much more fun than studying.

Hilary Gerber is a pre-doctoral research fellow who will be graduating from medical school in two weeks. After completing a traditional internship, she hopes to specialize in obstetrics and gynecology. Her fellowship research focused on evidence based labor and delivery interventions. Before medical school, Hilary gave birth twice with the help of midwives, once in a hospital, and once at a free standing birth center. She would love to have a home birth if it didn’t involve having another baby. She trained as a direct entry midwife and worked as a doula. Her article “Social Media, Power, and the Future of VBAC” was published in the Journal of Perinatal Education. Her sometimes dormant blog “Mom’s Tinfoil Hat” is not peer reviewed, however. She also has a studio art degree, has delivered pizzas, worked the graveyard shift at Denny’s, wrote a parenting blog for Mtv, and was in a band that is in the Rock and Roll Hall of Fame.

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Reply turned post, “reasonable” commenters style

Jill has had a great series of posts on The Unnecesarean about a large malpractice payment based on jury findings of a lack of appropriate informed consent prior to a shoulder dystocia that resulted in a permanently affected child, and a follow up post on how to properly counsel a patient with a baby with a large estimated fetal weight.

As you may have expected, both of these posts had lively comments sections. I only got involved in the second post. Yes, I haven’t just been MIA here, I have been MIA in the interwebs in general. However, I tend to jump in when I actually get a chance to read something, and then see someone creating straw men arguments or grossly misinflating aspects of the conversation in order to make a point, which happened a few times in the second comment thread.

My first comment was in regards to informed consent. A few commenters acted as if there is an exact formula for informed consent, and it includes presenting every worst case scenario, even if the risks of that scenario are diminishingly rare. Also, some commenters were treating the one verdict and award in this very specific case as the totality of case law on informed consent.

ACOG has a Committee Opinion on Informed Consent which discusses the complicated and amorphous subject of malpractice case law and informed consent. This opinion, which I recommend that you read, like I recommend you read all of the links I am including (yeah, I know, you haven’t got all day, but still), states that first of all, informed consent is more of an ethical issue than merely a legal issue. Secondly, the adequacy of disclosure, which is the issue that the huge malpractice payout in the original Unnecesarean post hinged on, has been judged by different criteria in different cases. In recent history, “common practice of the profession” was the most common trend for judgments. That could be troublesome, because standard of care in different areas can be quite variable, and not necessarily evidence based or best for the patient. Now, the trend seems to be moving towards the “reasonable person” criterion, which can also be troublesome. Especially if the all the commenters on these threads are “reasonable people.” Ahem.

Physicians are notoriously poor at presenting risk (pdf) in a way a reasonable person can understand. Many practitioners will very selectively and erratically present risk, sometimes exaggerating, downplaying or completely omitting risks or benefits in order to lead the patient in a certain direction. Ignoring that, statistics are still highly complicated even with the best of intentions. This article recommends using “natural frequencies”, such as saying three to five people out of ten taking Prozac will report some sexual dysfunction, as opposed to saying there is a 30 to 50% probability of sexual dysfunction. Many people will assume the latter will mean that every time they have a sexual encounter, there will be a 30 to 50% chance of there being a problem. Percentages or other comparative methods (__ times more likely) can be tricky.

For example, in Liu et al’s Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term, one of the outcomes measured was any hysterectomy. I picked this specific outcome because it is a good example of how to discuss the numbers, but also because one of the commenters grossly misrepresented this particular risk, stating it was ONLY a risk of vaginal birth, and not at all associated with cesarean section.

In this retrospective study, there were 27 hysterectomies in 46,766 cesarean deliveries, and 376 hysterectomies in 2,292,420 vaginal deliveries. That is the same as 0.6 per thousand cesareans, and 0.2 per thousand vaginal deliveries. The adjusted odds ratio of any hysterectomy is 3.2 higher odds for cesarean than vaginal delivery. So, three times higher, or 320% higher. Sounds huge, right? But, the absolute risk difference is 0.4 per 1,000. Or, four hysterectomies per 10,000 cesareans. Does increased risk of hysterectomy need to be part of the informed consent for cesarean section? Does it need to be part of the informed consent for vaginal delivery? How frequent does an adverse event need to be for it to deserve a mention? Does an adverse outcome such as nerve injury resulting in foot drop, usually due to epidural or spinal anesthesia, which only appears in isolated case reports, not even in large studies such as this, need to be mentioned?

I still haven’t touched on the topic of how to counsel a patient who is near term and has high estimated fetal weight. This is a complicated topic, and I don’t think I am going to cover it in this post. Based on the evidence, including the ACOG position statements on the topic and UpToDate’s review of the literature, shoulder dystocia is unpredictable and unpreventable. Prophylactic cesarean section does not prevent nerve injuries or neonatal death. Induction of labor (which is disappointingly common in these cases) actually increases neonatal poor outcomes. Instrumental vaginal delivery (use of vacuum extraction or forceps) increases the risk of shoulder dystocia. Estimated fetal weight is a tool with poor accuracy, given a rating of I for insufficient evidence to support its use by the United States Preventative Services Task Force. This list does not even take into account the maternal history and characteristics.

I think informed consent for any pregnant person should include the chance of a shoulder dystocia. I think as the risk factors increase (estimated fetal weight greater than 4500 g, gestational diabetes, prior macrosomic baby, prior shoulder dystocia, male fetal gender, small maternal pelvic size), that increased risk should be presented. If a practitioner is acting out of fear of a lawsuit in the extremely rare case that there is a very poor outcome, the practitioner should mention this fear.

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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

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Catching Babies Blog Series

I am participating in a blog series on Catching Babies, a novel about obstetrics and gynecology training by health economist J.D. Kleinke. As a medical student on her obstetrics and gynecology rotation who is (hopefully!) staring down an obstetrics and gynecology residency soon, it really resonated with me.

Amy Romano kicked it off with an interview with the author on Science and Sensibility, and Kristen Oganowski followed up with a great back and forth with him on Birthing Beautiful Ideas.

Stay tuned for more great posts!

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