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Wednesday
Dec162009

Defensive Medicine and Internet Message Boards

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Fetal death mentioned

I rarely jump into message boards to which I don’t already belong. When I do, it might be just to remind people that it’s okay to question their care provider if they have any doubts about their recommendations, but every now and then I pull out ACOG’s practice guidelines or articles about inaccuracy of fetal weight prediction. I went in with good intentions on a major baby/parenting site awhile ago. Here’s how it went down:

The original poster was all, “I’m 35 weeks and my doctor says the baby is huge and I might tear a lot” and Dr. Dangerpartum Von Deathtrap was all, “25 percent of babies over 9 pounds experience birth trauma so they should offer you a cesarean so you know your options” and I was like, “That is not true… cite” and meanwhile the person I later found out was the moderator was all “Are you calling him a liar? My money’s on the doctor” (because apparently it’s a competition) and then Dr. Von Deathtrap listed several factoids that didn’t address the 25 percent claim and another poster chimed in and was like, “Why would doctors rely so heavily on ultrasound if it’s so unreliable” and the doctor was all, like:

“It is because you have never had a baby die

with its head out and shoulders stuck…that is

why you don’t understand. Have have seen

docs leave Ob after the trauma of losing a baby.

One dead baby in a docs career is one too many.”

 

And with that, I felt bad for jumping in, realized the site wasn’t for me and apologized to the OP for what had devolved into an unsupportive thread and bailed. I just now found a follow-up comment from the group owner that asked why I was even there because the group was about being helpful and supportive.

Indeed. Support the pregnant woman in the last few months of her pregnancy by graphically describing dead babies and telling her how doctors rely on ultrasound to make inaccurate estimates of fetal weight after having had one bad outcome that they probably couldn’t have predicted in the first place and for which all future patients will pay by being, what, over-tested and sectioned?

It’s reassuring to believe that all doctors make their decisions based on scientific data. In fact, it seems that some doctors love to pat each other on the back and talk about how they work from facts and patients, or “laypeople” as they’re known in this social hierarchy, merely run around with anecdotal silliness.

This might be true. However, if doctors really have all of this data and accurate information about the risks and benefits of interventions, then why don’t they all share it with the pregnant women who trust them? Typically, the knee-jerk response to that question is “fear of litigation.” How many times have we heard doctors and the general public brush off defensive medicine as just an unpleasant reality of our litigious society? Even ACOG admitted publicly that doctors practice defensive medicine and “ultimately hurt patients.”

 

Defensive medicine involves lying to patients.

Defensive medicine is about putting a doctor’s or hospital’s interests before those of the patient.

Defensive medicine takes “First, do no harm” and turns it into “First, redefine harm and try to sell your patients on it without them suspecting.”

 

So if doctors really operate from facts, some of them sure put a lot of energy into trying to scare their pregnant patients into compliance. The problem with so many of them crying wolf is that it’s hard to know who can be trusted. Even creepier is that the anti out-of-hospital birth lobby thinks all women need to just suck it up and deal with it.

Over on another message board, I addressed a question I came across of a woman who had received some big baby warnings because of her possible case of gestational diabetes that had been discovered in her 35th week of pregnancy even though her 30 week screening was negative. I left a really long reply of mostly questions and personal experience, which is excerpted here:

I’m finding myself right now spending an inordinate amount of time trying to decide what to say succinctly (and failing at the succinct part). I blog about this a lot but I usually don’t jump in and chat with women directly, but I just answered a similar concern elsewhere last week which will tell you where I’m coming from.

You are not alone—this scenario is increasingly common. And yes, I think you are correct in saying that they are working really hard to scare the crap out of you. Just wait until they start telling you about procto-rectal episiotomies and the Zavanelli maneuver.

I was in your shoes four years ago to the day (with two exceptions: they scheduled me a c/s and the pointless GDM test, which they did a few days before I gave birth was “normal but on the high end”) and we had a really hard time fighting off a cesarean. I wasn’t planning on any interventions in labor if I could avoid them, nor was I opposed to surgery if there was an actual need for it. I also had the benefit of time, which I used to read medical journals and articles. It was a really stressful and fairly morbid way to spend the last week and a half of pregnancy when all I really wanted to do was nap and compulsively fold and organize baby socks.

I also had a Bizarro World experience when a friend convinced me to go spend a few hours with her home birth midwife. The only person in the last week and a half of my pregnancy that gave me any evidence-based information on shoulder dystocia, ultrasounds, macrosomia and birth in general was a home birth midwife. I looked up everything she told me and everything the doctors told me (which was not based on anything but their personal anecdotes) and it blew my mind. I’ve never really looked at the world the same, honestly.

