A Physician Responds to Claim about OB-GYN Education
Sunday, December 5, 2010 at 11:51PM
By Jill—Unnecesarean
Henry Dorn, M.D., responded in a comment on yesterday’s post, ACOG v. Midwives, Part a Million, to the following statement in a WTTW news feature:
Screencap of WTTW new clip“Dr. Abramowicz says that a physician may go through 12 to 15 years of training, including medical school, before delivering a baby.” [03:27 mark of the video]
Henry wrote:
As an OBGYN, I can attest that we start doing deliveries very early in our careers, often with varying degrees of supervision. In fact when I was in medical school, the labor floor was so busy that my first delivery was also the first one I had seen, since 2 other women were delivering simultaneously, and the very experienced labor & delivery nurse coached me through it. (I would note that the medicolegal climate has changed since then and this sort of occurrence is now a rarity.) We also had midwives working on the unit which gave me an early exposure to that type of practice, and certainly instilled in me confidence in their skills and abilities.
A vast majority of our training as an OBGYN is not in normal deliveries but in taking care of sick women, either with GYN related disease or women with high risk pregnancies. Therefore, the majority of the laboring patients we care for have been referred to us from other hospitals and practices, due to their degree of risk. We learn a great deal from seeing these kinds of patients in a concentrated environment, surrounded by experienced attending physicians, but it gives a skewed perspective on normal birth.
It was likely not until I practiced in New Zealand, which has midwives as the primary caregivers for pregnant women, and no history of malpractice lawsuits, that I really was able to witness normal childbirth. The obstetricians, of which there were few, only looked after the high risk patients, or came in when there were issues. Many women chose homebirth and few of these required transport to the hospital. I did not witness or hear of any catastrophes, and the statistics for that country for newborn outcomes exceeds that of the US.
I believe Marsden Wagner said that having an OBGYN attend normal deliveries of low risk women is like hiring a pediatrician for a babysitter, in case the child should get sick. The New Zealand model recognizes this and reserves their doctors for the women who truly need them.
I feel strongly that a system which allows deliveries by well trained midwives, who have a collegial relationship with a supportive physician community is a safe one and is far preferable to treating women who opt for homebirth as outsiders and their caregivers as criminals.
The biggest hurdle however is educating the OBGYN community, and I am afraid that once prejudices are established early in one’s career, it is nearly impossible to eradicate them.
So no, we don’t train 12-15 years before delivering babies, and at the end of that training, perhaps only 1-2 years is actually spent attending deliveries, which brings the CNM or CPM’s training in childbirth a lot closer to ours. Knowledge of ovarian cancer staging, or the ability to perform a laparoscopic hysterectomy does not make me a better caregiver for the patient in labor, and yet the midwife’s focus on facilitating the normal birthing process in healthy women does lessen their chance of adverse events, and this mode of care should at the very least be an option for women.
Reader Comments (17)
What a delightful read first thing on a Monday. Thank God for Henry Dorn.
Hear hear! I got goosebumps reading this. How well-phrased, thoughtful and truthful a response!
I hate the 12-15 years of education/training comments that always get brought up for physicians. Four years of that is a standard undergraduate degree; yes they take pre-med classes, but I also took all of them for my chemistry degree. This does not mean that I am four years into being a physician!
If you want to quantify medical education and training then lets start counting with medical school and the following residencies, internships, fellowships, etc.
Thanks, Henry, for the information!
This isn't the first I've seen someone suggest that the cure for our current childbirth ills won't come until we address OB education. It seems like such an impossibly tall order, though, given the makeup of the childbirth activism sphere (read: mostly not obstetricians or those who educate them). It's not usually the POV I have on education (either public or higher) but this is a great example of institutional hegemony and how it maintains a faulty system.
I'm about to sound like a total fangirl (woops, cuz I am), but for those interested in more on the topic of obstetric education, Robbie Davis-Floyd devotes a chapter to it in Birth as an American Rite of Passage.
Thanks for sharing this. Explains so much.
Wow - what a fantastic response. So refreshing.
An OBGYN colleague felt I should mention the difference in total numbers of deliveries between OBGYNs and CPMs in training, which is substantial, but the initial question I was responding to was how much training we have before we begin to do deliveries.
I am also fairly sure that CPMs and CNMs require a similar number of deliveries for their credentialing. (MWs please jump in with the specifics).
