"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.

Sunday, May 30, 2010

Good news and Horrible news

It seems there are some rumblings about ready to spill over at my hospitals in Ventura County. Wouldn't it be nice if everyone involved could speak honestly about what goes on there behind closed doors. With all the secrets and suspicions and threats one might think that national security was on the line. To me it is a ruse the powerful play to make what they do seem so almighty important. Its the doctors and nurses and midwives that are saving lives and yet its the administrators and lawyers that act as if only they carry the burden of righteousness.


This past week I was called into a meeting with the Chief of Staff and the Chairman of my OB/Gyn department. Four weeks ago and almost 10 months since the investigation into my practice which started me on this whole blogging thing began the decision was made as to whether further disciplinary action should end or continue. It took more than 2 weeks for their lawyer to draw up a letter and another 10 days before a mandatory meeting was called. So they knew for a month about my fate but because of the way an administrative system "works" could not express any humanity by letting me know sooner. I arrived for the meeting early while the other parties were 25 minutes late. No apology was offered. I was handed a letter exonerating me from any wrongdoing and ending any investigation. That was it!

Yes, they had me sign a piece of paper saying I received the letter. Ever heard of certified mail? No explanation or apology offered as to why they sat on this decision for a month. Clearly, to me a total lack of concern or empathy for what I might be dealing with. Then we had a discussion about making sure professional conduct rules were followed and the problems with our department came up. Clearly, the Chairman of my department and I see things differently and it was enlightening to see how little truthful information gets filtered through to the Chief of Staff. Hidden behind those rules of confidentiality is an ugly process by which the powerful can pick on and destroy those with which they take issue. Despite the lack of courtesy, I feel fortunate that I am now out from under their threat. At least for the moment. With the ACOG review panel coming in 2 weeks to scrutinize this OB Department there are some of us who hope a day of reckoning will come. And maybe, when the balance of power shifts to those who lead justly and with reason we may again see things like Midwives in Camarillo, breech deliveries and even a way to bring back VBAC.

Now, the horrible news. Sadly, the committee did claim one most wonderful and innocent victim this past week. After almost 3 years of tormenting one of my colleagues and a patient and nurse favorite they called her in to administration Thursday afternoon and suspended her from the staff. What I believe to be a series of lies, distortions, discrimination, pettiness, fraud and ethical violations by certain members of the OB Dept. all went against her. Complicit in the process are numerous administrators and other physicians who never took the time to look deeper and question the motivation and conflicts of interest of those that persecuted her. And to all of the staff not privy to the "confidential" information there is a feeling of sadness and astonishment that this could happen. Those of us that work with her know her to be caring, competent and appropriate in all she does. So we cannot understand the WHY? She has no greater incidence of complications or bad outcomes. In fact, compared to the members of the committee who led the charge to remove her she has a far better track record.

For reasons none of us can comprehend she now faces an inquiry from the Medical Board of California and will likely never again be able to perform hospital based deliveries. It is very unlikely that once you are kicked off a medical staff at one institution that any other will allow you onto their staff. However, on the positive side she has immense support and good friends. With ACOG coming to investigate we may have some light shown on what really happened. Interesting timing of suspending her 2 weeks before ACOG comes so that now she does not have a chance to speak to the panel as a member of the department. But her voice will be heard. Also, now that the one-sided administrative hearing process is complete she does have the opportunity to appeal in civil court where there will be an impartial judge, subpoena power and a jury made up of civilians free from subterfuge. Having sort of been through this type of process myself, my heart aches for the fear, anxiety, helplessness and unrequited anger she must be feeling. I think she knows how loved and supported she is and those that have hounded her will have their day of reckoning and right soon.

