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Thursday
Jan132011

Collateral Damage: A Patient’s Experience of Defensive Medicine

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By Emjaybee


Something is rotten in the state of provider-patient relations in this country.  And for many women, their first inkling of that fact occurs when they get pregnant.

Most people who have spent their lives relatively healthy are extremely trusting of their doctors. Why shouldn’t they be? Doctors work miracles and help us prolong our lives. And since the 1950s, there has scarcely been a television season that didn’t include a medical drama of some kind, always told from the practitioners’ point of view.  “Bad” or abusive doctors were nonexistent, except as perhaps a Story of the Week or a Very Special Episode, and they always got their comeuppance (or even redemption). 

If the hospital system itself came under critique, it was only because it was trying to prevent a heroic doctor from trying a risky procedure that Might Just Work, or because it was too beholden to the evil insurance companies who didn’t want to pay for little Timmy’s lifesaving liver transplant. 

Why am I using pop-culture examples when I want to talk about actual patient experiences? Because these are the stories we as a society tell ourselves about doctors and medicine.  They’re very nice stories.  They make us feel good about having to go the hospital one day, where gruff but kind surgeons and sassy nurses will take care of us.  They tell us doctors are amazing people who do what they do out of basic decency and a desire to help. And of course, many doctors are like that, or try to be.

But there is a problem with these stories, these scripts—mainly, that the patient herself is pushed into the role of extra. The patient is to be the quiet and cooperative plot device, lying in bed, smiling bravely around her respirator as she gratefully clutches the doctor’s hand.  Whatever their personal quirks, in the end the patients, Do What They’re Told, even if it seems unnecessarily painful or contradictory, and that’s what saves their lives. (See: every episode of House).

Not being a conspiracy theorist, I don’t think TV’s portrayal of doctors as healing, sexy saints is part of a sinister plot. We like heroes, and the work doctors do is often heroic. But it would be surprising if all those hours of medical soap opera starring brilliant saviors didn’t have an effect on our expectations. When it becomes our turn to enter the drama, to seek help or healing, we find the role of compliant, grateful, passive patient familiar and easy to slip into.

And let’s be honest; things are much easier for the hospital when we do. 

But what happens when we don’t? What happens when we challenge the doctor’s decision, disobey the nurse’s orders, educate ourselves and decide to try different approaches, or question interventions? What happens when we go off the script and start trying to make more decisions about our own treatment?

That’s usually when we find out that we are in hostile and unfamiliar territory. 

When I was pregnant with my son, the nurse-midwife practice I picked used all the right words; natural birth, no rushing, no pushing drugs or c/sections.  I had an uneventful pregnancy, and for the most part, the midwives I saw followed that model of care. Examinations were low-key. We talked about raspberry leaf tea and whether I should get a doula, an idea they supported.  There was lots of smiling and congratulations on my health and my baby’s health.

There was one midwife I didn’t like as well, though. She had a habit, as my pregnancy progressed, of frowning and saying “Hmm” in a worried tone. (In fact, let’s call her Midwife Hmm). After each “Hmm” she’d say something like: “I hope you go into labor soon, because I wouldn’t want this baby to get too big,” or “This baby certainly is measuring large,” or “I wouldn’t want you to have a c/section.”

Let’s pause for a minute and review these statements. What, exactly, was their purpose?

Were they directions as to what I should do or not do? No. I had no control over my baby’s size or when I went into labor. She had also met my 6 foot 4 husband and presumably noticed that I was not a short woman. My blood sugar levels stayed, if anything, low. My blood pressure was excellent. I felt fine except for aches and pains, and the baby was firmly head down. I had no evident risk factors for a c/section.

So why the hmm-ing, the frowning, the general air of pessimism about my ability to give birth vaginally? I can think of no other reason than that she was, consciously or unconsciously, attempting to manipulate my expectations and provide cover for whatever interventions she or the OB might want to make.

After all “managing patient expectations” is part of practicing defensive medicine. It sets the tone of the discussion, defines what is and isn’t possible or likely. 

I was taller and my baby larger than a lot of women. I was a first-time mom. I was pretty casual about her concerns and didn’t automatically panic at her head-shaking or hmm-ing. I was adamantly against early induction.  I even talked back and told her I thought we really didn’t have anything to worry about.  I was, in other words, not behaving compliantly, not having a reassuringly small baby and early labor, and therefore, a possible threat. And so she set about moving the goalposts and in the process, undermining my confidence.

