Thoughts on Pediatric Policy

As the motivation behind the banning of Certified Nurse Midwives at Pleasant Valley Hospital becomes clearer, I believe it deserves some logical analysis. By now, it is apparent that a major driving force behind the policy was the displeasure of some of the pediatricians at Pleasant Valley. They did not want to take responsibility for babies who were not going to become their patients and for whom they would be reimbursed poorly and feared liability. The merits of this fear are debatable but its existence is a fact and a byproduct of today’s medical-legal world. There was also distaste by the pediatricians for the desires of some of the parents of midwife delivered babies who often had differing views on newborn care. Pressure from them on their committee in turn became pressure on the obstetric committee and the administrative cascade was set in full swing. Whether any alternatives were ever considered is unknown as the process all resides behind a veil of secrecy. Had this been an open discussion, it is possible that another, far better, alternative might have been reached.

A little history is now appropriate. Before the 1980’s healthy newborns were not seen by pediatricians in the hospital setting. Healthy babies were taken to the nursery or roomed in with mothers and cared for by trained hospital nursing staff. Usually within a few days to weeks after going home the baby would be taken to the local family doctor’s office for a check up. Only if problems were discovered by the nurse or parents would a doctor be called. However, in the 80’s doctors were generally paid well by third party payers and pediatricians soon realized that newborn exams were a decent source of revenue. So, policies were created by hospital committees that began mandating newborn exams on every new baby, regardless of necessity or not. These policies were also justified under the guise of “safety” but were really self-serving and revenue generating. In fairness, this tendency was not limited to pediatricians but that is what is relevant here.

For 3 decades the well-baby exam became the norm. This habit was formed before the age of evidenced-based medicine. As Thomas Paine said, “The habit of not thinking a thing wrong gives it the superficial appearance of being right”. No one questioned it as long as everyone was paid well by third party payers. But, in the last decade there has been a steady decline in reimbursement for this service. Medi-Cal pays almost nothing. Pediatricians have come to resent having to come to the hospital and have their work be undervalued and their opinions questioned. Patients of the midwifery model often want early discharge but have to wait hours to have their baby discharged as there is no incentive for the pediatrician to be inconvenienced for a well newborn. Frustration and sometimes hostility ensue. Lost in this frustration is the mission of why we do what we do. The original monetary motivated, non-evidence related policy of requiring a doctor to see every newborn baby, regardless of need, has now risen up to bite them and, by default, all of us in the ass.

So, my suggestion would be for St. John’s staff and administration to reconsider their policy banning midwives and look at another evidenced based option. Eliminate the requirement that every newborn be seen by a doctor before going home. Create a new policy that restores low risk midwife patients to Pleasant Valley and allows the delivering practitioner and the well trained nursing staff at Pleasant Valley to decide which babies are in need of an exam and which can do just fine with loving parents following up with their family doctor or pediatrician in the office. Truthfully, there is no reason a well newborn needs to be taken away from its mother to be examined in the sterile environment of the little nursery area there. It would be rare indeed to find anything that is life threatening. And for babies that are sick, well, those babies are going to be transferred to St. John’s NICU anyway. On the rare occasion that a low risk mother delivers a baby in need of resuscitation there can be a trained technician or nurse in house while the NICU team is on the way. Quite frankly, most office based pediatricians are not comfortable with advanced resuscitation anyway. Some being years removed from it and wise enough to leave it to those that perform it frequently.

I believe there is a better solution to the pediatricians' concerns. There most certainly is a better process that could have been used. The committees that decided the policy to ban midwives should have opened up dialogue between the concerned parties. The midwives and the doctors that work with them were never consulted in the process. Secrecy has no place in this issue. This was not a peer review process so why the hiding behind confidentiality? Questions have been asked and gone unanswered for 10 days now. The pediatric committee was motivated by financial and legal concerns. The OB committee was all too eager, in their pettiness, to oblige and failed to consider other options. The administration has its agenda which may very well include closing the labor and delivery unit at Pleasant Valley Hospital. Since they are all forbidden by their lawyers to speak and they have offered no other logical explanation this must be true.

Bring Thomas Paine’s “common sense” back to Pleasant Valley. Let’s change the habit of not thinking something is wrong simply because it has been done that way for a long time. Pediatricians do not want to see some newborns at PV. So let’s have a policy that says they don’t have to unless a doctor or nurse requests it. Leave the healthy babies alone and let them thrive with their new families. Being born is not a disease!

Stuart Fischbein, MD FACOG