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Tuesday
Jan112011

The Trap of Overselling and Underdelivering

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By Henry Dorn, MD


In 1974, the noted obstetrician Marcus Filshie published a review of the relatively new electronic fetal monitoring in the British Journal of Hospital Medicine. He stated, somewhat fatefully:

“Now that the appropriate technology is available, the obstetrician may virtually eliminate intrapartum stillbirths and reduce morbidity to a minimum.”

Similar statements were made in the United States by leaders in the obstetrical community and headlines were created. Although there was significant evidence that spoke to the limitations of this technology, the obstetrical community and the general public leapt to embrace this new found “cure” for adverse neonatal outcomes. Certainly in an age in which man could travel to the moon, computers were becoming commonplace in academic settings and nuclear energy a reality, doctors should be able to reliably detect fetal distress and act upon it safely, sparing parents the grief of the past.

Likewise, ultrasounds have allowed us to peer into the womb, and into the bodies of our unborn children, allowing us to anticipate not only the gender of our babies, but also see things as subtle as heart or spine defects. Yet everyone knows a story of the girl who turned out to be a boy, despite our best imaging efforts, and the mixed feelings that that surprise engenders (pun intended).

Molecular biology has allowed us to go even further, and examine the blueprints of life in utero, allowing parents to prepare for a child with chromosomal issues, or reassuring those with family histories of hereditary disorders.

Altogether, ever advancing science has created a sense of control over what once had been a very insecure time for families and their caregivers. The idea that following the current best medical evidence will virtually guarantee best outcomes is an appealing extension of that new found power over nature, but is a belief system that is inherently flawed, and that fact is often not appreciated by those who are captivated by its seduction.

Joseph Campbell, the comparative mythologist noted that cultures which are the most subject to the variable forces of nature, such as seafaring peoples, have the most rituals, in order to exert some sense of control over the uncontrollable. The obstetrical community must fit that model, insisting on specific rituals of care, even in the absence of absolute evidence of their efficacy, in order to gain a sense of control and mastery of the birthing process. The fetal heart rate tracing is poured over like tea leaves or cast bones, and the doctor becomes the shaman.

This belief system has been preached to future physicians and  obstetricians, who passed it along to their students until the whole culture of childbirth medicine became steeped in a religious-like belief in the power of the fetal monitor, labor curves, ultrasound measurements and the like. This belief is similarly conveyed to patients who are assured that if their pregnancy was managed according to the protocols developed by trusted researchers, their babies would be delivered without fail and without harm.

Reality, however, has proven otherwise. Despite close and continuous monitoring in labor by the best trained and most capable staff and doctors, babies still die suddenly, or are born with unexpected asphyxia, or unanticipated illness. Families feel bewildered and betrayed and seek explanation and often recourse. If the latest technology was employed, then certainly human error must have been the cause.

Trial lawyers turn physician’s own promises against them and win huge lottery-like settlements, setting precedence, and further convincing the public that the fault was not in the system but in the individual caregiver.

If, however, one looks critically at the myriad of diagnostic methods, and treatments used by the modern obstetrician, it becomes quite clear that there is much that is uncertain and much we cannot control. Most experienced practitioners know this, but are often resistant to admit this to their patients and the public, but this lack of disclosure has a tendency to backfire.

This is not to say that modern obstetrics with all of its technologies and oft maligned “interventions” is without value. Huge numbers of babies and mothers have been saved by modern medical care, but the failure to admit to ourselves and the patients we serve that we cannot guarantee perfect outcomes does a disservice to us all. Bad things do happen to good doctors (and nurses, and midwives etc) and the sooner everyone understands this, the sooner we can start practicing evidence-based medicine as opposed to ritual-based medicine.

Conversations need to start with recommendations and explanations of their rationale, but leave room for the ever present uncertainty of outcomes as well as factoring in the patients desires and apprehensions. I believe that “I don’t know” are three of the most powerful words in medicine and should be used more often. Patients who don’t want to hear this need to realize that any practitioner who believes that they truly KNOW anything for certain is more dangerous than the one that makes allowances for the great amount of variability that life entails.

This more open communication should certainly help to restore the trust patients once had in their providers, and begin the process of reducing costs due to defensive medicine, as well as lessen patients’ sense of betrayal that sometimes occurs with unexpected bad outcomes.

 

 

Henry Dorn, MD, is an OB-GYN who currently practices in High Point, NC. www.drdorn.com

 

 

 

 

 

 

 

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Reader Comments (36)

"The fetal heart rate tracing is poured over like tea leaves or cast bones, and the doctor becomes the shaman."

I loved this part. I think this is my favorite post so far. Thank you Dr. Dorn!

January 13, 2011 | Unregistered CommenterHeather

Readers might also be interested in this article, written by Robbie Davis-Floyd, a medical anthropologist focusing on childbirth, obstetrics, and midwifery. http://www.davis-floyd.com/USERIMAGES/File/Obstetric%20Training%20as%20a%20Rite%20of%20Passage.pdf
It offers good insight into how the American medical education system contributes to training doctors to act as the shamans Dr. Dorn describes (though not explicitly referred to as such in her article).

January 13, 2011 | Unregistered CommenterLauren

Excellent and bravo! Technology gives us such a false sense of security, rather than being seen as a tool with limits being used and interpreted by humans. It is really hard for us to admit we can't control much in the grand scheme, birth included.

