"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.

Wednesday, May 26, 2010

The Industrialization of Medicine is Unhealthy for Patients

Talk show host Dennis Prager has popularized the phrase, “The bigger the government the smaller the citizen”. Calm and thoughtful people should consider well this premise. It seems that following the news of the European union and from Washington to Sacramento to city councils we are seeing the demise of personal liberty. So it is with health care. As government intrusion and industrial micromanaging overwhelm my medical profession the individuality of patients and of doctors who care for them is crushed. You have heard me say many times that one size does not fit all when it comes to patient care. We are all different, with varied life experiences and unique personalities. Informed consent and refusal require a free flow of information free from coercive forces. Doctors should be free to advise patients of choices based on what is good for the individual. But as medicine has become the purveyance and money engine of government, businessmen and lawyers our choices are being funneled by processes not often born of reason or the spirit of Hypocrates. Individuality does not fit the business model of bureaucrats and cubicle workers. Too hard to count beans if we honor our differences! In plain language, it is too hard to control. So the solution becomes a takeover of our health care in every facet so that choices can be limited, a façade of liability protection created and a sense of order mandated. As the beast grows it devours everything unique and special that was once the sacred doctor-patient relationship.

Last week I attended the biannual OB/Gyn department meeting at St. John’s Regional Medical Center. I have tried for years to be left alone and allowed to use my skills and allow patients their right of self-determination. Treating patients with that sort of individual dignity has led to conflict with the larger controlling machine of industrial medicine. While we are supposed to follow evidenced based medicine and rely on outcomes data to determine good health care policy, this only gets in the way of those who prefer power over preference. This is true today on almost every scale. When it comes to my local hospital I see a clear distinction. While I want to be left alone to provide the right of informed choice to each and every patient and allow other doctors to do the same, the hospital chooses a narrow path laid down by an admittedly dysfunctional committee. They make what often seem to be arbitrary policies sometimes lacking any sort of sound medical reasoning and then force them upon the doctors and nursing staff with little or no input from the rank and file. These blanket, often kneejerk, policies are not thought out beyond the immediate false satisfaction gained by the creating institution. Thomas Sowell calls this Stage 1 thinking. There seems to be almost no thought for the, Stage 2, long term consequences that result in less choice, higher intervention rates and far more paperwork but no evidence that outcomes will be improved. In fact, as we have seen with premature policies surrounding fetal monitoring and VBAC based on opinion rather than hard evidence, outcomes often worsen. At this department meeting we were provided with a list of policies and protocols put in place at my institution in just the past year.

Delivery Privileges for Certified Nurse Midwives (new, restriction)
Professional Conduct (revised)
Emergency Privileges during a Disaster (revised)
Oxytocin Inductions/Augmentation
Epidural analgesia/anesthesia During Labor
Post cesarean section routine orders
Bakri tamponade balloon protocol
Obstetric hemorrhage protocol
Admission and discharge criteria-St. John’s Pleasant Valley Hospital (restrictions)
Vaginal Packing policy
HIV, Preventing perinatal transmission of
Vacuum assisted vaginal delivery protocol
Post c-section routine orders
Admission/Induction orders
Updated 1-page guide to OB hemorrhage protocol (added per anesthesia dept.)
Final OB hemorrhage policy
Foley catheter policy



Now, maybe some of these 16 new policies will do some good but I have never seen any reports that show they were ever proven to do anything prior to their adoption. And with all these policies now in place will there be any evaluation as to whether outcomes have improved? Were things that bad that we really needed 16 new policies?While not all of medicine is yet lost to this sort of micromanaging, it is becoming pervasive. What is essentially gone is the “Art” of medicine. It seems to me that the job of so many hospital administrators these days is to constantly find things to change. It makes them seem busy and important and justifies their salaries but they so often leap before they look. Their premise is always liability mitigation and economics and sometimes just meddlesome. And it is all under the guise of patient safety protocols. As you can see from the list above, as these policies become more massive and micromanaging there is little or no room for the individual. Sadly, in the current monolithic healthcare model there is no going back. Choices in childbirth, caregivers, prescription drugs, facilities and procedures will continue to shrink and the single patient as a unique person model will fade into history. I am still hopeful that creating smaller alternatives such as birth centers and free standing maternity centers unencumbered by massive government or insurance industry oversight will provide an oasis for those pregnant women who desire the freedom to educate themselves and choose their own path. There will be a cost to remain free but it will surely be small compared to the cost of giving up our individuality. Dr F

1 comment:

  1. So sad to consider success being simply measured by "no lawsuits"

    ReplyDelete