Ethics in the eyes of the beholder!

In this months Green Journal, the ACOG publication, were 3 articles concerning the ethics of home birth. If anyone is interested in reading them please send me your email and I can send them to you. They are proprietary and password protected and cannot be linked here. One nearly brought me to tears called "An Obstetrician's Lament". The writer eloquently painted a picture of a somewhat professionally self inflicted dilemma. One took an honest look at relative vs. absolute risk and true informed consent. The third, surprisingly, upset me more than I thought. Dogmatically labeling obstetricians who participate in home birth as lacking integrity and suggesting that educated patients who refuse hospital birth should be given "respectful persuasion". In response to this article I wrote the following letter to the president of ACOG.

Dear Dr. Waldman, I just was reading the articles in this months Green Journal and came across one in particular that I found very troubling. I think you know that I am an advocate for true, not skewed, informed consent and a supporter of midwives and the option of out of hospital birthing for well informed low risk women. Dr. Chervenak and colleagues in an article titled, "Obstetric Ethics" seems to continue the College's selective bias against home birth and those who support it.

In the abstract he says this," ...Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with "respectful persuasion". As a matter of beneficence-based professional integrity, obstetricians should not participate in planned home birth."

As my president I have to ask you if you believe this statement to be true.

As for myself, I find so much wrong with this in the context of known hospital based risks which the college does not seem as eager to recommend disclosure of. Also, the restrictions on choice occuring because of ACOG opinions and the legal and economic climate in which hospital policies restricting those choices are made. I find it repulsive that the authors, and I suspect the editors of the journal, condone respectful persuasion which seems to be just another nicer name for skewing informed consent. Am I and other obstetricians who support patients who desire an out of hospital birth acting without integrity and unethically as Dr. Chervenak proposes?

The demand by a better educated populace for a say in how and where they give birth is coming. The current trend in c/section statistics and interventions do not speak well for the medical model in low risk birth when compared to the midwifery model of pregnancy as wellness not illness. The obstetric profession is not preparing its doctors in training in the art of medicine any longer. Skills of breech birth, forcep and vacuum deliveries and twin vaginal birthing have disappeared from the training programs under our watch. Fear has replaced trust in that most natural of life's events. The authors and ACOG are running with a strawman argument that home birth is unsafe and building upon that questionable foundation. There is far more evidence based medicine that supports the safety of selective home birth. Certainly enough that should give pause to reasonable people labeling those that have a different view as unethical or lacking in professional integrity.

I am very concerned that we now have articles endorsed by our college that dogmatically define ethics and integrity to fit their definitions of what normal pregnancy should look like. Personally, I resent the implication. Just as the authors seem certain they know what is better for individual patients and have taken it upon themselves to label those who differ unethical, I am certain their hubris and possibly well-meaning paternalistic views are a violation of our oath and mission statement.

Again, as my president, I need to know if you agree with the finality of Dr. Chervenak's definitive statement.

Sincerely, Stuart J. Fischbein, MD

Kim Rivers responds to PV midwife ban

Thanks to Kim Rivers for writing a response the the Ventura County Star article on the midwife ban at Pleasant Valley hospital. And congratulations to Kim on getting the Star to post her op-ed piece in yesterday's edition. You can find her article at:

http://www.vcstar.com/news/2011/apr/25/rivers-why-are-midwives-being-targeted/

I encourage you to read and comment. It is a rare chance for small voices to be heard. Dr. F

Another Home VBAC

Why do babies so often come in the wee hours of the morning? Does seem disproportionate but makes the driving easier. I had the privilege of assisting a wonderful couple with their HBAC this morning in their bedroom in Santa Barbara. Well informed and also aware of the hostility towards VBAC in their local hospital they made a choice to birth at home. From the spontaneous rupture of membranes to the birth of the beautiful little boy took only 4 1/2 hours. Assisted by dad with grandparents hovering about we welcomed Lucas's little brother Matias Esteban into the world. Dr. F

I guess "When" is this Monday

The Headline in the Ventura County Star reads:

Midwife restrictions at St. John's Pleasant Valley Hospital will be lifted next week

http://www.vcstar.com/news/2011/apr/18/midwife-restrictions-will-be-lifted-next-week/

While good news is always nice to pass along, midwife Lynn Olson says it best. This (ban) should never have happened in the first place. So 14 months after they were inexplicably removed to the canard of "safety issues" per the former CEO, midwives are set to return on Monday. Oddly, seems that Lynn and Joyce, the only 2 CNMs working there, need to be recredentialed. Sort of unusual since they have maintained their credentials at the sister hospital, St Johns, all this time. This would seem to be a new policy or legal barrier placed on them and only them as it has always been that credentialing at one of the 2 campuses gave you privileges at both. Lastly, the administration has supposedly used these 14 months to create new policies to ensure safety of midwife patients. Yet they do not detail what those policies are nor why doctors working there throughout the midwife ban could function without them. I have the belief that these decisons will someday be looked at under a microscope and those most involved held responsible for their unrepentant and inexplicable actions against these devoted CNMs. For now, good news for the women of Camarillo. Dr F

Where we are likely headed....