Additionally there is a very different skill set learned from running in a room at the last minute as most interns do and delivering a woman with an epidural, vs attending the entirety of a normal labor, which is the midwifery training experience.
Do midwifes vary in their experience & quality? Certainly, as do physicians. (I would however put an experienced midwife head to head with any OB when it comes to dealing with a shoulder dystocia, which is probably our biggest nightmare.)
What I am advocating is the availability of well trained, properly credentialed midwives who have a close relationship with an OBGYN and who know which patients require referral due to their risk profile. This integrated system will be a struggle to achieve in the US in the near future, but has proven itself to be effective around the globe, and will likely expand care to needy populations in our underserved areas, in a cost effective manner.
Dr. Dorn, thank you so much for your response! And thanks to Jill for highlighting it. It's so heartening to see OBs who want to work with midwives and improve overall care for laboring women.
Thank you, Dr. Dorn. Wish there were more out there like you.
Ditto on the goosebumps - nice to see some honesty.
I am a little late in getting up to speed on this ongoing discussion:
Thank you Dr. Dorn for breaking rank and exhibiting bravery about this discussion. As far as I can tell it is the only way that this problem is going to be ameliorated for doctors to peel back the layers, setting aside the party line and saying we truly want mothers and babies to be safe.
As far as Dr. Jacques Abramowicz is concerned I just have to say: Dr. Abramowicz I love your circular fallacious reasoning.
I submit for your consideration Unnecesarean fans and foes:
1. If we do not license and regulate providers then we have NO IDEA what their credentials are and can have no influence over their training, their retraining or their fitness for their profession. We cannot support the good ones and sanction the really bad ones.
2. Is Illinois a state where a middle class family can afford to pay for a hospital birth? If not, then offer them a SAFE alternative and know who is attending births in your state or dramatically lower your fees and let people have autonomy during their hospital birth.
3. Midwifery is not medicine.
4.Certified Professional Midwives do indeed have training in all of the medical emergencies that you describe, please stop leading or trying to lead the public astray with your, I'm the doctor so my training is superior so I know what is best for you rubbish. I am pleased to see that the legislator in this report gets what you fail to see. It is about patient safety first.
5. My dentist told me last week that I was an informed and educated consumer because I knew so much about my periodontal problems and how to take good care to avoid an unfortunate escalation of them. She is not concerned that I am going to attempt my own root canal but respects the fact that I have done my research about my own condition. Why does obstetrics feel so threatened by an informed consumer in the realm of their specialty?
6. Regulating home birth midwives will not cause the flinging open of the L&D units of your state. Parents will continue to have their babies in hospitals. Regulation and statute will instead provide needed transparency in a practice that goes on anyway despite the fact that ACOG does not approve. Your state will be protecting the 1% of home birthing parents that need the state's oversight with regard to health care practices.
7. Not regulating midwives creates such a fallacious paradigm regarding money: A midwife whose training is "in the wind" and not standardized will have no reason to NOT take a high risk client/clientele. A person can tell themselves whatever they want about the safety of birth and attending them without the essential training to spot and treat emergencies. Every day that there is no recognition of midwives other than CNMs in your state is a day that the state puts their most vulnerable constituents at risk.
8. Stop trying to save us from ourselves.
9. If a cab driver, baby brother or sister, police person or parent attends the birth at someone's home and things go well, we send a news crew out and say Bravo, but when a baby is born in the mundane manner of a routine vaginal birth at home they have committed a feat against nature apparently.
10. I don't have anything ground breaking for number 10, I just like things to be even.
A great read!!!
Bravo, Dr. Dorn, you are my hero! Wish there were more docs like you, you are a breath of fresh air. Please keep speaking up!
Thanks, Dr. Dorn for your commitment to normal birth!
Thanks Dr. Dorn and SaanenMother!!
Thanks for this! What an inspiration.
Thank you, Dr. Dorn! I read your comment on the original post, and I'm glad Jill has highlighted it here. It's so good to know that there are OBs out there who allow themselves to think critically about this situation rather than towing ACOG's line. More importantly, you give me hope that there are OBs out there who have the not their own, but the iinterests of ALL women at heart, both the high-risk moms who need OB care and the vast majority who can benefit equally or more from midwifery care.