ethics among physicians - Page 3

[Defenestrator]

I just took a look at the NARM grievance procedures. They share some similarities with the process in Idaho in that the client comes and makes a presentation in the presence of the midwife. If handled right, they could achieve the same goals, which would be to provide some sense of justice/closure for the client and to make recommendations for the actions the midwife would need to take in the future. In the NARM process the committee are not described as mediators -- more as judges. After all of the evidence is presented, they have to go down a checklist and judge whether or not the midwife acted appropriately according to a list of subjective criteria. The criteria are all pretty vague. They say things like "midwife provided adequate prenatal care".

I don't have a problem with the NARM core competancies or ethics statement.

Oh, and if you were addressing the CPM question to me -- I will be a CPM soon. My training to be a midwife was a bit unorthodox, which is something for another thread, and I didn't start pursuing certification until I had been in practice for more than 2 years.

[mothercat]

Stacia, the "why aren't you a CPM" comment was not meant specifically for you. Looking at the number of hits this thread has gotten makes me think that there are a variety of consumers and providers checking it.

Certification and licensure are being discussed, as well as ethics. As a CNM I had just always assumed I couldn't practice as a midwife unless I was licensed. It was just a given. Just wanted to hear others' comments and reasoning on the subject.


For all:
If this is a time of year for you to be enjoying festivities, I hope you are.

[mwherbs]

[QUOTE=mothercat;10088136]For the readers that are not certified by ACNM or NARM, how familiar are you with NARM's core competencies and standards and why or why not should they be used as referenced documents for such things as ethics, standards, and licensing? >>>>>>>>>>>

I pretty familiar with the core competencies and standards, you can get the info about requirements and ethics statements from NARM and there is the Evans and Weaver check-list workbook for skills, you can also talk to CPMs
>>>>>>>>If you aren't a CPM, why not?>>>>>>>>>>>>
working toward licensing in my state right now, I started out doing midwifery I a state where I could not be licensed and pre-CPM , then I was busy having and homeschooling my kids and only did a few births a year and did mostly research and assisting- my interest didn't go away just no time-- then I moved here where it is a FELONY to practice sans license, and I knew what was happening on the political front and called all the LMs in the state and they pretty much felt they could not change what was happening, some were indifferent and some were supporting the bill (thought they could get some essential things through it they traded this for that but it didn't happen) any how I was kidding myself to think oh well I am too busy and not going to keep doing midwifery-- but when I had spare time I started going to lectures given by a clandestine Brazilian MW- and yep I ended up assisting her, but when she went up and took the NARM exam- I didn't have the money and I didn't think that it was going to end up meaning or being anything-- (I was wrong) I worked with several mws licensed and others that went on to be CPMs or LMs -- I have to also say that philosophically I felt that there shouldn't be laws controlling women's choices and a bunch of other things similar to what people now say about not wanting licensing -- I knew the law and skirted it-- midwives I had worked with had been threatened- and in particular the one that was the most trained and concencious was "turned in" by a jealous(and I would say incompetent) gal who was being questioned on her involvement with an newborn death-- she said "why are you doing this to me x had a death a year ago and you did nothing!"well x had a baby with anomalies very different case-- on top of that my kids were bigger and I saw that ok I need to be real I am not going to stop doing this- and I need to really look at being legal and not worrying my family-- then I had a plan when our youngest was old enough I would get a license (rather than a cpm, because of costs) now the tricky part--and an even longer personal story but as it is I am on the crest here-- and if it isn't LM it will be CPM--
What effect do you think complying with those documents and standards would have on your current practice style?
no impact at all CPM isn't really a hinderance, nor does it dictate allowable practice (no exclusions on breeches, twins, VBAC...)-- what makes a difference is what a state does as far as allowed practice ( the better states have some sort of self-regulation) we have the old fashioned big-brother health department- that went from a job description of education as well as regulation to strictly enforcement, luckily we do have protocols in rule otherwise they would probably try to cut back what a mw can do -- even if it is very limiting--
>>>>>>>>>
I understand the complaints about licensing- to a degree,because the state laws/regulations and how they are carried out can really have an impact--
VBAC comes to mind as a big example-- many states don't allow for VBAC and with moms not being able to get a VBAC in hosptial then the common alternative is also cut out-- I started out in the early 80's and at that time we did alot of VBACs -- and the medical studies were with us-- what happened? any how -- to say that areas where midwives may serve or be skilled at providing care are limited because of laws-- another piece of this is that laws are an external control but midwives who come up practicing in an illegal environment are internal locus of control folks -- and there is also calling, which is harder to define, but women who are trusted and asked to attend births of other women- may not always have the same skill set that it takes to be licensed or to do the schooling-profession path-- CPM for the most part still answers these needs -but a state's laws may not (Washington comes to mind) --
Katie has it right when she says put licensing in and if you don't want to be legal then don't be, but it allows for more choices--
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not my reasong but
there has been a very long standing program/predating the NARM?CPM process and some of the women who did that program feel a bit angry that the study program was not included in the process and that you have to pay for the education evaluation rather than being MEAC accredited.. politics, politics... and some women feel that they have "earned" their dues and shouldn't have to now comply-- fine if you live in a state that already licenses and you get grandfathered in but in completely illegal states your expderience can = little-- and having apprenticed after having practiced for many years I can say that power can go to anyone head, regardless of how experienced or in experienced a person is.. apprenticeship can be very humbling --
----

