"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Tuesday, December 22, 2009

Something Nice

Letter dated 12/9/09

Dear Dr. Fischbein,

I just wanted to say thank you to you and the rest of the lovely staff at The Woman's Place for providing such exquisite care. Both Aaron and I really appreciated you taking the time to talk with us at the follow up appointment last week. I wanted you to know that we fully agree and support The Woman's Place and what it represents. Wanting a different experience than your "standard hospital birth", was what drew me to your practice in the first place. Both Aaron and I could not be more thrilled with our choice.
Wishing you all the best,

Jeni Halverson

And a Merry Christmas to all of you! Stu

Community Standard ?

So, I finally got tired of being ignored and called Dr. Torres as he apparently did not have the courtesy to return my e-mails and letters. He told me that members of the OB committee met last week and decided there was no need to have any meetings or discussion about making a breech delivery protocol. Although in September I was assured that I would have some input in the discussion, it did not happen. Since no one but me in the community offers breech deliveries, he states that I am outside of the "community standard" and elective breech deliveries would not be allowed. When I pointed out that Terry Cole also does breech deliveries he mumbled something about not caring what Dr. Cole does at Community Memorial Hospital down the road. When I asked if only one doctor in our department was doing a certain special surgical procedure would that, too, be outside the "community standard" and be banned? He had no honest answer. I received a letter later today reiterating our conversation and suggesting that I seek privileges at another institution if I wanted to do breeches. This is a disingenuous suggestion as changing hospitals is not a simple task. So while I am credentialed to perform breech deliveries at my hospitals and ACOG and SOGC support this option the administration has made a final decision not to allow this without any meeting, hearing or due process. A sad day for the women of Ventura County. I am looking at all options and am open to any suggestions. Dr. F

Thursday, December 17, 2009

What Keeps Us Going....

Those of us that support a woman's choice, informed consent and the midwifery model of care often feel we stand alone. A thank you to this lovely nurse from Washington state for sending words of encouragement. SF

Dr. Fischbein:

I just had to take the time today to say thank you for all that you are doing for women and babies in this country. I first heard of you during an interview you did for "The Other Side of the Glass". I have since searched for and found other videos of you online. I was completely taken aback that there was an outspoken OBGYN who was being vocal about support for things such as breech deliveries and delayed cord clamping. You are a real hero in the birth world. It is so difficult to find MD's who are openly supportive of such things.

I am a registered nurse and I work in a small, community hospital in Washington state. I am a nursery and postpartum RN there. While I don't do labor and delivery, I am present at deliveries to be there for the babies. Lately, I have been asking myself how much longer I can stand there and watch the things that are being done to women without full consent.

I am very passionate about women's birth rights but lately I find myself wanting to give up. I find that I am simply beating my head against the wall and making a journey upriver without any paddles for my poor, dilapidated boat. Yet it never fails... just when I am ready to throw in the towel and give up on the whole political mess, another sick (or traumatized or injured or harmed) baby is placed in my arms and it serves as the fuel to keep me going. Despite the fact that we live in the information age, it seems nearly impossible to educate. It seems so hard to get the truth out and to be heard above the throngs of other voices out there.

There is a running joke we have in the hospital where I work. If a nurse says something, it doesn't mean a darned thing. But if a physician walks in and says the exact same thing, it's taken as gospel truth. We laugh about it because the words are exactly the same, but it makes a difference to patients who it's coming from. Patients trust their physicians implicitly. This is why I am so happy you are being so outspoken about the truth. Midwives and nurses and lay people have been shouting these messages for a long time, but I believe it will make a much larger impact on people if the same messages are being delivered by obstetricians (pun totally intended!)

Thank you for taking time out of your personal life to be an advocate for women and babies. You are making a difference. It is my sincere hope and prayer that if we all just continue talking about this and continue our attempts at educating women, that somehow, some way we can afford change through the upper ranks of administration and government. It is tiring, but it is worth it.

Christina Harris, RN

Wednesday, December 16, 2009

Laboring Patient Sits in Lobby

Last night I had a MediCal patient in labor. She had planned to deliver at Pleasant Valley Hospital but because there is no MediCal pediatric coverage there she had to go to St. John's Regional in Oxnard. There were available empty labor rooms at Pleasant Valley Hospital but there were none at St. John's where the nurses described the labor floor as "swamped". So, because of the failure of the hospital administration to solve this problem and, likely, in continued violation of their licensing requirements my actively laboring patient had to sit in the waiting room for nearly 2 hours until a room and bed became available. In this particular case she would have liked pain relief a lot sooner. Conincidently, I had sent an e-mail earlier that day on this issue to the administration:

Hi All, I spoke with Mike Murray and Laurie Bingham one week ago about the absence of MediCal pediatric coverage at Pleasant Valley Hospital. We had a cordial conversation where concerns on all sides were expressed. My colleagues and I would like an update on what is being done to remedy the situation and a timeline for when we can expect this issue to be resolved. Several of our patients have been inconvenienced by having to go to a hospital not of their choosing. It is also more difficult for us to travel back and forth. We believe the hospital has a legal obligation to provide MediCal patients a pediatric option and cannot turn them away from Pleasant Valley. We are happy to work with you on this but that would require the respect of being kept in the loop. I am available to discuss this at any time. On behalf of the patients we care for and their desire to deliver in their own community we hope to hear from you promptly.

