The Trap of Overselling and Underdelivering
Tuesday, January 11, 2011 at 9:39PM
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
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!
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).
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! :)
Thank you. Excellent essay from a great role model.
Wow. This is a very powerful article. I was nodding my head "Yes!" with every word. Thank you!!
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
"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.
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.
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!
"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.
I loved this post, and MomTFH thank you for your comment which encapsulates everything I would say in response to Dr. Tuteur's comment. The obvious coin flip of the argument that standard prenatal care and hospital procedures/births are for safety is that women come to expect that if they do everything "right", they and their babies will be safe. Having worked enough in birth, I know that this is not true, but most people don't understand this. Yes, birth feels risky to them, but only in that interventions will enable them to avert risk. I spent a summer internship at a large county health department calling mothers who had suffered fetal or infant losses, and a constant refrain was that they did not understand why their babies had died and felt there must have been a mistake made by somebody, somewhere, along the way. Having had an ultrasound not long before the loss was not uncommon (most were fetal losses) and multiple women talked about how they couldn't understand why everything looked fine one week and was a catastrophe the next: you have an ultrasound to make sure everything's OK with the baby, so if you have an OK ultrasound and then your baby dies, someone must have not read it correctly -- right? It didn't help that many were from traditionally disenfranchised groups and had a hard time trusting that they had gotten the highest quality of care.
These women were not considering suing anybody as far as I know. Most wouldn't have had the resources to pursue a lawsuit even if they'd had grounds. They were just grieving and angry and guilty -- if they didn't blame their doctors, they often blamed themselves, for not eating correctly or resting enough. (Or, in a double whammy, they would blame themselves for not advocating strongly enough for themselves in the medical setting, wondering if that could have made a difference in their care.)
It's the paradox of public health -- we tell people how to make themselves safER, and it's human nature to interpret our advice as a bulletproof shield for staying absolutely safe. When it comes to medicine, I think it's even more tempting for patient and provider alike to engage in some magical thinking. Emphasizing the fallibility of medical care would not just help open communication and trust, but could also help the women who have experienced unexplained losses with some of their sense of betrayal.
How much do I love the Joseph Campbell reference? Oh, so much. I had never actually thought of various interventions or procedures as "ritual" but of course, when you see things such as the unwillingness to encourage and support women to birth out of the lithotomy position, which defies both good practice and common sense, it's hard not to think that the attachment practitioners and hospitals have to this practice is emotional, not rational.
So much of the time, all we as birth advocates are trying to say is that experts are not immune to prejudice, to ignorance, or to sexism, because even the best practitioner is a human being immersed in our culture. Although it's a cliche right out of comic books, the great power that doctors have entails a great responsibility to use that power wisely and humanely as best they can.
Thank you Dr. Dorn.
emjaybee, I shared your excitement over seeing "Joseph Campbell."
@emjaybee and Jill-U
........rite and ritual so close in meaning and derivation. Someone else mentioned Robbie Davis Floyd's paper: "Obstetric Training as a Rite of passage"- that paper opens a lot of doors of the mind. One poor outcome for an OB resident can set them down a path of safety and control for their entire career- very powerful. I think anyone interested in birth would enjoy this paper and RDF balances her argument well.
Great post Dr. Dorn, I like that it gives the reader a sense that you're telling us the painful truth of your side of "the table" while breaking it to us gently. I appreciate your insight and continued dialogue with us here.It's like a breath of fresh OB air.
For clarification, I did not claim that "obstetricians teach their students to have a "religious-like" belief in the power of EFM, labor curves, and ultrasound" as Amy states, but that the belief that "current best medical evidence will virtually guarantee best outcomes" is hammered into 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".
Certainly, if any experience could be likened to joining a monastery as a novice, it's a medical residency, with its subjugation, routines, long hours, hierarchy, and teachings. Doctors are often like Trappists or Benedictines, with similar core beliefs but regionally determined ways of doing things, despite reading from the same "book".
We are taught the limitations of the available technologies as Amy points out, but witness slavish devotion to their use. The amount of time dedicated to evaluating fetal heart tracings can only serve to reinforce in the future obstetrician its vital importance in assessing the baby. (My chairman however was particularly adamant in assessing the whole patient, with the strip being only one of many indicators of fetal well being, for which I am very grateful.)
My point is that despite our empirical knowledge, I believe that we physicians often approach care with a religious fervor, excluding or dismissing other "faiths", since we believe strongly that what we know is RIGHT, in the most devout sense of the word. This orthodoxy has the potential to be dangerous or divisive, as many here can attest.
This is of course just my assessment of the situation based on my experience, and I certainly do not claim to speak for my colleagues as a whole. (Dr. Tuteur does that enough for the both of us.)
Thanks for the clarification!
Yep. A lot of it is ritual and not just ritual, but superstition as well.
I also think I can answer a question for you.. Why many women gravitate towards the paternilistic doctors. Their promises are prettier than yours. They promise a healthy mom and healthy baby , if you just do XYZ or just hand over all control, all of the decisions, to them and their machines. Doctors like you make much more realistic promises to them. But I think most folks prefer to think that they can really control the uncontrollable, if they just do XYZ.. They also believe "doing" is better than not.. They grew up with family/mother's/friends who all had a doctor that did XYZ and so if the doctor doesn't do XYZ or gives them choices or tells them things like, just for an example, "I won't generally induce before... or for convenience", or whatever, and does not explain why satisfactorily to the women, it might be seen as a weakness rather than the strength that it really is, which can earn a doctor a "bad wrap" or have women leave the practice quickly. Plus, of course you always have word of mouth "He saved my / my baby's life! " stories from their friends/relatives/acquaintances.. Nevermind if the doctor made something up or caused the problem in the first place.... You also have pop culture, which exemplifies paternilistic birthing and that is what women come to expect, and therefore hold to be the standard. I am pretty sure by the majority that your own article explains, in general, though, -why- they usually choose them.. They want their shaman to talk like all the rest of the shaman do.
Well-written article.
@Fogedaboudid
You read my mind. I could not have answered my own somewhat rhetorical question better!
Obviously, I need to quit all this patient autonomy, informed consent, evidence-based bullshit so I can retire before I'm 90.
Obviously. ;)
Yes, that about sums up the paternalistic doctor attraction, I would think.
Some friends also adored their paternalistic doc. Everything was beautiful. Then they took a childbirth ed class and asked some questions. Things turned ugly. They won't use him again. Oh, and I just saw him get a glowing recommendation on an email list this morning. And so it goes.
I hope you can retire before 90, Dr. Dorn. Clearly your style appeals to many potential patients, too!
More cowbell, more Joseph Campbell.