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#181 of 229 Old 04-16-2012, 07:03 PM
 
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Holly- They really should offer a class in your program on how to interpret scientific literature. It doesn’t look like you can actually do this on your own. People here have posted a few scientific studies that clearly show that this is not black and white and you refuse to answer their questions. What the WHO, the ACNM and the ICM do is interpret data that they see fit, and come up with a series of recommendations that may apply to the majority. Some of us don’t live in Africa. Most of us are well nourished. If I want to be treated like cattle, I will look for a vet.

I want evidence based practice to be used when I look for a provider. I want someone who is capable of understanding original research and can keep up with new literature, not just pointing to recommendations that may not apply to me as an individual or relying on outdated recommendations. As others have pointed out here, if you really follow evidence based practice, you should read the original peer review literature. Come on, you can do it! And if you need access to those pdfs people have mentioned, just pm me. I will be happy to share them with you. 

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#182 of 229 Old 04-16-2012, 07:04 PM
 
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Originally Posted by stik View Post

ACOG has issued a statement opposing using court orders to force women into specific treatment protocols.  It has happened anyway in a few cases, but I think it's worth noting that the broad medical consensus is that it's poor practice, it reflects horrible doctor/patient relationships, and doctors who do that are asshats.  

 

Holly has a protocol.  She's been taught it.  It's evidence-based.  It has good results.  She's comfortable with it.  She's honest about it, so if you don't like it you can easily not hire her.  There are other CNMs and OBs who don't automatically use cord traction or pit, and the fact that a bunch of people here are shocked by the existence of fundal massage is clear evidence that not everyone does that either.  

 

 

I don't actually give a crap what ACOG (or the SOGC, for that matter) say about anything.  I see the court orders as a natural extension of the attitude the medical profession, as a whole (yes - there are exceptions) has towards pregnant/birthing women.


I personally have no idea what third stage protocols my medical professionals might have - one has to get to third stage to find out that kind of thing. If Holly's honest about her protocol, that's great (she says she is, but I've never had a licensed provider who actually told me much, and moms don't always know what questions to ask). Women can choose to go elsewhere if they don't want "gentle cord traction". As long as licensing boards are forbidding anyone from providing care without said traction, the woman still has choices.


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#183 of 229 Old 04-16-2012, 07:06 PM
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You can find another provider, even late in pregnancy.  Or, you can show up at the hospital in labor and sign AMA forms for procedures you don't want.  They cannot turn you away.  They are unlikely to seek a court order for treatment.

 

If you feel you need that particular doctor, then you have some reason to feel that doctor's advice has value, and you should probably consider taking it.  

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#184 of 229 Old 04-16-2012, 07:08 PM
 
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Yes, your choices are to either 1) refuse or 2) not refuse. It's the providers choice to either keep you as a patient or not. Both of you have agency. Both of you have the right to choose. But I believe at 39 weeks patient abandonment would begin to be a legal issue, which is why it is so important to have these conversations at the beginning of pregnancy while you both have time to determine if it's a good patient/provider match.
 

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That's not "consent". In order to give informed consent, you cannot be coerced. If a doctor is threatening to drop you as a patient in your 39th week if you don't do what (s)he wants, then you no longer have the ability to give "consent". All you can do is either refuse or give in to her/his demands. That's not consent.



 


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#185 of 229 Old 04-16-2012, 07:11 PM
 
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Picking individual pieces of literature that support your viewpoint does not determine evidence based practice and it does not determine standard of care. It takes more than one (or two) pieces of literature to create practice protocols. If you have a problem with how the WHO, the ACNM, ACOG or the ICM interpret the vast body of literature, then by all means, please write to them and inform them of their errors.

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Holly- They really should offer a class in your program on how to interpret scientific literature. It doesn’t look like you can actually do this on your own. People here have posted a few scientific studies that clearly show that this is not black and white and you refuse to answer their questions. What the WHO, the ACNM and the ICM do is interpret data that they see fit, and come up with a series of recommendations that may apply to the majority. Some of us don’t live in Africa. Most of us are well nourished. If I want to be treated like cattle, I will look for a vet.