How I long for a simpler time where honest men went into medicine for a single purpose of helping others. How that time was lost is a subject for a great novel at some point. When I see what has happened to Dr. Biter, my colleague, many midwives and myself to a lesser degree I want to cry for a moment and then I am energized to fight back to reclaim common sense and hold those who would abuse their positions accountable and liable. The peer review system is so broken at my institution and the undercurrent of discontent with those that abuse it and support it in its current form is about to explode. Sad, that it will take outsiders and the civil court system to make transparency and honesty happen. But happen it must! Dr. F

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 fa├žade 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

Tuesday, May 25, 2010

Laying Low and letting the process work

I have not posted in nearly two weeks. But that does not mean things aren't happening out here in Ventura County. Some revealing events are taking shape but the details are protected by their veil of confidentiality. One important event happening next month is the arrival of an investigative panel sent by ACOG to review the policies, procedures and doings of the OB committee. Apparently, things have finally gotten so obviously bad with this committee that even the always complicit hospital administration had to do something. There was no hiding it anymore. So they have hired a group of ACOG physicians and nurses, at a price tag of more than $37,000.00, to come for 4 days and perform an "objective" investigation, chart, policy and meeting minute reviews and conduct personal interviews with all members of the department including midwives. At the OB department meeting I was specifically assured by one of the hospitals top administrators that anyone who wanted to be interviewed would have 30 minutes in private. Now, however, there are rumors that they may be backing away from this promise. There are many of us who would make a lot of noise if they even try something like that. I am hopeful that this will be the first step in returning honesty, common sense and reason back to our department. I would like to see those that have for so long abused their position of power be humbled to the point of apology and punishment and we can hope for a revamping of the committee model and a return to evidenced based medicine and national standards that benefit patients rather than a small totalitarian group of petty obstetricians forcing their will upon us.

Also, Joyce, Victoria and I have almost completed the final edits of "Fearless Pregnancy, 2nd edition" and hope to have a release date in early June. It will be available online in real soft-cover book form or as a download e-book format. Amy Tinney and I also have 2 meetings this week with persons possibly interested in helping with our maternity center idea. I see Laurel Phillips has some fundraising events going on up in Santa Barbara. Please check out the Santa Barbabra Birth Center web site for details. I may also soon be helping out with the Sanctuary birth team as a consultant in the Los Angeles office and I have heard exciting news that they will soon have a facility for midwife assisted out of hospital birthing on LA's west side. All the best, Dr. F

Wednesday, May 12, 2010

“There’s really been no change in anything,” said St. John's Chief of Staff

And so it goes. Despite a petition from over 700 residents of Ventura County calling for an end to the midwife ban delivered by BAC chairperson, Kim Rivers, St. John's continues to refuse to explain the hypocrisy or release any supportive evidence for their decision to ban midwives from Pleasant Valley Hospital. The Ventura County Star, to their credit, has written a followup story which confirms the title of this blog but at least feels the issue is unresolved and worthy of continued scrutiny.

http://www.vcstar.com/news/2010/may/11/battle-continues-against-hospitals-ban-on/

Reading the comments section can be fascinating and frustrating as some just do not understand what midwives do. Others have the sky is falling approach to birth while voices of reason try to elucidate common sense. BAC is committed to keeping the issue alive. Here is a copy of their press release:

St. John’s Denies BAC’s Meeting Request to Discuss the
Community’s Response to Ban on Nurse-Midwives from Attending Births

Ventura, Ca. – On May 6, 2010 a representative from the Human Resources department at St. John’s Regional Medical Center canceled a meeting with Ms. Kimberly Rivers, President of the Birth Action Coalition (BAC), that was scheduled for 3:00pm on Friday May 7th. The meeting was set with Mr. John Bibby, Director of Human Resources and St. John’s Chief Medical Officer, Dr. Eugene Fussell. The meeting was requested and set in order for Mrs. Rivers to present BAC’s petition regarding the recent midwifery ban at Pleasant Valley Hospital in Camarillo. On Monday May 10th without an appointment Mrs. Rivers presented the petition to the Human Resources office desk at St. John’s and was told it would be delivered to Mr. Bebe.