[doctorjen]

Heres a question I have, that applies to both midwives and physicians and even others involved in childbirth or other types of medical care.
What if you know another provider is not practicing following a standard of care, but you can't prove said knowledge? What if you've heard the same stories from so many women, or from, say nurses who've been involved, or perhaps doulas who've seen a bunch of births, to the point that you are pretty certain that the bad practices actually exist rather than it being just a case of personality clashes. What is our obligation, then? Since talking about the person in question can be perceived as gossip or slander, and especially if you personally have no means to prove your opinion (no access to that person's charts, or whatever), what can be done?
It's easier in a situation where you have direct knowledge, or are involved in peer review, or something, but what is our responsibility if we know someone is practicing outside the standard of care, but have no method of proof?

[mwherbs]

well good question-- I have had first hand experience with similar situations... one thing I have done besides discuss it with other professionals- is to organize continuing education classes -- or made local mini-conferences and have asked the person to be a presenter on a different subject, but with the presenter's privilege of attending the others for free. Educate consumers ...
I guess I mainly address my own profession- I know of and see and hear about all sorts of doctor's actions I really do little other than to try and steer clear of them- and to steer women I know away from them -additionally I have encouraged letters of complaint to the doctor/midwife with copies to the administration(if there is one), her insurance company,and the medical (midwifery)association -- also for a group practice CC the other partners.
If it is someone I know who is approachable I have said something directly--

I have seen group letters written stating concern put together by other professionals (I didn't like this at the time) , I have seen people turned into be investigated (with the midwifery climate makes for a mess for all),

[mothercat]

doctorjen
It is good to have the nurses on your side. They have authorized access to the chart and can be the place to start.

This happened when I was a nurse. There were two OB's who would just order the most bizarre tests, treatments and consults. Things like soap suds enemas for every PP woman (they all needed help with that first BM). If they refused one would order flat plates to be sure there was no ileus. Blood gases on all C/sec. moms; any normal abnormalities and there would be a pulmonologist consult. Injecting Pit or Methergine into the uterine muscle on all C/sec. moms before closing and then ordering IM narcotics in very restrictive dosages because he didn't want to risk the ileus. Then we had moms with very inadequate pain control, who didn't want to get out of bed because they were just in too much pain.