I want evidence based practice to be used when I look for a provider. I want someone who is capable of understanding original research and can keep up with new literature, not just pointing to recommendations that may not apply to me as an individual or relying on outdated recommendations. As others have pointed out here, if you really follow evidence based practice, you should read the original peer review literature. Come on, you can do it! And if you need access to those pdfs people have mentioned, just pm me. I will be happy to share them with you. 


 

 


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#186 of 229 Old 04-16-2012, 07:12 PM
 
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You can find another provider, even late in pregnancy.  Or, you can show up at the hospital in labor and sign AMA forms for procedures you don't want.  They cannot turn you away.  They are unlikely to seek a court order for treatment.

 

If you feel you need that particular doctor, then you have some reason to feel that doctor's advice has value, and you should probably consider taking it.  




That's a good point. You are always covered under EMTALA if you are in active labor.


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#187 of 229 Old 04-16-2012, 07:13 PM
 
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Fundal massage is a low-risk method of treating pph that has a long history of working and has few side effects.  If you gave birth with any kind of care provider, someone checked your fundus after the placenta was delivered.  If it felt huge and floppy, that person probably proceeded to pummel you in the stomach for a while, because that it what care providers do to encourage the uterus to clamp down so that bleeding stops faster, really no matter what their philosophy is on active management of the third stage.  If you had a c-section, they probably did it before stitching you up.  Fundal massage is described as a treatment for PPH in all the UC materials I have seen.  I'm kind of boggled that fundal massage has been viewed with such skepticism in this thread.

 



A treatment is something one uses when a condition is present. If there is no PPH, then performing fundal massage isn't a treatment. As for side effects...the OP described is as torture. Putting pregnant and post-partum women through hell "just in case" is absolutely standard of care, in all kinds of ways. That doesn't mean it has few side effects. It just means that excess pain for the pregnant/post-partum woman isn't considered to be relevant. The only time the medical profession cares about what a pregnant/labouring/post-partum woman is going through is when they sell you on the epidural.

 

I have no objection to fundal massage as a treatment for PPH...but PPH doesn't occur in 100% of births.


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#188 of 229 Old 04-16-2012, 07:19 PM
 
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It was her original assertion that fundal massage is absolutely.necessary.in.every.single.birth or the mother will always lose an "uncommon amount" of blood.

 

Like I said, Holly can practice however she wants, but speaking in these absolute terms is simply not true. 



You know...I missed that. WTF? How can it be the loss of an "uncommon amount' of blood, if every woman would lose it without fundal massage? That doesn't even make sense.


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#189 of 229 Old 04-16-2012, 07:21 PM
 
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Originally Posted by holly6737 View Post

Yes, your choices are to either 1) refuse or 2) not refuse. It's the providers choice to either keep you as a patient or not. Both of you have agency. Both of you have the right to choose. But I believe at 39 weeks patient abandonment would begin to be a legal issue, which is why it is so important to have these conversations at the beginning of pregnancy while you both have time to determine if it's a good patient/provider match.
 

 

There's a reason that the expression "bait and switch" is so prevalent in NCB/VBAC circles. I've never experienced a full on bait and switch, but one of my OBs sure seemed to have a different perspective as my pregnancy progressed. The only thing he stayed constant on was his repetitious "offer" of a tubal.


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#190 of 229 Old 04-16-2012, 07:21 PM
 
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Oh, no. I don't think you understood what I was trying to say. I apologize. I was trying to tell you to read the papers other have provided and also the ones you also provided.  It didn't seem like you understood them since in some of their recommendations were misinterpreted by you. Please read them! Others here have already tried to tell you this but I don't think you are open minded enough. And no, I don't think these organizations are wrong. Their recommendations are just not right for every women on earth and I am grateful for that! Evidence based means reading the original literature, understanding it, and applying to real situations.
 

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Picking individual pieces of literature that support your viewpoint does not determine evidence based practice and it does not determine standard of care. It takes more than one (or two) pieces of literature to create practice protocols. If you have a problem with how the WHO, the ACNM, ACOG or the ICM interpret the vast body of literature, then by all means, please write to them and inform them of their errors.


 

 



 

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#191 of 229 Old 04-16-2012, 07:22 PM
 
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You know...I missed that. WTF? How can it be the loss of an "uncommon amount' of blood, if every woman would lose it without fundal massage? That doesn't even make sense.

 

post 28 and 29
 

Holly:  "It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood."