Jason Fodeman, MD wrote an article on Townhall.com today that is worthy of mention. It is titled: "The New Heath Law: Bad for Doctors, Awful for Patients". You can find it at:

http://townhall.com/columnists/jasonfodeman/2011/04/16/the_new_health_law_bad_for_doctors,_awful_for_patients

The article is taken from a White Paper analyzing the PPACA (better known as ObamaCare) authored by Dr. Fodeman for the Galen Insitute. It is certainly worth reading no matter where you fall in the debate. I happen to agree with him and am not optimistic about the long term health of our health care system. Please take the time to read the full link below.

http://www.galen.org/fileuploads/NewHealthLaw_BadForDoctors_AwfulForPatients.pdf

Thanks, Dr. F

Text of Dr. F's 2011 Tax Day Rally Speech

For the second year in a row I was asked to speak at the Tax Day Tea Party Rally at the Thousand Oaks post office. This is the text of my address:

I have been asked to give a practicing doctor’s perspective on what is happening to our health care system.

I would like to begin by telling a brief parable about the farmer and his horse:

The Farmer & His Horse

There once was a farmer who had a beautiful farm and a devoted horse. The horse worked long hours, never complained and loved his work. Twice a day the farmer would feed the horse and all was right in the world.

But then the farming business went into a slump and the farmer asked the horse to work longer days and plow more fields just to make ends meet. The horse never complained and loved his work. Once a day the farmer would feed the horse and all was still ok in the world.

Soon the farmer was told that the cost of hay was increasing. There were no more hours left in the day to work harder to pay the increasing costs. So he decided he would just feed the horse a little less hay each day. The horse never complained about his hunger, did his work as best he could but the world was not so good anymore.

This went on for some time. The farmer continued to work his horse really hard, had to lay off his workers and spend less on hay for his horse in order to keep his farm running. The farmer noticed his fields were looking a bit shabby. His harvest was the worst he ever had. He was baffled. Why was this happening?

Finally, he woke one morning before dawn. Dragged himself out to the barn and there was his devoted horse, lying in his stall. Starved to death!

Medical professionals and the patients they serve cannot be squeezed indefinitely. Like the poor farmer and his horse, the story will not end well.

Healthcare is not an inanimate commodity to be treated and bartered like oil or water or even hay, for that matter. It is us! And each and every one is unique.

Centralization is a bad idea and a terrible one for medicine.
What we will see as government and insurance companies continue to micromanage our lives are mandates based on ideological, nanny state one size fits all ideals. You will begin to see laws and commercials and public service announcements, paid for by government stimulus money, really, our tax dollars, which entice you by reward or punishment to follow their advice. Advice based most often on emotion and not science. You will see more brainwashing type curriculum in public schools with the purpose of indoctrinating our children early on towards the “correct” way to think.

Really, this extends far beyond just the healthcare law. What we have now unleashed in our country is a hostage situation to the American legal system. Whether it’s the local restaurateur, the small businessman, the ski resort, your family doctor or your local hospital or school we are all intimidated by a lack of restraint on our legal tort system. Quite frankly, my biased opinion thinks that the biggest obstacle to American values and common sense returning to us is the American civil legal system which promotes victimhood and extortion. If any industry was in need of reform it is that one. Where are the future leaders who are willing to take on the trial lawyers? Now that would show real bravery. Dennis Prager has rightly labeled ObamaCare, “The trial lawyers of America stimulus package”.

Recently, a midwife friendly hospital serving the needy in Greenwich Village closed its doors due to its inability to stay financially solvent while trying to comply with all the mandates, regulations and legal protections required. Many doctors are already at the point where they cannot afford malpractice insurance or continue to take on more patients for ever decreasing reimbursement. As costs inevitably go up reimbursement to providers will be decreased or care will be rationed. MediCal and medicare patients are going to find it harder to make appointments and are going to be waiting longer. Lowering reimbursement further will just devalue the doctor-patient relationship. It will push small community hospitals out of business, as it has in Greenwich Village, and lead to rationing by default. How much more work can you squeeze from a starving horse. Most doctors love our profession but hate what the business of medicine has become.

