The ultimate KALI questionnaire

This is the absolute last version of the KALI questionnaire. (You can access the previous incarnations here.)

How do I know this? Well, first of all, one of my mentors gave me the lifted eyebrow when I went to him to talk about the wording, again, on Monday. I am particular and a hair splitter, but I also had a good reason to change the wording of this part. I had a problem with it from the beginning, and one of my beta testers also had an issue with it. I was editing the second to last question, and it used to say “How often do you consult the following sources regarding obstetrical practice?” But, I really didn’t want to know how often the physicians literally consulted these sources. No physician furtively looks in a textbook “always” or “often”. I wanted to know how useful these sources were in clinical decision making, how valuable the physicians considered each source to be, and how often they applied the knowledge from these sources to their clinical practice. And, I wanted it to be in one question, since I had three complaints about the length of the survey by beta testers. (This version is also a few questions shorter, and one question is a combination of two previous ones.)

So, I ended up with: “This final section lists potential sources that you may consult to stay up to date on obstetrical standards of care. How often are the following sources useful in making clinical decisions?” Not perfect, but I am accepting it and moving on.

The second reason I know this is the final version, at least for this research, is because I sent out a few email invites yesterday. (Eep! Wish me a good response rate!) I will be phoning ob/gyn offices today, begging for email addresses for the physicians in the practice. (Eep! Wish me good luck getting email addresses!)

So, here is the final questionnaire:

The KALI Project Survey

Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.

First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.

1. You are:
[1] Female
[2] Male

2. Age:
____________ years old

3. Do you have children?
[1] Yes
[2] No

4. Ethnicity:
[1] Hispanic or Latino
[2] Haitian
[3] Neither Hispanic nor Haitian

5. Race (choose as many as apply):
[1] African American / Black [4] Native Hawaiian / Pacific Islander
[2] Asian or Asian American [5] White / Caucasian
[3] Native American Indian /Alaskan [6] Other:_______________________

6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] Military
[5] Other: ____________________________

7. Year of residency completion _____________

8. Which of the following most accurately describes your practice type?
[1] Public hospital
[2] Community health center
[3] University based practice
[4] Private practice
If private –
[1] Large partnership (four or more partners)
[2] Small partnership (two or three partners)
[3] Solo practice
[5] Military / government
[6] Other:____________________________________________

9. Do you currently practice obstetrics?
[1] Yes
If yes:
9a. Average time spent with prenatal clients:
[1] Less than 20%
[2] 20% to less than 50%
[3] 50% to less than 80%
[4] 80% to 100%
9b. Average number of deliveries per year:________________
[2] No

10. Which of the following most accurately describes your personal practice scope?
[1] General obstetrics and gynecology
[2] General gynecology only
[3] Obstetrics only
[4] Laborist
[5] Maternal Fetal Medicine
[6] Reproductive Endocrinologist
[7] Gynecologic Oncology
[8] Urogynecology
[9] Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
[1] None / I “go bare”
[2] I pay for individual malpractice insurance
[3] My practice pays my malpractice premiums
[4] I am an employee of an institution that pays my malpractice premiums
[5] I am an employee of an organization or institution that provides legal defense but not malpractice insurance
[6] Other: __________________________________________________

Please rate the following statements about obstetrics as accurately as possible. Please choose whether you:

[1] Strongly disagree
[2] Disagree
[3] Neither agree nor disagree
[4] Agree
[5] Strongly agree

1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.

2. _____Elective cesarean section should not be performed on a woman desiring several children.

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.

4. _____Episiotomy should be avoided if at all possible.

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.

7. _____I employ episiotomy routinely, because it is easier to repair than lacerations that
result when an episiotomy is not used.

8. _____Fear of liability claims limit the options I present to my obstetrical patients.

9. _____Liability insurance company policies forbid me from performing vaginal births after cesareans (VBACs).

10. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.

11. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

[1]Strongly disagree [2]Disagree [3]Neither agree nor disagree [4]Agree [5]Strongly Agree

12. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.

13. _____I regularly employ episiotomy to shorten the second stage of labor and delivery.

14. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.

15. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.

16. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies.

17. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.

18. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.

19. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.

20. _____I regularly employ episiotomy to prevent pelvic floor relaxation.

21. _____Hospital policies forbid me from performing VBACs.

22. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.

23. _____I have made changes to my practice because of the risk or fear of liability claims.

24. _____Childbirth is only normal in retrospect.

25. _____Clinical guidelines are useful tools for me in daily clinical practice.

26. _____The use of continuous EFM reduces perinatal mortality and morbidity.

[1]Strongly disagree [2]Disagree [3]Neither agree nor disagree [4]Agree [5]Strongly Agree

27. _____Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks.

