"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.

Friday, January 22, 2010

Could not make this stuff up!

OK, so my office manager today tells me that Triwest (Tricare), the health insurer for the U.S. Military, has denied me payment for assisting Dr. Lara on a c/section. They also denied our appeal. Their reason: Triwest has decided they will no longer pay for an assistant at c/section. Explaining to them that an assistant at a c/section is the standard of care, medically necessary and mandated by the non-teaching hospital I work at fell on deaf ears. They have done some absurd things in the past but this was a new twist. I called, myself, and spoke to a customer service representative. Well, as you guessed that was a waste of time. He said the policy was decided by their medical director. I asked for his phone number or e-mail but was told they can only be contacted by writing a letter via regular mail. We sent one but does anybody think I will ever get an answer let alone be reimbursed for my work? I was also told that I was not allowed to bill the patient. I guess we are expected to come in at any hour of the day, give of our skill and time, accept liability and do it for free. To not help would only cause difficulties for the attending obstetrician and the patient. So we are now placed over another barrel, not of our choosing, with no recourse because it is the government. Am feeling abused and helpless....again. Hate that feeling. Ahhh, medicine....what a great profession.


  1. So sorry to hear it! Man you just can't win for losing lately. I'm surprised though, I'm down in the San Diego area and recently had a homebirth with a CNM that was approved by Triwest. Still waiting on reimbursement but my midwife has worked with tricare a number of times (which is part of why we chose her) and they pay fairly quickly.

    I do hope they sort it out, but realistically it sounds like you're high and dry. Just not right. :(

  2. Wow... I'm just speechless over this one. Really? No assistant? I guess it's just a matter of time before hospital policy changes huh? Our hospital's policy specifically states that an OB MUST have an assistant prior to first cut unless it's an emergency. I know because we've had some issues with the policy.

    What kind of liability does this open up to the scrub/OR tech? Does this put the OR tech in the position of actually "assisting", despite having a medical license? What if something goes wrong? I know in our hospital, if an assist isn't there and it's a true emergency, our charge nurse is required to assist.

    I'm just dumbfounded over this.

  3. Oops... obviously that statement above should have read "...despite NOT having a medical license?"

  4. It is truly the theatre of the absurd, isn't it? I have been writing about these sort of things for nearly 2 decades. You would think nothing could still surprise me and, yet, here we are again. The bottom line is they just do not care and there is no way to hold them accountable. They know we are bound to do the work anyway. We still have an oath to uphold and advocate for patients. Doctors have too long been foolish and kindhearted and will contiunue to do the right thing until we all quit or become assembly line employees working a shift, unionize and stop caring.

  5. And they complained about the mortgage brokers!! The real criminals are right under our noses.