I also appreciate how you invoke ritual-- calling that out.

Nicely done, and thank you yet again for participating in this forum.

PS Jill-- how many more of these posts?! I haven't done any work this week! :)

January 13, 2011 | Unregistered CommenterAnother Rachel

Thank you. Excellent essay from a great role model.

January 13, 2011 | Unregistered CommenterMomTFH

Wow. This is a very powerful article. I was nodding my head "Yes!" with every word. Thank you!!

January 13, 2011 | Unregistered CommenterTine

YES!!!! My birthing pattern doesn't follow the norm and so therefore must be disordered and *fixed*.. no- it is normal FOR ME- my mom birthed the same way!!! Let nature be and ride with it and birth will be cheaper and less frightening

January 13, 2011 | Unregistered CommenterChris

"This belief system has been preached to future physicians and  obstetricians, who passed it along to their students until the whole culture of childbirth medicine became steeped in a religious-like belief in the power of the fetal monitor, labor curves, ultrasound measurements and the like."

What??!!! Where did you train, and who on earth ever said any of that?

NO obstetrician has a "religious-like" belief in the power of the fetal monitor. ALL obstetricians are aware that the fetal monitor has a low false negative rate and high false positive rate and this information has been out there for decades.

NO obstetrician has a "religious-like" belief in the power of ultrasound. ALL obstetricians know that ultrasound for dates is accurate +/- 1 week in the first trimester, +/- 2 weeks in the second trimester, and +/- 3 weeks in the 3rd trimester. And ALL obstetricians know that fetal weights are less accurate the closer you get to term, varying +/- 1 lb or more.

The problem is not that obstetricians have a "religious-like" belief in their technology; the problem is that it's the best technology that we have at the moment.

January 13, 2011 | Unregistered CommenterAmy Tuteur, MD

Dr. Tutuer,

The only thing consistent about your comments is their contrary hostility. You accuse writers in this series of bashing OBs then proceed to call OBs you knew "butchers" in same thread. Then, you insulting ask Dr. Dorn where he trained. Who is the one who is bashing OBs?

There are many OBs who use third trimester ultrasounds to date gestations to the day (this is how the results are presented) and make treatment decisions, even though the USPSTF rates this practice poorly, and they rarely mention the margin of error. No one is saying ALL OBs do this. You are the one making sweeping generalizations about ALL OBs.

Many OBs and hospitals insist on using continuous fetal monitoring and don't acknowledge the high rate of intrareader variability. There is a program in my area that was using internal fetal monitoring for every single delivery until they had two cases of herpes encepalopathy.

I can attest to personally knowing of OBs who have practice patterns that fit Dr. Dorn's descriptions. I am in the hospitals currently. You haven't practiced for more than a decade. Dr. Dorn is practicing currently. I also personally discussed the overuse of unsubstantiated technology and interventions with Dr. Berghella, who was the primary author on the USPSTF paper on Evidence Based Labor and Delivery Management, at ACOG's Annual Clinical Meeting last year, and he said the misuse and misrepresentation of these interventions and technology make him furious. He is the director of maternal fetal medicine at Thomas Jefferson.

Your practice of angrily arguing on these posts doesn't make you right or relevant. I am happy I have good role models like Dr. Dorn as examples, and I am not surprised other commenters have praised his insight and honesty.

January 13, 2011 | Unregistered CommenterMomTFH

Usually I refuse to respond to her but... dr Amy, saying 'No obstitrician' means that you have personal knowledge of ALL obstrtricians upon which to base this claim. Clearly it would be impossible for you to know, much less know the heart beliefs of every single obgyn in America, much less the world (given that this is the interent and availible world-wide and you made no qualifications for your statement). If you had said 'i've never met an obstitrician that said' or 'i doubt many/most', or any number of more believable things you might have had a leg to stand upon. As is, you just sound arrogant and ignorant. And it's hard to take anything else you might have to say when you carry the belief that you speak for every obgyn out there. I have PERSONALLY met an obgyn who said ultrasounds were "spot on" to determine dates throughout pregnancy, and I've only met a handful!

January 13, 2011 | Unregistered Commenterjespren

"I can attest to personally knowing of OBs who have practice patterns that fit Dr. Dorn's descriptions."

But we are not talking about practice patterns. Dr. Dorn claimed that obstetricians teach their students to have a "religious-like" belief in the power of EFM, labor curves, and ultrasound.

But that can't possibly be the case. There has been controversy about the value of EFM since it was first widely introduced back in 1971. Though Dr. Dorn quotes Filshie, his doesn't mention that his was the minority view.

I trained WITH Dr. Friedman and he never advocated slavish devotion to the curve.

And as far as ultrasound is concerned, obstetricians are well aware of the limitations.

Honestly, Hilary, did any of your OB instructors tell you that EFM is infallible, that labor curves must be adhered to rigidly or that ultrasound is 100% accurate? I can't imagine that anyone ever said that within the last decade, if ever.

Did you read Mr. Tilson's piece in this series? Did you see what he said? He said that as far as plaintiffs lawyers (and many juries) are concerned, even one episode of fetal bradycardia is reason enough for a C-section. It's not obstetricians who have a "religious-like" belief in EFM; if anyone has that belief, it's plaintiffs lawyers.

January 13, 2011 | Unregistered CommenterAmy Tuteur, MD
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