We would have to deal the consultants who asked why on earth these things were ordered and what was wrong with this woman. We would say something to the OB chief and he finally got tired of listening to us. Not sure what he was thinking, but he asked us to document the stuff we thought was really out of line. The nurses went to work and about 2 months later, the one OB was called before the chief and lost his privileges. I don't think he remained in the area after that.

So, for hospital based HCP, the nurses may be the way to go. If they understand that theirs is a separate profession and their responsibility for patient care is as great as the physician, they should be willing to work on this with you.

For OOH providers, I've had to deal with that also. I wrote to the certifying org. with a long list of things I had witnessed (mostly) or been told by the client. The same HCP I wrote about earlier (morphine and cytotec) also gave a woman a shot ( IM) of Pit during an OOH labor. She told the mom it was to prevent shoulder dystocia and help a stalled labor. That was the one that made me realize that even if the certifying group didn't believe me, I still had to try to do something.
Luckily, enough women had connected with each other that had been in her care and also decided to file complaints. I received a letter from the org. saying mine was mostly hearsay, even though it was the clients who told me, and they couldn't use it. However, they did take the women seriously and started the grievance process. The midwife is still practicing, but lost her credentials. It is pretty powerful stuff to have one pregnant woman advise another not to use a HCP because they have had their credentials revoked or are in disrepute among their sister midwives.

[mothercat]

After some PM's I would like to get comments about the "what to do" part of this discussion.

For those of you that blew the whistle (or tried to) on an HCP that really concerned you, could you answer two things?

Did you document the things that worried you that seemed not standard of care?

Second, what was the fallout and aftereffects of telling someone what you knew or suspected?

[nashvillemidwife]

Originally Posted by jengacnm

No one woman is worth my license.

Amen, sister. I really do feel for the families who can't find a midwife willing to serve their needs, but if I did so and I lost my license, then NO families would every benefit from my services in the future, my family would suffer, and I'd have to choose a new career. Plus, censure of my license is going to bring down scrutiny on all the midwives, again hindering the ability of future families to benefit from midwifery care.

[nashvillemidwife]

Originally Posted by mothercat

For me, ethically, if a patient was harmed and the HCP tried to justify their end of things by placing some of the blame with the client (she didn't do what I told her), then I likely would report her. A client hires an HCP for their knowledge and hopefully ability to be objective in emotional situations.

So which way is it going to be? Midwives refusing to take mothers with increased liability, or going out on a limb for them? If I've got a client who does not follow my recommendations, should I dump her? You've got one side arguing for the rights of the mother to have whatever she wants, saying what a shame it is that midwives won't help these women. Then you've got a side saying that midwives shouldn't be expected to take these risks.

If I've got a surprise breech and the mother refuses to go to the hospital, baby gets stuck and dies, you'll think less of me when I try to defend myself by saying "I told her we needed to go to the hospital and she refused"? Forcing her against her will is assault. What would you have the midwife do?

[nashvillemidwife]

Originally Posted by SublimeBirthGirl

I realize that the practical application won't always work-what midwife would want to attend a birth of a cocaine addict with HIV and schizophrenia (to use an extreme example)? But within reason, women should have the right to make their own choice and have those choices respected no matter WHERE they give birth.

But according to whose reason?

But what about women who are forced to have a RCS because "VBACs are dangerous?"

Perhaps you mean that women should not be risked out in accordance with evidence based practice? You keep mentioning VBAC, but what about insulin-dependent diabetics? Babies known to have neural tube defects? You're making very broad statements.

[maxmama]

Originally Posted by jengacnm

No one woman is worth my license.

Amen, sister. That license is my livelihood, my family's livelihood, my future and the way that I am able to care for women at all. One patient does not trump all of those for me.

[nashvillemidwife]

Originally Posted by doctorjen

What if you know another provider is not practicing following a standard of care, but you can't prove said knowledge? What if you've heard the same stories from so many women, or from, say nurses who've been involved, or perhaps doulas who've seen a bunch of births, to the point that you are pretty certain that the bad practices actually exist rather than it being just a case of personality clashes.