As for my practice: Carolyn asks whether I would consider giving it up and retiring early. The question is actually can I afford to keep going? This year I will turn 55. I love my work. I could continue to practice for another 20 years. The real question is “Would I be a fool for doing so”? Not only will doctors able to quit consider doing so but who in their right mind will become the future doctors in our country. Years of training and sacrifice of social life lead to a loss of a decade of fun and earning power and massive debt. Only to come out and see your expenses rising and uncontrolled but your earning power capped and regulated. The devastating threat of a career ending law suit hanging over your head like the sword of Damocles is no way to live. Having the authorization for a test or procedure denied by some non-medically trained faceless cubicle worker who can’t spell the diagnosis is maddening to those of us who care. Your medical decisions weighed and scrutinized by faceless utilization review boards, government agencies and hospital committees. None of whom will ever bother to get to know the patient you are advocating for. How many of you would want to live like this? How many of you want your children to live like this?

And I have yet to mention the looming specter of Electronic Medical Records coming by 2014. Every detail of your medical history and that of your children will be mandated to be online for bean counters of all shapes and motivations to see. Do you trust that it will remain confidential and used wisely? I don’t! And there will be a large cost of installing the hardware and mandated annual updates that will not be reimbursable to the practitioner. Adding another undo burden on the small, independent practice of doctor, midwife, chiropractor and therapist. Another not so subtle hammer to force solo doctors like me out of business or submit to joining large impersonal multispecialty groups where the individuality and art of medicine I love will disappear.

Solving this will be a complicated process. Remember, healthcare is not the problem. We have the best in the world. It is more accurate to call this dilemma a problem of healthcare access. I know it sounds radical and probably too late but I don't believe the government has any business being in the business of health care. Evidence based medicine is a simple premise that supposes that medical decisions are based on scientifically proven studies What is most scary to me in an era where we are supposed to rely on evidenced based medicine is this. All these regulations that are being instituted and forced upon us have never, I repeat, never been studied to show that they have actually improved healthcare delivery and outcomes. If anything, other countries that have tried this are backing away from it. These edicts are being rammed down out throats with no science to back them up. They are theoretical only, and the motivation is financial and control, not betterment of health and not individualized care. The canard that is always used is "safety". Albert Camus, the French philosopher, said, "The welfare of humanity is always the alibi of tyrants."

How can the Tea Party help? In my perfect world, first, repeal Obama-care entirely and end the fraud that has been played on America. Then insist on tort reform and insurance reform and demand our elected leaders “Read the Bills”! Stop having insurance companies, lawyers, politicians and hospital administrators dictate medical decision making that belongs by right to patients and their practitioners. Also, encourage states that limit competition from allied health professionals such as midwives, naturopaths and alternative medical practitioners to lessen their restrictions on these caring men and women. Leave pharmaceutical companies alone. They are not the villain. And reign in the FDA and its draconian restrictions on new drug development and patient choice. Let the free market loose and trust the educated consumer to make their own life decisions and accept the consequences of those decisions.

Most doctors are excellent caring professionals. Go after fraud and bad doctors but do not lump us all together. Do not micromanage all of us who mostly want to do good work for those we serve. Confident knowledgeable people do not need micromanagement. I would like to know that when I am sick I am being cared for by someone who is a leader and not a follower.


So, we have come to a place where we have to decide who we trust. No longer can we be passive when it comes to something as important as our family’s health care. We have to take a stand. I trust the relationship I have with my personal physician. I trust my ability to judge him by his actions. I trust that she has my welfare as her primary concern. I encourage you all to educate yourselves and ask questions. You have the right to be truly informed. I trust that if he does not serve me well I can go someplace else. I do not trust big government or big business to have my back. I do not trust the nanny state to make decisions that are in my family’s best interest. I will do that and I want a country that allows me the freedom to succeed or fail. One size does not fit all. We must get away from that mentality. The best and the brightest should be going into noble professions like medicine. Sadly, unless we continue to elect leaders who repeal this horrible health care legislation, medicine will no longer remain an appealing avocation and the best and brightest will seek other interests. Possibly wasting their talents as lawyers or government workers because that’s where the money and lifestyle remain.

Finally, the government should not have the right to take my hard earned skills and demand of me to give them away for what they determine they are worth. I am not a horse to be fed ever decreasing amounts of hay. And, I never dreamed I would be before you all today making empassioned speeches. All I wanted to do was to practice my profession as I was trained to do and love my family. I am lucky. I have the good fortune of collaborating with midwives and the honor of assisting families who desire home birthing. Working outside many of the pressures and restrictions I have discussed today. But, I cannot sit idly by and watch this happen to the profession I love. I want my children to know that their dad stood up for self determination and personal responsibility.