28. _____I encourage my patients to try alternative or upright positions during the pushing stage.

29. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.

30. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.

31. _____Women should have the right to refuse an episiotomy.

32. _____I recommend that most patients use a doula for their labor and delivery.

33. _____Women should be able to have a caesarean section even if there are no clear maternal or fetal indications.

34. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.

35. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.

36. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.

37. _____I would refer out any patient who wants to hire a doula.

38. ¬¬_____Time and scheduling pressures affect the way I manage labor and delivery.

39. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.

40. _____Episiotomies increase the risk of third and fourth degree tears.

41. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.

This final section lists potential sources that you may consult to stay up to date on obstetrical standards of care. How often are the following sources useful in making clinical decisions?

[1] Never
[2] Rarely
[3] Sometimes
[4] Often
[5] Always

1. _____ACOG Practice Bulletins
2. _____ACOG Committee Opinions
3. _____Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. _____Cochrane Database
5. _____Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. _____Books and/or textbooks
7. _____Professional conferences
8. _____Physicians in my practice
9. _____Physicians in my local community
10. _____Physicians I trained with in residency
11. _____Physicians I consider experts in the field
12. Other sources: ______________________________________________________

Have you ever been the subject of a professional liability claim or litigation?
[1] Yes
If yes – Did the liability claim involve an obstetrical claim?
[a] Yes
[b] No
[2] No

Thank you for your time and participation!

Mammograms and the USPSTF: it’s the denominator, stupid

There has been a lot of brouhaha over the new mammography recommendations by the United States Preventative Services Task Force (USPSTF). Rachel at Women’s Health News has an excellent round up of posts on the issue, if you feel like you need to do some background reading.

I am also a big fan of Barbara Ehrenreich’s take on it.

Take your time if you need to check out those links, since I highly recommend it. Back? Good.

I have many thoughts on this issue. First of all, I am completely in support of the new recommendations. If you have been reading my blog for long, this may come as no surprise, since I tend to prefer using interventions only when absolutely necessary, and am a big fan of evidence based medicine.

Secondly, I don’t think it is anti-feminist to discuss the anxiety caused by false positive diagnoses, whether it be false positive mammography results or false positive prenatal genetic screening results. Not only is the anxiety potentially substantial to many, but, the false positives also lead to more invasive tests. My mother, who is as low risk as I am for breast cancer (white, has had children and has breastfed, non-smoker, not a heavy drinker, no first degree relatives who have had breast cancer, etc.) is also endowed with huge breasts, as I am. She had at least three biopsies and lots of ultrasounds in her 40’s. None of these came up with anything of concern, but there was plenty of anxiety leading into them. And, a biopsy is not comfortable or risk free. Come to think of it, neither is a mammogram. In fact, the radiation from repeated mammograms may actually cause breast cancer in some women. I know this is an anecdotal story, but my mother is the primo example of who this consensus opinion is talking about. These mammograms are not improving outcomes in typical low risk women in their 40’s, like my mom was when she started getting mammograms and subsequent biopsies.

Third, I had an argument with a fellow student today. He said that the public wants the extra mammograms, and they are too stupid to understand the nuance to the issue. He also said all they want is “the best care.” I said the best care is evidence based care, and that I plan on educating my patients. I do not believe in the can-I-have-fries-with-that-have-it-your-way approach to medicine. I do believe that patients’ values and opinions definitely matter. But, in the end, if a patient insists on a procedure I think will cause more harm than good, I will politely refuse and refer them to a practitioner that will accommodate them, if I know of one.

Fourth, and possibly coolest, I heard a discussion on Doctor Radio that made my nerdy day. The oncologist, Dr. Silvia Formenti, is fully supportive of the new recommendations. She also explained why there is an apparent discrepancy in breast cancer survival rates between the United States and United Kingdom, which is one of the few if only outcomes that appear better in the United States. She explained that this is a false comparison, since the denominator is different. My public health instructor has always harped about the denominator of any rate being key, but I thought it was just a nitpicky instructor thing – sure, you only include women of childbearing age in maternity rate stats, got it – but it’s more important than that. Dr. Formenti said that the reason our rates seem better is that we are currently overscreening younger women, and overtreating in situ cancers. So, our denominator is stacked with low risk women who are not really that sick. In fact, I spent too much time looking over the ACOG site for the article, but I read something recently in one of their publications that showed that a wait-and-see protocol for such cancers led to a shocking remission rate. I remember it being over 20%, but since I cannot find the article, please don’t quote me on it.