The similar concern that I had addressed elsewhere that was mentioned above was this Yahoo! Answers question:

Question: I’ve heard so many people say the doctors guessed the baby’s weight by ultrasound and were off by 2 lbs or so. They think my baby weighs 10lb 4oz now. I’m 4 days past my due date and baby has measured at least a week ahead from my first ultrasound. They said it could be off by a pound. How many of you were told your baby would be this big and it was much smaller? And were any told baby was this big and it was bigger?! Women who have delivered 10+ lb babies, did your baby have shoulder dystocia?

My answer: 

Hi! You got some good comments. I was in your shoes a few years ago. I was told the baby was 10#2 at 37 weeks. She was born with no problem at 39.5 weeks and weighed 10#3, which would have put her about 9-ish lbs at the time of the u/s. Big babies run in the family and I later had an 11#5 baby, again with no problem. In the absence of gestational diabetes, babies over 10 lbs. are rare.

The hospital (midwives, docs) went nuts trying to push me into a c-section based on the u/s estimate. I declined because they gave me no evidence— only anecdotes of their personal experience that they had seen shoulder dystocia and “it’s really bad.”

It can be really bad. However, the problem with their claim was that 1) there is no truly accurate predictor of fetal weight and 2) shoulder dystocia occurs unpredictably and 50% of the time it occurs in babies that are not considered macrosomic (big). So if they couldn’t tell with scientific accuracy the actual weight of the baby, then as far as anyone knew, I wasn’t actually at an increased risk of shoulder dystocia.

Most cases of SD are resolved with no injury. It would take 3,700 of scheduled cesareans on suspected macrosomic babies to prevent ONE case of permanent brachial plexus injury.

Sorry… long answer. Anyway, sorry you’re having to focus on morbid stuff at this point in your pregnancy. Another thing to keep in mind is that there is a recent study suggests that inducing a macrosomic baby with Pitocin makes shoulder dystocia 23 times more likely.

I had to fight to give birth normally, unfortunately. I’m not sure if they’re giving you the c/s push or not, but ask what you can sign in advance to let them know you understand their concerns if you are fine with labor taking its course. Good luck! –Jill

The best part was finding her reply in my inbox:

Great info, this is why I was worried about inducing and ending up with a c-section. Fortunately I ended up going into labor the night I asked this question and he was born after a 4 hour total labor at 10lbs 8.7oz. He had no problems at all. Thanks!

 

That’s about it for 2009. I don’t give a lot of advice, but I will share my experience and try to point people in the direction of asking questions of multiple sources so they can make their own decisions and hopefully feel good about them. This blog and its Facebook fan page have shown me that there’s really no need to poke around the internet to find women who have felt the discriminatory sting of defensive medicine or who are suffering the consequences of trying to give birth vaginally in a system that is slowly snuffing out a woman’s right to do so. They’ll search for you.

 

 

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Reader Comments (222)

Ugh, I know what you are talking about. At least the forum I moderate is all about doing it yourself LOL
I usually send people private messages if I need to go against the grain, and just say take it for what it is worth. I get more positive reactions from doing that. I don't even post publicly on mainstream forums anymore. Am just there to get a idea as to where most women are when it comes to pregnancy, birth and maternity care. It is rather appalling and tragic.

December 16, 2009 | Unregistered Commentermaria

I have been banned from a few message boards just by simply saying what you were saying. I started a few riots. *eye roll*
I try to help when I can... but it's sad when you have to watch out what you say and how you say it because someone won't like it. God forbid you think for yourself. God forbid you question anything.

That's awesome that woman ended up having her baby vaginally with no problems--10 lbs and all! Woo-hoo!!

December 16, 2009 | Unregistered Commentermichele

Doctors don't like it when their idea of "facts" and "science" is exposed. I never went to medical school but you don't need an MD to smell bullshit.

And yes, what is it with "support" apparently meaning "encourage subject to take the route that is most dangerous, non-evidence based, and not what she wants at all"?

December 16, 2009 | Unregistered CommenterJill

"Defensive medicine involves lying to patients.

Defensive medicine is about putting a doctor’s or hospital’s interests before those of the patient.

Defensive medicine takes “First, do no harm” and turns it into “First, redefine harm and try to sell your patients on it without them suspecting.”

Are you serious? You think the only person who is harmed by a dead baby is the doctor?

Defensive medicine is about doing everything possible to prevent preventable deaths. We could have a meaningful ethical discussion about whether we can ethically justify doing "everything possible" in light of the fact that "doing everything" has risks of its own. However, you've effectively short circuited any possibility of a meaningful discussion by flinging absurd charges.