Royal College of Ob/Gyn Supports Delayed Cord Clamping

The RCOG recommends that the time at which the cord is clamped should be recorded. Early cord clamping is defined as immediately or within the first 30 seconds. The cord should not be clamped earlier than is necessary, based on the clinical assessment of the situation. Evidence suggests that delayed cord clamping (more than 30 seconds) may benefit the neonate in reducing anaemia and particularly the preterm neonate, by allowing time for transfusion of placental blood to the new born infant which can provide an additional 30% blood volume. In the preterm infant (less than 37 +0 weeks) this may reduce the need for transfusion and reduce intraventricular haemorrhage. Delayed cord clamping does not appear to increase the risk of PPH. The timing of cord clamping needs to be made by the doctor or other attendant in the light of the clinical situation. Early clamping may be required if there is postpartum haemorrhage, placenta or vasa praevia, there is a tight nuchal cord, or the baby is asphyxiated and requires immediate resuscitation

. April 2011

The International Federation of Obstetrics and Gynecology and the World Health Organization no longer recommend immediate cord clamping as a component of active management. Dr. F

HBAC in Water

Spreading the word and announcing another beautiful home birth in water this past week. I was honored to attend the home birth after c/section of a wonderful family in Simi Valley. In a county that for all intents and purposes has banned the choice of vaginal birth after a c/section in the hospital I am happy to offer this option to families in the comfort of their own home. I will continue to advocate for reason and the respect for choices in childbirth that belongs to mothers.
Dr. F

ACOG silence remains deafening

MEDSCAPE: Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong: A Flawed Analysis

This is potentially very significant. The authors of the British Columbia and Netherlands home birth studies that were allegedly included in the Wax Paper have published a devastating attack on that study on Medscape:

http://www.medscape.com/viewarticle/739987

Thanks to Susan Jenkins and Linda Bennett for forwarding me this link. My respect goes out to the authors of this rebuttal to the Wax, et al paper. These men and women did the honorable and tedious work of breaking down the data and critically analyzing Wax's methods and conclusions. I forwarded this information to the President of ACOG, Richard Waldman, MD. It is very difficult these days for anyone to admit they made a mistake. There is no shame in doing so, I know, and it is time for ACOG to do the same regarding Committee Opinion #476. Dr. F

Questioning Veracity

After some prodding by me and others, finally, last week the Ventura County Star and writer Tom Kisken finally reported on the status of the longstanding midwife ban at Pleasant Valley Hospital in Camarillo, CA. I found the headline to be misleading, the article to be very milk toast and Mr Kisken's investigative effort into the veracity of the hospital administration to be lax at best. Those that have followed me for the past year and a half know of the issues to which I am referring. Please read and add your comment to the story at:

Midwives ban to be lifted at Camarillo hospital; question is when

http://www.vcstar.com/news/2011/mar/31/midwives-ban-to-be-lifted-at-camarillo-hospital/

I have sent Mr. Kisken the following e-mail after returning home from a fun filled weekend with my daughter and her Westlake High School choir class at the Heritage Music Festival in Anaheim. Hoarse and exhausted from chaperoning 160 kids through the event and long, good days at Disneyland and California Adventure.


Dear Tom, I just read your article is last weeks Star. I found it very disappointing. Once again you failed to get anyone to explain anything. You allowed administration to avoid answering the obvious question. "Why Certified midwives banned and not doctors?" Laurie Eberst was not even here when this happened. What could she possibly know about the truth other than what she had been fed? Where are the quotes from Ann Kelley or Eugene Fussell? If no one is talking doesn't that bother you? You quoted anonymous sources but did not say why anyone would need to remain anonymous here. How about explaining that your sources were reprimanded last time for talking to you? How about some investigative journalism into why anesthesia is and has been obstructing the midwives return? Did you speak with Dr. Kalcic? How can it possibly take more than a year to implement any policy change if they really want to change? Good investigative reporting would have asked those questions and not allowed a non-answer. Also, since I was a major part of their reasoning for the ban, why not approach me for information? Was not I the one who gave you the "push" in the first place? And what is that headline supposed to mean? It seemed almost tongue in cheek and very inappropriate. Was that story really your best work?

Sincerely, Stuart Fischbein, MD

I will patiently await his reponse and happily report any error in my facts should he wish to clarify. My colleague, Kim Rivers, has written a letter to the editor in reponse to the article. With her permission, I will post it if the Star refuses to.
Dr.F