"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 29, 2011

Board Recertification Abuse

When the chains of bureaucracy obstruct the physician’s ability

to care for patients appropriately, the physician has an ethical duty to

discard the chains and escape, to be free to practice according to the

physician’s best clinical judgment, as opposed to the substituted

judgment and whims of arrogant bureaucrats

Lawrence R. Huntoon, M.D., Ph.D.

The American Association of Physicians & Surgeons has taken a stand on the ridiculous burden of annual Board recertification. The onerous and tedious requirement of annual board certification is without evidence to support its efficacy. It has long gone past the goal of quality maintenance and taken on the life of a self sustaining monster with the apparent self-interest of monetary gain and power. Here are some comments by my longtime associate and friend, Howard Mandel, MD FACOG as well as Dr. L.R. Huntoon that expose another view of annual MOC (Maintenance of Certification).

Dear Dr. Huntoon:

I thank the editors of the Journal of American Physicians and Surgeons for their publication of Dr. Dubravic's insightful article regarding board certification and recertification. As an obstetrician/gynecologist who finished my residency in 1985, I was required to take my boards and earned a 10 year certificate. If I would have graduated in 1984, I would have been boarded for life. The ABOG, requires a two part exam, the first written and the second a three hour oral examination, part of which is based on the first entire list of all the physician's hospitalized patients plus a significant number of representative outpatient visits. I passed both examinations the first time and was reboarded 10 years later. Since that time, my speciality board has changed the requirements to six years and now a yearly exam as well as the MOC. In Los Angeles where I practice, we have observed the erosion of younger physicians partaking in our local speciality meetings. The LA OB/Gyn Society is a skeleton of what it once was. The LA OB/GYN Annual Assembly, which was once world renown, with upwards of 700 participants attending, barely has 150 attendees, many of which are retirees. I hypothesize that the numerous hours and costs required to maintain our certification have added to the demise of these once impressive meetings and organizations. Another unfortunate outcome is the destruction of the collegial relationships developed by OB/GYNs in our region. I would scientifically study my theory, yet I am too busy preparing for yet another annual examination. Perhaps, the ABMS or any of the individual sub specialities can spend some of their resources on why comradery, collegiality and membership in local organized medicine has plummeted since the introduction of reboarding.

Howard C. Mandel M.D., FACOG
10309 Santa Monica Boulevard
Los Angeles, California 90025

And another message from Dr Huntoon, The Editor-in chief of the Journal of American Physicians & Surgeons:

Subject: Re: MOC article from the Journal of American Physicians and Surgeons

This is not unlike what happened with the AMA.

When the AMA made the "secret" agreement with the
government for exclusive use of the CPT coding system (in 1983),
the AMA made a huge leap in the direction of no longer being
financially dependent on membership dues for survival.

Once an organization gets in a position of no longer depending
on membership dues for survival, they are no longer accountable
to the membership and the needs of the membership.

In the current MOC environment, our specialty organizations see the
potential for huge windfall profits as the specialty organizations will be providing
the CME and practice evaluation tools needed to comply with MOC.
Once the specialty organizations start down this road, there will be no turning back.
The specialty organizations, like the AMA, will no longer be dependent on membership
dues for survival and accountability to the membership will be severely eroded or lost.

The leadership of specialty organizations, many of whom are in academic medicine and
who may see a significant financial benefit by providing compliant CME/evaluation tools,
are not likely going to lobby to stop this trend.

It is likely that the grassroots membership is the only hope for stopping it.
Alas, physician apathy and reluctance to "get involved" or "speak out against"
the trend are significant barriers to overcome.

Those who believe in exerting ever increasing control over medicine (like implementing
onerous MOC and MOL requirements), fail to appreciate the adverse consequences
of their actions.

A significant percentage of physicians in this country are over the age of 55.
As physicians get closer to retirement, many will simply refuse to jump through
all of the nonsensical, non-evidence-based bureaucratic hoops, just to remain in
practice in an environment where they can be expected to be paid less and less
which each passing year. They will retire or do something else.
The shortage of physicians, which will occur, cannot be replaced over night.
Many patients will suffer with increased waiting times and decreased access to care.
The MOC/MOL bureaucrats who engineered this debacle cannot provide the care.