In my state we do have CPM licensure and our association has regular peer review, and we are asked to present all transport cases. Peer review is not binding as we have no legal authority, but is a way to hold each other accountable. We are required in our informed consent documents to disclose the appropriate procedures and contact information for a client to file a grievance. The only outcomes we are capable of providing are telling the clients that after hearing the evidence we feel the midwife did nothing wrong, or that the midwife needs some more education. The client's other recourse is to make a complaint with the state licensing board. They can do this at any time but we try to route them through peer review first simply because it's more timely and financially efficient.

As the president of our state midwives association I frequently hear concerns or complaints about other midwives. Some of them I dismiss as petty quarrels or difference of opinion, but some I know have merit. Yet I can't call them out based on hear-say. My recommendation is to ask the parties involved to make a formal letter of complaint. Then I at least have something to go on.

[mwherbs]

the classes have worked well-- and sometimes in a surprising ways -- like networking I have found especially for older very busy midwives that they are more isolated than you would think
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as for the group letter writing , the woman closed down and closed ranks- and got her self a lawyer to write replies... and was very angry and also played the martyr ... was sure to talk crap about the others in the area .
there was also the state investigator that came around and asked questions of everyone in the area- that either filed an unattended birth or was teaching or involved in the local birth world-- this guy had been a welfare fraud investigator and quite the creepy guy to even speak with at all- came to my door and I wasn't on the complaint list I told him as little as possible- not how I think that midwifery should be regulated at all
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another time complaints were handled by a state appointed advisory board- woman lost her license- she sued the board and raised the cost of midwifery licensing for the entire state for years... have some sort of protection insurance for your board and be sure of your laws/scope - actually this was only one case and the majority of cases are not so dramatic and are handled with peer review, education and fines
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fights, fights and more fights--
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lawsuits
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In the State of Washington prosicution of a LM I know she still has an outstanding $30,000+ dollars in bills despite very successful fundraisers and donations to her defense-- unrealistic hoops to jump though like attending within a year a number of complete breech births--- so although found innocent of certian charges because of the informed consent issue (and if you read the laws not something that should be able to be judged on- it is spelled out in WA laws but she was judged on that - this also protected the state from having to pay her legal fees)
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letters from lawyers and to lawyers
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changes in the way the state handles information from midwives
complete copies going to the state regulatory person in order to oversee- ongoing care- yes clients records with a state agency saying that you don't have to get client permission to turn this info in!
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peer reviews where families were happy with being able to be heard, and were satisified with how the complaints were handled, families unhappy with peer review process- because of time it takes and time limits- or not enough power with peer review to mean much to some parents--
peer review process where there were things said to complaining students on their actions as well as the mw they were complaining against...
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deep divisions in loyalties and how state organizations are run- complaints about bullying by people who are bullies themselves-(if things do go my way, and people won't do what I want they are being mean to me)
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there are some things that I have found no answers for-- difference in practice that drive me nuts and I have to think about my own actions but cannot change another's- for example the births were midwives pray only at births, very unsafe in my eyes- but the only thing I can do is accept that this is a parent's choice and not something under my control --- educate clients is about it -- that their outcomes put a shadow over other types of midwifery- just how it goes, I am not willing to standardize practice to the point that it limits parent's choices in that way.
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I have compiled research, on particular subjects and had extensive discussions-- sometimes I am not able to change the basic thinking but can change something like- informed choice statements or stuff like that-- but I think that this only works if someone is open to talking or listening to you to start with--
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I also think that Susan Arms works on this , I am guessing that she does it deliberately but maybe not- at the MANA conference in 1990 she had a room full of us each turn to the other and confess out loud all at the same time everything that we have done wrong, mistakes we have made... the room was full of sounds of midwives talking--
in my veiw there has to be some sort of admission and not denial to move on and change , and it was also clear that no one was guilt free or perfect that none of us are alone is another way to think about it--
Odent also touches on this not as much but still talks about it.