BAC, a community organization focused on educating and advocating for supportive birth environments, has been calling for St. John's to respond to community member requests for access to midwives, and clarification over reasons for the recent ban on nurse-midwives at Pleasant Valley Hospital since the ban. Administrators at St. John’s Regional Medical Center, part of Catholic Healthcare West, cite “patient safety” and availability of a NICU (neonatal intensive care unit) at the facility as the reasons for approving the policy that prohibits certified nurse midwives (CNM) from attending births at Pleasant Valley Hospital.

BAC hopes to gain a response from St. John’s through its monthly protests in front of St. John's Regional Medical Center in Oxnard and is circulating a community petition The petition asks that St. John’s administrators immediately reinstate privileges for all CNM’s at Pleasant Valley Hospital, or, that St. John’s administrators provide evidence supporting their statements that the CNM’s have been removed from the Camarillo facility due to “patient safety” (we ask that this evidence show outcomes for all care providers who have attended births at Pleasant Valley Hospital), or that St. John’s administrators retract their claims that the midwifery ban is due to “patient safety”.

(See petition at: www.petitinonline.com/speakout)

On two separate occasions Ms. Rivers contacted St. John’s for a meeting requesting 5 minutes to present the petition signed by over 700 people. Finally on May 3 an appointment was confirmed with Mr. Bebe’s office for 3:00 pm on Friday, May 7 but was then canceled on May 6. When asked for a reason why the scheduled meeting with Ms. Rivers was canceled, it was suggested that Mr. Bibby and Dr. Fussell were advised not to speak with Ms. Rivers without further explanation. “St. John’s is now outright refusing to listen to a member of the community regarding a policy they have put in place that affects the birthing women of Camarillo,” says Rivers. “ BAC plans to notify Mr. Lloyd Dean of Catholic Healthcare West regarding this clear dismissal of the concerns of community members, and we will continue to speak out on this issue until the community receives a satisfactory response. ”

Monday, May 10, 2010

More absurd secrecy?

First, I admit I only heard about this through an email blast this weekend from L. Janel Martin. The details are sketchy but all too hauntingly familiar for me to ignore. Dr. Robert Biter from the Carlsbad, CA area has apparently lost his admitting privileges at Scripps Encinitas Hospital:

As of 5 pm Friday, May7th, Dr. Biter's privileges to deliver babies at Scripps Encinitas Hospital have been suspended. He will still be able to see his current patients postpartum (after they deliver) in the hospital. He is hoping that this will be resolved quickly & is working hard to ensure that there is a backup plan for his patients that are due to have their babies soon.

Here's what I know: There have been no obstetrical malpractice issues against him---ever. The hospital, specifically some OBs, have been attacking him for the last 3 years for protecting women's rights for natural birth. I believe it''s all out of greed for money--less interventions means less money for the hospital. Other doctors were losing their patients to Dr. Biter because they wanted a doctor who would support them & that trusted birth as being a woman's birthright rather than a medical procedure.

An effort to support him is being organized by Carol Yeh-Garner at:

Carol Yeh-Garner
3192 Corte Tradicion
Carlsbad, CA 92009

awelllivedlife@hotmail.com.

My own experiences suggest that the rules of peer review and the convenient veil of confidentiality will prevent us from knowing the real reasons for the hospital committee's actions. However, I do suspect that Carol's suspicions are likely correct. What we can do, if Dr. Biter so desires, is contact and barrage the hospital administration with calls and letters asking them for explanations. The one thing that hospitals hate most is negative publicity in the media and having a light shone on their internal policies and politics. If you have any information, please comment here on my blog to educate the rest of us. Also, for those who care to write here is an address:

Write a letter to the CEO of Scripps Encinitas:
Chris Van Gorder--President & CEO of Scripps
4275 Campus Point Court
San Diego, CA 92121

I have heard that Dr. Biter is planning to open a free standing maternity center supportive of the midwifery birthing model. The timing of this latest absurdity against him cannot just be a coincidence. I am hopeful that we will know more soon. Although, he may be restricted from discussing this openly by the rules of the hospital set up to always favor the hospital. Through my own experience I find such secrecy, when not directly involving patient confidentiality, to always be suspicious of nefarious reasoning. Dr. F