Stuart Fischbein, MD
for The Woman's Place, Inc

No response so far. On behalf of our patients and the Camarillo community we will keep inquiring. SF

Another Letter to Chairman

Below is an e-mail sent today. Just the latest in a series of attempts to get the OB department at St. John's Regional Medical Center to honor their word to me and obligation to the community.

Dear Juan, I just saw another patient at 36 weeks who is breech. She meets all the ACOG criteria for a vaginal attempt should efforts to turn the baby fail. I have been patiently waiting since September for a promised meeting about breech deliveries. I submitted a protocol to you through Claudia at the last department meeting per Dr. Niesluchowski's suggestion. I would like to be able to offer this woman a vaginal birth at St. John's. I am competent, willing and privileged to do so but seemed to be blocked by the inaction of our department. I am asking again for you to contact me to schedule a meeting to discuss forming a breech protocol. Further delays seem unreasonable. I would like to work with the department on this to be sure that patients in our community are given all viable options. Please work with me on this. As I am aware of the slow process involved I would like permission on a case by case basis to perform selected breech deliveries. I would be happy to discuss each individual case with you or the incoming new chairman.

Sincerely, Stuart

Thursday, December 10, 2009

Visit to Washington DC

Returned late last night from a 20 hour turn-around trip to Washington DC advocating for patient focused care. The trip was organized by Docs4patientcare.org which is a grass roots organization formed as an alternative to the AMA. Like most of my colleagues, I don't know any doctors that belong to the AMA or think that it represents practicing doctors and the interest of their patients. Unfortunately, the AMA still has name recognition and its endorsement of the Health Care Bill has been used by the Obama administration as a sign that doctors support his plan. Nothing could be further from the truth.

We have a Hypocratic oath that in effect states we are to serve our patients. The current legislation would be so cumbersome and overbearing that serving our patients best interests would become impossible. A group of doctors gathered from several states at the Heritage Foundation. We met with some leaders from the Heritage Foundation who explained a little bit about the process of lawmaking. I am still scratching my head. Apparently, the current bill is purposely designed to be vague. The supporters have not read it, don't need to and never intend to. This is common practice in lawmaking which the rest of us might find curious. Its supporters just want to pass anything, claim victory and then spend the next 3-4 years trying to figure out how to pay for it and create the micromanaging details and definitions. It is a set-up for rationing, legal disputes and chaos. I am still shaking my head.

I visited with Senator Feinstein's office and had a very cordial conversation with her aide, Kristin Wikelius. She initialized the conversation by saying she only had a few moments to spend with us and reiterated standard reasons Senator Feinstein supports the bill. However, she listened and dialogued with us for nearly 40 minutes. I stressed the importance of patient decision making, non interference in doc-pt relationship and my belief that the Senate bill would most certainly lead to rationing and be a massive hindrance to good medical care which takes place in exam room, not boardroom. Also, I discussed the inevitable future shortage of doctors and why I felt few good people would choose that as a profession and many my age would quit if this bill passes. I cannot possibly state here all that is wrong with the current bill. I would suggest going to the Heritage Foundation website and reading some of their analysis of the bill and what the Congrssional Budget Office has to say.

I then met with Cecelia Daly, aide to Congressman Elton Gallegly from my district here in Westlake, California. Again, a very cordial conversation but with the difference being that the congressman is opposed to much of the bill. In both offices, we did discuss some things I thought would be helpful. Taking small steps and correcting those things first rather than a massive government overhaul/takeover. But it is clear that the goal of this administration is a takeover of 1/6th of the American economy for ideological reasons. I would suggest that we all look closely at supporters or endorsers of this bill. They either do not understand how the true delivery of care to patients takes place or don't care because they are idealogues of socialism or they have a vested financial interest in a government takeover and stand to gain enormous sums of money from the bill's passage. This is, sadly, the feeling I got from talking to so many people yesterday. Let's be clear that this bill is not about health care. The doctor and the patient are at the bottom of the list on the agenda.

One suggestion proposed by a doctor from New York was interesting. It will never come to pass because it would actually work and mean smaller government and less control. He suggested that doctor's be given a tax deduction for providing free care to those in need. This would eliminate a huge waste of bureaucratic administration and the need for any expansion of Medicaid and all the expense, waste and fraud that goes along with it. Another doctor from Georgia told me this metaphorical story. A child asks his father why the cost of bread has only risen 4 times in the last 20 years but the cost of health care has risen 20 times during that time. The father responds by saying that is because people pay for the bread.