It’s not like it was all that hard. Like any first-time mom, I was full of worries.  Little by little, her negativity had the effect of isolating me and weakening me, psychologically.  However casual I acted, it shook me that one of my own midwives did not think much of my chances of giving birth without interventions. And given that most of the people around me didn’t either (my family history was full of c/sections and twilight births) I began to feel more and more uncertain of myself.

All the same, I clung to one decision I had made; I was not going to be induced before the full 42 weeks was up and I’d given my son a chance to come out on his own. This eminently sensible idea was greeted by Midwife Hmm, and also, the clinic’s director, as risky and foolhardy—though as I later learned, it was actually just inconvenient to the hospital’s schedule (they preferred delivering on Thursdays to free up the weekend). 

And, to everyone’s increasing disgruntlement but mine,  my son seemed determined to wait his time out. Although every stress test came up beautifully and my son and I were fine, I soon had the feeling that I had been demoted from the Compliant Patient column to the Shit List.  What’s funny is that, in a way, Midwife Hmm’s little psych-outs had backfired on this front; she’d made me so nervous about failing at labor that I was no longer eager to get started.

Nevertheless, I had agreed to be induced the first Monday of my 43rd week, and went to bed the night before D-Day without a detectable contraction.  Then at 5am I woke up suddenly and my water broke, spectacularly and messily; I leapt out of bed like a startled but very pregnant deer and ran to the bathroom before my husband had cracked open his eyes.  I was in labor!  I was ecstatic.  I was triumphant.  I thought I had proved them wrong and that now, finally, they would see that I could do this and everything would be OK.  I could just go to the hospital and have my baby.

But here’s the thing about being on the Shit List as a patient: it’s a permanent demotion. A little thing like a healthy pregnancy and spontaneous labor was not going to change my status as Problem Patient.

When I got to the hospital, I was told hospital policy was that I must be put on Pitocin because I was at 42 weeks.  I assumed, though I was not actually told one way or another, that it was accept Pitocin or leave the hospital. With my water gushing between my legs, presumably.

I went quickly from triumphant to afraid. My birthing classes taught me a lot about squatting, but nothing about EMTALA, the law that protected me from being kicked out while I was in active labor, regardless of whether I was compliant or not. I had legal protections, but they had been hastily skimmed over and buried in the fine print, and no matter how good a weapon you have, it’s useless if you don’t know how to use it.

The grim faces, frowns, and even anger that confronted my timid request that I not be induced were very effective in the face of my ignorance. We didn’t have a car and had taken a taxi in to the hospital; now that I was in labor, I was terribly afraid of being forced to leave if I didn’t comply. I had visions of walking around the hospital parking lot shivering in the November wind and leaking amniotic fluid until it was time to push and they grudgingly let me back in. All the weeks of insecurity and anxiety, my resistance to the idea that a medical person would actually tell me to do something harmful, combined with the desire to stay in my nice warm hospital room, were too much for me. I caved. I let them hook up the Pitocin and hoped for the best.

I don’t know how high they turned it up, but the contractions became unbearable and fast a few hours later, a near-continuous ring of fire around my back and pelvis that had me climbing the walls. I was told I couldn’t remove the damned itching and beeping monitor, so I couldn’t use the shower for pain relief. I was told to stop leaning on the end of the bed, because it wasn’t sturdy enough, which left me to either stand up clutching the back of a chair or kneel on the cold, dirty floor, which I couldn’t make myself do. Random people came in to my room, entered data in a computer in the corner, and left, never talking to me. My husband was afraid. My doula was inexperienced.  The birth ball did not help. The ice chips made me shiver and ache, but gave me no strength. I could not relax, and so the fear took over.

Finally, I took the epidural because it was the only way left to me to deal with the pain. And it worked, but the baby stalled. I fell into an exhausted doze on my bed, frightened and withdrawn.

I woke up to Midwife Hmm standing over me again, with her familiar frown. I was taking too long, she told me. We really needed to c/section if we wanted to avoid “risks.” Drugged, exhausted, and uncaring, I said yes.

An hour or so later I lay alone in the recovery room, deeply shaken by the surgery, my baby taken away screaming because they wouldn’t let him stay with me and breastfeed. As I lay there stunned and trembling, I believed that, just as Midwife Hmm had hinted, what had happened was all my fault. I was weak and my body was broken and vaginal birth was just not going to happen for me.  I’d clearly been foolish to even try it. To think someone faulty like me could do something extraordinary like that.

I’d lost the battle, and I’d lost big.