So, the denominator matters, and not just in a nit-picky way. Also, I was happy to see that the National Health Service, of which I am a fan, is not failing women with breast cancer, which was bugging me a little. What especially impressed me with her commentary was that not only is she a renowned oncologist and an attending at NYU Langone, but she practices in the United States. She could have easily said “Hooray for my team, hooray for my field, we’re kicking butt.” It’s really refreshing to hear someone value truth over seeming to be the best.

And, finally, I am a little chagrined by how many people are saying that these USPSTF recommendations are going to change the way the insurance companies reimburse mammography, and change medicine in the United States dramatically. I am still waiting for that to happen due to their recommendations of labor and delivery from November of 2008, in which many interventions are panned as inconclusively supported by evidence or detrimental to patients (such as third trimester estimation of fetal weight, denying nutrition p.o. to laboring patients, and episiotomy) and others are highlighted as extremely effective and highly recommended (e.g. upright positioning for pushing and the continuous support of a doula during labor.) I wish there was an uproar following those dramatic recommendations, but there was barely a peep. Hello, sweeping changes? Helloooooooo?

Reply turned post, Dr. Amy is still there? style

Doesn’t Dr. Amy know a good take down when she reads one?

Sigh.

Well, I guess she does to a certain extent, since she mostly ignored it, other than to tell me I called the Obstetrics and Gynecology Risk Research Group article a scientific study, which I didn’t. I called it a peer reviewed article and an excellent source, which it is, and which is something she has yet to produce in about a dozen comments she has made on the derail from hell on The Unnecessarean.

Even though she has ignored the substance of my comment, she has continued to bicker with many other commenters on the thread. Jill, the intrepid hostess of the blog, has decided to sit aside, eat popcorn, and referee the worst shit-throwing while allowing people to interrogate Dr. Amy.

So, here is my next reply:

Thanks Jill. I actually wish the thread ended with my last comment, but I guess Dr. Amy came back later and ignored it.

Dr. Amy, what is your response to the Lyerly et al article about the values, or lack thereof, of intentionally distorting risk and ignoring women’s values and well-being in order to push non-evidence based and non-patient centered care? Can you find a comparable consensus from as prestigious and relevant a group on risk and pregnancy that supports your tactics and point of view, or criticizes ours?

Have you ever wondered why you seem to be willing to dismiss the risks of procedures that are not women centered and exaggerate the risks of interventions or standards of care that are woman centered? Especially when it comes to the point that you have to ignore the actual evidence of levels of risk of these interventions. What is your opinion on the patriarchal paradigm of patient care, and can you find any sources supporting it?

How many more people can ask you for a source for your misrepresentations of risk on this thread? You had no problem quoting the Farm as the source for numbers in one of your numerous comments, (a source which you distorted and misquoted). Citations only take one line, and less time than your protracted comments that artfully ignore all the best points and questions (like” “source?”) of the thread.

Why are you here? Why show up in communities that seem to be populated by people with a different point of view than you, and seem to be able to support it much better than you can support yours?

Why do you dehumanize women who care strongly about their autonomy in what is the MOST IMPORTANT DAY OF THEIR LIVES by trying to pretend they are a homogenous straw woman, this pretend selfish upper class privileged white Western woman who just needs Dr. Amy to come tell her some fake statistics and exaggerate a few risks to scare her for her own good and the safety of her baby?

Oh, one more:

What is the difference between physiology and pathology? Which do you need to treat?

Good things a brewin

I haven’t had time to post recently. But, good things have been brewing, so I wanted to throw up some links.

First, a study finds homebirth as safe as hospital birth. Of course, this occurred in the Netherlands. I would love to practice there one day. An American DO needs to pave the way, since our licensing is ambiguous in that country. Note the complication rate was 7 per 1000. That includes NICU admission or any neonatal mortality.

Note that in the United States, our infant mortality rate alone is 7 in 1000.

Hillary Clinton gave a rousing defense of comprehensive international reproductive medicine. I still get misty when I hear our administration advocating for evidence based, women centered medicine that will save more lives of women and children.

Also good stuff, the FDA is going to be extending over the counter, non prescription status for plan B to 17 yr olds. It is safer than a pregnancy for all ages, children who can’t talk to their parents about it are high risk and should have more access. Unfortunately, proving your age requires ID. I think the requirement should be lifted because privacy outweighs the negligible risk. If a young woman is in a small town, she will be forced to show her license in order to get Plan B. We need mroe progress on this issue. Plan B needs to be available without a prescription, end of story.

The New England Journal of Medicine published a study on using PCR, a cheap DNA analysis is better than a pap smear when screening for cervical cancer. Very interesting. I may be doing some research on PCR testing for HPV during my research fellowship.

And, finally, Shakesville has been cracking me the hell up.