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Sunday
Dec052010

A Physician Responds to Claim about OB-GYN Education

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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.

 

 

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Reader Comments (17)

What a delightful read first thing on a Monday. Thank God for Henry Dorn.

December 6, 2010 | Unregistered CommenterKemi Johnson

Hear hear! I got goosebumps reading this. How well-phrased, thoughtful and truthful a response!

December 6, 2010 | Unregistered CommenterHeather Nugent

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.

December 6, 2010 | Unregistered CommenterMeghan

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.

December 6, 2010 | Unregistered CommenterJMT

Thanks for sharing this. Explains so much.

December 6, 2010 | Unregistered CommenterAnother Rachel

Wow - what a fantastic response. So refreshing.

December 6, 2010 | Unregistered CommenterChristy @ pureMotherhood

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.

December 6, 2010 | Unregistered CommenterHenry Dorn MD

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.

December 6, 2010 | Unregistered Commenteremjaybee

Thank you, Dr. Dorn. Wish there were more out there like you.

December 6, 2010 | Unregistered CommenterBecca

Ditto on the goosebumps - nice to see some honesty.

December 6, 2010 | Unregistered CommenterMychel
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