Ultimately, we need to educate patients about these predictable adverse consequences

As a start, feel free to copy the articles our journal has published on MOC and
place them in your waiting rooms for patients and distribute them to your colleagues.
AAPS has published a White Paper on our recertification survey. You can find all of the
articles we have published by searching the Cumulative Index on our website under the terms
"maintenance of certification" and "maintenance of licensure."
Our journal website is www.jpands.org
And, as I have said before, we would be happy to accept more commentaries
on this topic.

L.R. Huntoon, M.D., Ph.D., F.A.A.N.
Journal of American Physicians and Surgeons

Thursday, May 26, 2011

Welcome Taj

For those in the obstetric profession who have not experienced the joy and peace and marvel of a home birth, whatever their reason may be, I would suggest they stop and think a second time. Last evening Karni and I were once again privileged to assist in the home birth of baby Taj and the rebirth of a woman and her family unit. That is all there is to say. Home birth is filled with wonderful stories that never make a headline and yesterday was one of those moments. There is so much more to giving birth than just giving birth and the home environment absolutely enhances the experience for informed women who freely choose that option. There is room in the birthing debate for more open mindedness and a respect for the process. Congratulations to Amara & Mike and thank you for the privilege. Dr. F

Tuesday, May 24, 2011

Panel discussion at Bini Birth on June 1st, 2011

Check out what Bini Birth and Ana Paula Markel are up to on June 1st. After an all day workshop with Naoli Vinaver there will be a panel discussion with Naoli, Dr. Elliot Berlin, Dr. Suzanne Gilbert-Lenz, Davi Kaur Khalsa and me on Breech and Other Variations of Normal. June 1st from 7-9 PM at Bini Birth, 5355 Cartwright Ave, Unit 313, North Hollywood, CA 91601. Hope to see you there.


Friday, May 20, 2011

Another sign of the times.

I had the great fortune to attend my stepson's graduation ceremony from NYU Film School this past Wednesday in New York City. A time honored tradition that the NYU faculty did a fantastic job with. About 35,000 people attended the ceremonies at Yankee Stadium and mother nature was kind as we had dry skies in an otherwise rainy week. Even the sun poked out for a moment while former President Bill Clinton gave the keynote speech to the graduates and happy families. Then each college dean recognized their respective graduating class. What was most telling for me was that the NYU Law School graduated 1020 new lawyers while the Medical School produced only 178 physicians. Almost a 6:1 ratio of lawyers to doctors. Shouldn't it be the other way around?

A sad statistic on an otherwise glorious day.

Sunday, May 15, 2011

More on Breech and Informed Consent


For those interested, the Royal College of Obstetrics & Gynecology has put out revised parameters supporting an option of vaginal breech delivery. Based on research that debunked a lot of the information in the earlier Term Breech Trial that organized medicine originally jumped on to recommend c/section for all breeches. The RCOG is way ahead of ACOG in the strength of their statement and the commitment to try to reeducate practitoners in the art of breech delivery. If you are breech or have a client who is breech at 35-36 weeks this would be an excellent educational, calm reasonable website to refer to families who want to know more. Might keep them from surfing the interent in unfiltered and sometimes hysterical sites.

When considering a home breech delivery, as that may be the only option left in many areas, it is important to give true informed consent. The most significant difference in a home birth with a skilled practitioner is the lack of ability to use Piper forceps for my midwife colleagues since this is out of their scope of practice. Trained physicians can use these helpful aids and I carry them in my birth supplies. Once again, showing the collaborative approach of midwife and doctor teaming up can provide optimal care. Of course, we all know how few doctors there are willing to collaborate with the midwife community and the pressure those few are under from their peers. Also, the diminishing number of doctors skilled in breech delivery is concerning. Lastly, home birthing also lacks the immediate availability of general anesthesia in the extremely rare case where complete uterine relaxation is necessary to assist in delivery of an entrapped head. Women need to know these things but they must be presented in the light of the reality that the likelihood of this frightening problem is extremely rare when proper selection criteria labor management for breech delivery are used. In my opinion, the risks of a complication that is life threatening is more common from a surgical birth and these should be discussed as well. Then, whatever decision is accepted by the family should be respected. Where vaginal breech delivery is the preference but not an option, an ethical practitioner should refer that patient to someone who can honor her request.