I lost because I didn’t know it was a battle, or rather, I didn’t want to believe it was a battle. I could not really believe what was happening to me, even while it was happening. I wanted to believe my practitioners, my heroes, were on my side, like they were supposed to be. I could not comprehend how my ostensible allies had turned on me.  My naivete, my ignorance, made me vulnerable.  So much so that  by the time I limped home from the hospital clutching my baby and my scarred belly, I almost felt lucky to get out alive.

When medical practitioners use the term “defensive medicine” do they ever stop to consider what that implies about their relationships with those in their care? Do they ever ponder how strange it is that those with all the power, those with the knowledge and the apparatus of medicine, consider the people under their care as a threat, as an enemy?

To practice defensive medicine is to make every clinic and hospital a battleground, and every patient a potential casualty.  It warps and distorts the science of medicine and poisons the doctor-patient relationship. 

My doctor-patient relationships certainly suffered. It was two years from my postpartum exam before I could go to an OB-Gyn again; even then, I’ve had to use anxiety-management techniques before I can go through with them without leaping off the table.  I suffered traumatizing medical complications from my c/section, with one side effect being that my milk never fully came in and I couldn’t sustain breastfeeding. I ended up going through therapy to deal with my PTSD. My marriage was placed under severe strain for several years. 

Some women turn away from medicine entirely after experiences like mine, but I haven’t done so. I still believe in science, and I still think medicine saves lives. But whatever my belief in medicine, I have a much more complicated relationship with its practitioners. I have developed a wary skepticism, and always double-check what they tell me. I am not an easy patient; I have a jaded attitude towards those who talk up a great new treatment, and a quick-flaring rage towards anyone who treats patient autonomy as unimportant or inconvenient.  I ask lots of questions and I don’t always accept the answers.

Here is the result of defensive medicine as practiced on this patient: treating me with hostility has made me hostile; being abused by the system has made me angry; being lied to and manipulated has turned me into an activist for women’s medical rights in labor and birth.   

And though I’m sure that’s not what its proponents intended, defensive medicine has taught me this above all: there is no safety in being a noncombatant.

 

 

Emjaybee is a writer, editor, part-time birth activist, occasional graphic designer, sometime music video producer, and mom.  A traumatic unnecesarean turned her into one of those tiresome types who makes sure every pregnant woman she meets knows what EMTALA is and how to use it. She lives in Texas. @emjb

 

 

 

 

 

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Reader Comments (58)

I wish you healing and all happiness. This was terrible, inappropriate treatment of you, your family, and your baby. Your diagnosis of the problem is spot on.

January 13, 2011 | Unregistered Commentershinejil

Why do you think the midwives, doctors and nurses did what they did? What were they trying to accomplish?

What did they see as the goal of your labor? What did you see as the goal?

What level of risk was acceptable for them? What level of risk was acceptable to you?

There is no doubt that your experience was sacrificed to ensure your baby's health. Your entire piece, though, is based on the assumption that had you the birth experience that you had envisioned, you would also have had the healthy baby that you got. But that's an unjustified assumption. You may have gotten an injured baby or a dead baby instead. Whose fault would that have been?

January 13, 2011 | Unregistered CommenterAmy Tuteur, MD

I could have written this post except for the water breaking at the beginning of labor, and c-section. I was able to get my vaginal birth with my first, but only because I fought the doctors at every single turn. They threatened to use the vacuum to "pull" my son's head down because they felt I wasn't pushing him out fast enough...I pushed for 15 minutes TOTAL. It's in the record. Really, 15 minutes is too long!? The lady next to me pushed for 4 hours. I can sympathise with you 110%, and it's a disgusting fact in our nation that hospitals and doctors are out of control when it comes to inductions and c-sections! If I had continued to see my OB/GYN this pregnancy, I am certain she would have tried to induce me early, just so my baby would come on her schedule, not on his. They forget that babies are PEOPLE, not inconveniences. I am seeing a midwife, I am 6 days "overdue" today, and she's not concerned. However, if I do not have the baby by 42 weeks I will have to see her supervising OB/GYN in which case I am certain my baby's birthday will be decided by them, and not by the baby. I have tried every old wives tale except castor oil because I did that with my 1st and it was a horrid experience...Anyway, I totally relate, and thank you for sharing your experience to educate others!

January 13, 2011 | Unregistered CommenterSabrina

This reminded me of my story... I cried for you... I am so sorry... I still grieve over my experience too.

