"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, January 30, 2013

Stage 2 Consequences

Much of what passes for legislation these days seems to be feelings based and reactionary. With litte time given to debate or deep thought. As long as it feels good there is no concern whether once implemented it will actually do good. The Affordable Care Act (Obmacare) is the penultimate example of stopping at stage 1 thinking. As Nancy Pelosi so famously said, "You will have to pass the bill to find out what is in it!" Well, think on this! I recently read an opinion piece in the Wall Street Journal titled, "The Doctor's Office as Union Shop" by Dr. David Leffell, a practicing physician and the former CEO of the Yale Medical Group and a professor at the Yale School of Medicine. As you know me by now, I am a critical reader of opinion pieces and pretty much anything that passes as mainstream news these days. It is hard to know what to believe. I could not find any fault, however, in Dr. Leffell’s arguments about what is likely to happen to doctors in the wake of the government takeover of health care thus reducing the once proud sole proprietor into nothing more than a salaried service worker. If you have followed my blog for some time you will find that I am not a fan of the poorly named “Affordable Care Act” for a myriad of reasons. One of which has been the inevitable discouragement of the ambitious and brightest from undertaking the years of commitment and expense it takes to become a physician. Those young men and women who prefer to be shepherds of their destinies and not sheep will look to other opportunities. What will remain are dedicated workers who will prefer defined hours, a better lifestyle and the security of a set salary. While this is not a bad thing in and of itself it is like the proverbial finding of half a worm in an apple. For their employer will no longer be “the self” but will be the government or some big faceless corporate entity dependent on government rules and regulations that define treatment protocols and regulate reimbursement. Dr. Leffell says, “The truth is that physicians are now becoming service workers. They are well-educated and expensive to train, and their decisions have substantial significance in the lives of others. But doctors essentially provide a service, one that cannot be outsourced to India or China……When doctors occupy a service niche like the chambermaid in Las Vegas or the school teacher in Chicago, the expectations and compensation of the physician-worker will be defined in ways that may make the benefits of collective bargaining appear very attractive…… If doctors unionize, that raises an immediate question about their right to strike—the key lever in collective bargaining. That's a question for another day. For now, it's enough to contemplate what will occur when the practice of medicine becomes detached from its past as a profession—when doctors may in time come to see themselves not solely as healers but as workers, units of labor, in a system that is committed to delivering care to the greatest number.” It is inevitable then, as government inserts itself into the equation, that choice for consumers will decline and services will be rationed. Cost containment will fall heavily on doctors and hospitals. With no relief from threats of malpractice lawsuits and pressure to adhere to artificially set performance standards piled on top of less financial reward we will inevitably see rising job dissatisfaction. And although the expectations of Americans will be that they should get the same quality of care for less money in reality that is not possible. All the micromanaging and theories about efficiency do not take into account what happens in the real world. No longer individual professionals but now salaried workers, likely disgruntled salaried workers, what is to keep physicians from unionizing? Leaders of the dwindling private sector organized labor movement will drool at the prospect of a whole new profession to appeal to. As Dr. Leffell’s concludes: As has happened in other countries that have charted the course we are now on, a new reason for lack of access may at times be: "Office closed, doctors on strike." Dr. F

Wednesday, January 9, 2013

Power Point Debut

Today the gracious members of the Orange County DASC hosted a gathering and invited me to come and share my thoughts on home birth and a recent opinion piece in the AJOG which took a strong stance against it. It was an educational experience for all of us and I really appreciated the attention and feedback. I talked about logic and ethics and how this opinion article skewed its ethical arguments, applied faulty logic and created straw man arguments in an attempt to vilify home birth and those who support it. We tend to be a headline reading society and rarely have the time or expertise to truly analyze the content in a critical manner. Doing so here led me to the surprising conclusion that ethicists are not always ethical and the editors of the AJOG ought to not blindly accept shameful submissions from well credentialed authors without vetting the data. I would be happy to share or debate my take on this with any inquiring minds. Happy New year! Lets make it a safe and honest one. Dr. F