From the AMA's Code of Ethics:
The patient should make his or her own determination on treatment. The physician's obligation is to present the medical facts accurately to the patient ... and to make recommendations for management in accordance with good medical practice ... Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment

Dr. F

Friday, May 13, 2011

Bad news has decibels.

There is a lot of buzz when a homebirth goes awry. No one should relish in the misfortune of another. Bad things happen in birth sometimes. No matter what the location. Yet there does seem to be some piling on when a homebirth is involved. Below are a couple of links to stories or blogs in the aftermath of a midwife who pled guilty to two felonies in a home breech delivery case in Maryland. I added my thoughts to the comments section on both of them. Dr. F



Tuesday, May 10, 2011

Tragic ending to a tragic story.

Not much I can add to this well written story in Slate. I thought the writer did an excellent job of reporting on this sad tale. Please read and comment here. Thanks, Dr. F


Monday, May 9, 2011

What is.....Breech delivery at home?

If I were playing Jeopardy and the answer was: "The only option left in SoCal to a woman whose baby is butt first", the question would be.......(see title).

Proud to announce the delivery of little Andrew this morning, bruised bottom and all, to excited first time parents, Eva & Jared. When faced with no other option but forced, not elective, cesarean section they chose, instead, the unlikely option of a home breech delivery. Informed of options, risks and benefits and knowing they would like to have many children they felt that c/section was a bad choice for them. Hospital vaginal birth with the one doctor who still accepts primip breeches was financially nonviable due the limitations of their HMO policy. The Sanctuary Birth and Family Wellness Center midwives and I were delighted to help this couple achieve their goal in the comfort and privacy of their own bedroom. Using the skills I learned in training and adhering to specific guidelines for the safety of breech vaginal birth made this choice possible. Respecting the right of true informed consent and all birth options made it a wonderful day for all involved. Thanks Molly and Heather Anne. Dr. F

Sunday, May 8, 2011

First Tranport

5/07/2011: Birthing at home can be a miracle and a blessing. On rare occasions even the best laid plans can fall short. Sometimes exhaustion sets in when too little sleep and nourishment occur over the course of a 29 hour labor. After 9 months of assisting in home birthing I finally had my first need to transport a family in labor. Thank God for backup physicians like Dr. David Kline and the judicious use of epidurals and pitocin. They do have their place. With his patience and skill a beautiful baby girl was born vaginally early Saturday morning. Mom, dad and baby were home again inless than 6 hours. This family was delighted and had the satisfaction of knowing that these interventions were necessary and what was needed by their sweet baby girl to enter this world.

Happy mother's day to them and to all of you. Big hugs all around. Relish in them as there is an emptiness when your mother is no longer with you to hold.

As for me, this was a watershed moment. It was the first time I can recall in my 25 years in private practice that I had to relinquish the care of a woman to another colleague. This felt very strange for me as I am a healthy bit obsessive about completing tasks to which I have committed. I have shared this feeling with some of my midwife colleagues today and want to thank them for their awesome support. A big hug to my friend and colleague for 29 years, Dr. David Kline, too. Thanks, Dave.
Dr. F

Sunday, May 1, 2011

Only 2 state-licensed birthing centers in Central Indiana close

Citing problems with insurance coverage and insurers reluctance to pay for birthing center births despite the savings of about 50% from the cost of a hospital birth these 2 centers were forced to close. The midwife running the 2 centers, Barbara Bechtel, also stated that the insurers demanded an obstetrician be her backup rather than the family medicine doctor she had been relying on. She could not find cooperation from the local obstetric community and so this option for mothers is no longer available. There was no mention of problems with bad outcomes to justify the noncooperation. But is it hard to figure out why? See the full article at the link below. Dr. F