January 13, 2011 | Unregistered CommenterBrittany J

thank you for sharing. it's so important for people to know that they do have rights, even if doctors and nurses glaze over them or even flat out lie. Sadly, it happens all the time.
I have similar experiences, although not related to birth. I now know, having learned the hard way, to ask questions ad that it's my right to say no. There are doctors out there that are good with that. Some even welcome it.
We cannot forget that hospitals are businesses. They do not intend to do harm, but their first priority is not the individual. That's up to us and our families. it's sad that is currently that way. And I hope that with enough of us out there, sharing our stories and showing that you can have a say that more and more people will realize that medicine is both art and science. There are no absolutes in life. Even from doctors. We have to remember that they are people too. Prone to their own experiences, biases and judgements. They are not infallible. They usually do the best with what they have, just like any other profession.
Again, thank you for sharing. I completely believe that it's better to be on the "shit list" than on the "compliant" list. But I hope that some day the shit list turns into "active participant".

January 13, 2011 | Unregistered CommenterCristina

Amy wrote: “Why do you think the midwives, doctors and nurses did what they did? What were they trying to accomplish?

What did they see as the goal of your labor? What did you see as the goal?

What level of risk was acceptable for them? What level of risk was acceptable to you?”


Risk of what? Death? Injury? Morbidity? (stemming from either delivery method)?

Or the risk of being sued?


Patient goal: Healthy baby, healthy mother.

Care provider goal: Healthy baby, healthy mother, minimization of risk of being sued.

Because the cesarean is safer than ever, it is easier than ever to meet the care provider’s goal. Some patients do not care that there might have been an extra goal thrown in there as long as the outcome appears the same at face value. Obviously, some patients find this disconcerting and start blogs that seek to explore the extraneous factors influencing medical decision making and wondering aloud if we as a society find this ethically acceptable.

If anyone was trying to choose “an experience” in this story, it was Emjaybee’s care providers, who sought the experience of being able to walk away knowing that they could prove one day that no one could blindside them later for not performing a cesarean. For all they knew, Emjaybee would have been a vicious plaintiff.

One funny sidenote here is that, based on everything I’ve read that Emjaybee has shared publicly on Twitter, she is… shall we say, not the kind of person interested in fluff, woo or faith. It will make pinning the notion that she’s angry because she wanted Enya and candles and ended up in an operating room difficult.

January 13, 2011 | Registered CommenterJill

Dr. Tuteur, I know exactly why my particular midwives did what they did, because in my postpartum exam with a different midwife in the same group (these were all CNMs, btw), she admitted as much. The director of the clinic told me upfront later that they wanted to induce me because the OBs did not like delivering on the weekends when it was busy. The midwife who did my postpartum exam was deeply saddened by what happened to me and confided that she also felt the mandatory use of Pitocin was unnecessary and unhelpful in my case, and driven by the demands of hospital's scheduling demands.

As per the dead baby fear, there was no indication that my son was ever in any distress, even after the epidural and slowdown of labor. What I *did* get was a c/s by an incompetent surgeon who left tissue inside me that got infected and resulted in a hemorrhage and hospital stay 10 days postpartum. You ask me to worry that my son might have died; what happened instead is that I worried that I might have died and left my son without a mother. What happened instead is that my son missed out on the proven benefits of breastmilk because of that infection stopping my milk from coming in. What happened instead is that my son had a mother who was profoundly depressed for the first two years of his life. These are not inconsequential results.

I fully take responsibility for not understanding my rights under EMTALA; I could have refused the induction, and let my perfectly normal, healthy labor progess as it was unless some other risk factor (I had none, according to my chart) presented itself. I could have eaten and drunk in defiance of hospital rules, removed my monitor to use the shower for pain relief; these were rights I had but did not know about or was too timid to insist upon. Like a lot of women, especially first-time mothers, I was afraid of birth and unsure of myself.

January 13, 2011 | Unregistered Commenteremjaybee

Oh, the Shit List. I know it well. It makes me crazy that being informed and asking questions means that you're treated differently.

Amanda

January 13, 2011 | Unregistered CommenterFamilyNature

1. There is a post by a doctor on monitoring, the perceived guarantee of a perfect baby and overselling these benefits forthcoming.

2. I'm sure someone could put together something compelling about process vs. outcomes, quality measures, hospital administration and process theory in general, but it's not me.

January 13, 2011 | Registered CommenterJill

"If anyone was trying to choose “an experience” in this story, it was Emjaybee’s care providers, who sought the experience of being able to walk away knowing that they could prove one day that no one could blindside them later for not performing a cesarean."

OMG, lightbulb moment! People always go on and on and on about how mothers are putting their babies at risk by caring more about the "experience" of birth rather than the outcome, but nobody's ever put the same amount of ownership on the doctors and care providers.

January 13, 2011 | Unregistered CommenterLisa
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