December 16, 2009 | Unregistered CommenterAmy Tuteur, MD

Ah, Amy, you are back. And again, you have totally misinterpreted the comments. Nowhere did Jill say that a dead baby only affects doctors. What she said was that the weight of evidence does not support the interventions suggested. She also pointed out that many doctors act on anecdotal rather than scientific evidence, and in my experience this can be true of ALL HCP's. All HCP's are capable of doing things because they have "seen" a given outcome. The simple fact is that when a doctor or other HCP who is practicing based on anecdotal experience acts against the weight of evidence, said HCP has a responsibility to provide the woman with the scientific evidence as well. For example, within my practice, I sometimes suggest women consider visiting a cranial osteopath. I councel them on the fact that I cannot give them any scientific data to support this evidence, as there isn't any. I point out that while many women report improvement in settling babies following this intervention, no studies have been done to prove that it actually works. I then leave it in their hands to make a decision. Some go, some don't. Some are happy to accept anecdotal evidence others are not. In the case of a recommended C section for macrosomia, there IS scientific evidence, and that evidene does not support the intervention. But, you can recommend it anyway, as long as you present BOTH the scientific evidence against AND the anedotal evidene for.
I HATE the dead baby card. It can be used in any situation. It is emotive, non scientific and completely inappropriate. The problem with pulling out the dead baby card is two fold: One, it is used in situations where women could be given balanced fats to make an informed decision, but are instead threatened and bullied. two: the use of the dead baby card in the aforementioned way results in women mistrusting their care providers, so that when I recently had a client at 5 cms who's baby was suffering a bradycardia to 70bpm and was told we needed to urgently deliver the baby, she felt the need to question for a full five minutes. All that time, the babies hear rate stayed low, and when it was eventually born by CS it was in a very bad way. But all the earlier inappropriate usage of dead baby threats had left her unable to trust that this was not one of those situations. Terrifying.

To my mind, when a woman is carrying a potentially macrosomic infant, it is important to tell her the risks and benefits of interventions, and also to offer her all the options available to her, including CS. But, relative risk s an important discussion to have. even infants of diabetic mothers have more risks from CS than from vaginal birth, even including SD. Amy, if you want to discuss defensive medicine and the varying ethics of "doing everything possible" please do. Nothing that has been said on this thread is preventing that. But, bring your references with you, love.

December 16, 2009 | Unregistered CommenterAnna

Wikipedia has a neat and tidy little definition:

Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited [1] as the driving force behind defensive medicine. Defensive medicine is especially common in the United States of America, with rates as high as 79% [2] to 93% [3], particularly in emergency medicine, obstetrics, and other high-risk specialties.

Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances [3].

Theoretical arguments based on utilitarianism conclude that defensive medicine is, on average, harmful to patients.[4]


From a September 11, 2009 ACOG press release:

ACOG Releases 2009 Medical Liability Survey
Results Paint Dismal Reality for Ob-Gyns and Their Patients

Washington, DC -- As the negative state of the medical liability environment continues, ob-gyns across the US are forced to make changes to their practice that ultimately hurt patients, according to The American College of Obstetricians and Gynecologists' (ACOG) 2009 Survey on Professional Liability. More than 63% of ob-gyns report making changes to their practice due to the risk or fear of liability claims or litigation; 60% have made changes to their practice because liability insurance is either unavailable or unaffordable.


Medicinenet.com’s definition:

Defensive medicine: Medical practices designed to avert the future possibility of malpractice suits. In defensive medicine, responses are undertaken primarily to avoid liability rather than to benefit the patient. Doctors may order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability. Defensive medicine is one of the least desirable effects of the rise in medical litigation. Defensive medicine increases the cost of health care and may expose patients to unnecessary risks.


Merriam-Webster online:

Main Entry: defensive medicine
Function: noun
Date: 1973
: the practice of ordering medical tests, procedures, or consultations of doubtful clinical value in order to protect the prescribing physician from malpractice suits


Amy Tuteur’s definition of defensive medicine:
“Defensive medicine is about doing everything possible to prevent preventable deaths.”


Sounds closer to the definition of preventative medicine. There’s a huge difference.

December 16, 2009 | Registered CommenterJill

I find it ironic, Jill, that you feel it necessary to practice defensive medicine while condemning others for doing so. Why is that disclaimer at the bottom of this page if not because you fear being sued?

December 16, 2009 | Unregistered CommenterAmy Tuteur, MD

Sorry, is Jill a doctor now? Or any type of HCP? Amy, come now, you can do much better. That is a standard dislaimer for any and all websites which discuss medical information. It is defensive, possibly, but it is certainly not medicine!

December 16, 2009 | Unregistered CommenterAnna

Ever since you suggested a google alert along the lines of "big baby c-section ultrasound", I have had one set up. Hoo-boy, it does kick up a lot! I have tried to keep my fingers out of it (have sometimes just considered posting a link to your website!) and look on it more as an educational experience than an opportunity to tell someone they're Wrong on the Internet (see the xkcd comic Rixa posted) in part for not wanting to get drawn into the situation you experience with your first posting. But I'm glad you are jumping in sometimes and giving the info! It's a nice counterbalance to 'if ur dr says u need it then u prolly do".

December 16, 2009 | Unregistered CommenterRebecca

Jill, I think I have a girl-crush on you. Excellent post and follow-up. Thanks!

December 16, 2009 | Unregistered CommenterLori
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