Lastly, I did not get to meet with Senator Boxer or her staff because they could only offer a 7PM appointment and I had to leave for the airport at 4. But just some thoughts about the Senator's postion. Some of my midwife colleagues are happy because Senator Boxer sponsored the birth center-medicaid bill. But her support of the overall health care bill will likely end up killing out of hospital birthing by midwives. My logic is that licensed midwifery in many states has to have backup doctors. With the passage of this bill, without tort reform and with the crushing of the spirit of the private doctor there will be no incentive to back up midwives and birthing center births. I hope I am wrong but I know I am not. The birth center bill is an example of a small good thing. But all the small good things that could possibly work will be crushed by the massive health care bill. I urge all of you to contact your elected officials and express your concerns about more government intervention in our profession. And do it now for tomorrow will be too late. My experience from yesterday tells me they will listen and our voices can make a difference.

Monday, December 7, 2009

Pediatrics pulls out

Just a quick note to say that all the pediatricians on staff at St. John's Regional Medical Center have decided not to cover MediCal babies born at St. John's Pleasant Valley Hospital. As of December 1st they refuse to be on call for any patient who does not have a pediatrician. And since MediCal patients usually use MediCal providing doctors and there are now no pediatricians at Pleasant Valley Hospital who accept MediCal there is an obvious dilemma. My understanding of the explanation I have been given is that it is a combination of fearing that midwife deliveries are risky exacerbated by a recent tragic outcome, lack of an NICU for backup and poor reimbursement for their services. While I understand the latter two reasons, I am uncertain as to why they feel midwifery and its low risks patients are considered higher risk than physician patients. I have spoken to administration and offered to attend any meeting to help answer questions they may have about midwifery and to get some answers to my questions, too. So far no invitation has been offered. I had a low risk MediCal patient scheduled for a routine repeat c/section tomorrow morning at Pleasant Valley Hospital that I was ordered to either move to St.John's in Oxnard or cancel due to a lack of pediatric coverage which is required by their policy. This is inconvenient for and undesired by both the patient and my staff. I have been told they are working on a solution and are aware of the urgency of need for a resolution. For should a MediCal patient show up in labor at Pleasant Valley their would be no pediatric coverage. Hopeful they will come up with something soon.

Each one of these new twists and obstacles makes it crystal clear that another option for birthing in our community is essential.

Am off tomorrow night to Washington DC to meet with Senator Feinstein's office and Congressman Gallegly's staff on Wednesday. The topic will be the Health Care Bill with focus on reminding our representatives that medicine is not an inert commodity. We are patients and health care practitioners. We are individuals. Medicine takes place in the privacy of an exam room and is a very personal decision. Government probably won't listen but they really have no business being in the business of health care. But you already know that's my take. SF

Sunday, December 6, 2009

Dog days

Have not written in a while as not heard anything back from multiple cordial attempts at contacting the OB committee at St. John's Regional Medical Center about their "promise" to set up an ad hoc cmmittee on protocols for breech as well as reviewing others. Does this seem like a broken record? They make demands under severe threat. I respond with requests at their recommendation which they ignore. Feel free to right a letter or to call Dr. Juan Torres, current head of OB there. Let him know your dissent with their policies and their nonresponsiveness. For, every delay causes potential harm and inconvenience to some patients.

As I have said before, there is unlikely to be any movement toward respect for patient autonomy in this current model. The hospital has no competition and employs an economic model that favors ts policies as long as they live in a vacuum. So we need to create an alternative option for women and maybe then they will understand what we all do. Decisions belong to the informed patient. Amy Tinney, RN LM is working with me to organize our dream of a free standing birthing center, staffed by midwives, doulas, chiropractors, acupuncturists and doctors. A birthing center that also contains an surgery center option where c/sections can be performed. With safe policies that favor mother-baby and treat birth as a natural process. We are in the discovery phase of our planning but are confident that before 2010 is out we will have it up and running. We are open to any suggestions or offers of expertise or help. Comment here or e-mail me anytime.

Amy and I attended the wonderful Tribute to Women at The Sunrise Birth Center tonight. It was an elegant affair reflective of Karne and all the dedicated birth goddesses, new mothers, artists, musicians and generous donors. Bought some great smelling candles from Krystal McCauley. It was nice to see so many of you there. The Birth Action Coalition will benefit from the event and soon will have non-profit status. Things are happening. I heard there is an event next week in Santa Barbara hosted by Laurel Phillips in support of her birthing center dream up there. I have heard through the grapevine that there are happenings on the west side with Sacred Entrance as well. So, the movement is gaining momentum.

Lastly, I am flying to Washington DC Tuesday night to spend 10 hours on Capitol Hill. I am going as a representative from Docs4patientcare.org to speak with the offices of Senators Boxer and Feinstein about patient centered issues, protecting the sanctity of the doctor patient relationship and reminding them that one size fits all medicine cannot work. You can be sure I will put in the word for midwifery and its wonderful benefits and reigning in those that lobby against it and asking for a loosening up on all the regulations restricting access to them. We have to try.

You can be certain I will persist in getting a response from Dr. Torres. It would be so much easier and more professional for him to honor his word. The hypocrisy of that department is legend around the community. But I am biding my time, taking the high road and documenting everything they do. Oh, and I was interviewed last week by a writer from the Washington Post about the breech restriction. She has attempted to contact Dr Torres and Niesluchowski but as of Friday had no response. Watch for the story and I will post it once it comes out. So I guess there are things happening and worth wrting about. We will chat soon. Hope you all had a great Thanksgiving. Stu