 

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#192 of 229 Old 04-16-2012, 07:47 PM
 
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No, I read them. And I read that woman's post. I didn't acknowledge it because it seems that she picked studies that supported her viewpoint as opposed to looking at the overall spirit of the body of literature. To get an idea of what the entire body of literature conveys, one looks to recommendations and meta-analysis. These are much more worthwhile to determine practice standards as opposed to individual studies, as one can find an individual study to support one's viewpoint if you only look hard enough.

 

Cochrane: http://www.ncbi.nlm.nih.gov/pubmed/10908457

"Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries)."

 

National Guideline Clearinghouse:

http://www.guideline.gov/content.aspx?id=15263

"Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. (I-A)"

And that is rated the highest level of evidence and is based on RCTs.

 

Dynamed:

"Active management of third stage of labor:

active management of third stage of labor should be used to decrease postpartum blood loss, length of third stage and incidence of postpartum hemorrhage

  • active management of third stage of labor includes 3 components
    • uterotonic drug (for example, oxytocin) on delivery of anterior shoulder
    • controlled cord traction to deliver placenta
    • uterine massage"

Access to this is provided by institutions. It sounds as if you would have access to it, so to view it, just search "overview of labor & delivery" on dynamed and click on "management of third stage". It goes into much more detail, including references, for your viewing pleasure.

 

ICM Statement PDF, November 2006:

 

"Active Management of the Third Stage of Labour (AMTSL)

Data support the use of active management of the third stage of labour (AMTSL) by all skilled birth attendants regardless of where they practice. AMTSL reduces the incidence of PPH, the quantity of blood loss and the use of blood transfusion4, and thus should be included in any programme of interventions aimed at reducing deaths from PPH.
The usual components of AMTSL include:

  • Administration of oxytocin∗ or another uterotonic drug within one minute after the birth of the baby

  • Controlled cord traction∗∗

  • Uterine massage after delivery of the placenta as appropriate"

 


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#193 of 229 Old 04-16-2012, 07:48 PM
 
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Quote:

 

post 28 and 29
 

Holly:  "It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood."

 




That's right. Fundal massage is in imperative part of the birthing process. It prevents PPH. That's accepted by basically every major medical organization in the world, as I have noted.


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#194 of 229 Old 04-16-2012, 07:57 PM
 
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That's right. Fundal massage is in imperative part of the birthing process. It prevents PPH. That's accepted by basically every major medical organization in the world, as I have noted.

I guess I should've just asked a long time ago... can you show me the evidence that all women (particularly those with natural/non-augmented births) will always have pph or uncommon blood loss 100% of the time when fundal massage is not performed?

 

I am only objecting to your use of absolutes.
 

I stated many times in the beginning that I fully understand fundal massage can be very necessary in some scenarios.

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Where did I say that all women without fundal massage will hemorrhage? That's a ridiculous assertion. I don't believe that so I never would have said it.

 

What I said was that all women should get fundal massage unless you are okay with a PPH. You can't know who is going to hemorrhage and who is not. You CAN know that more women are going to hemorrhage without fundal massage as opposed to with fundal massage. So, if you don't want a PPH, you should get fundal massage.

 

It's the same concept as the pertussis vaccine. The pertussis vaccine prevents pertussis infection. So, if you don't want pertussis, you should get the vaccine. That doesn't mean that 100% of people without the pertussis vaccine will get pertussis. That means that the pertussis vax prevents pertussis, so unless you want to get pertussis, you probably should get the pertussis vax, since the pertussis vax makes that end result less likely.

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Quote:

I guess I should've just asked a long time ago... can you show me the evidence that all women (particularly those with natural/non-augmented births) will always have pph or uncommon blood loss 100% of the time when fundal massage is not performed?

 

I am only objecting to your use of absolutes.
 

I stated many times in the beginning that I fully understand fundal massage can be very necessary in some scenarios.



 


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#196 of 229 Old 04-16-2012, 08:17 PM
 
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Fundal massage is standard protocol, and should be done in all births. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood. It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.


unless you want to lose an uncommon amount of blood, pretty much sounds like a gaurantee - that I will pph and/or want to.

 

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Before I comment I just want to clarify something. When you talk about "fundal massage" are you talking about actively rubbing the fundus before there are signs of placental separation?

I'll comment further when I'm sure we're talking about the same thing.

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Before I comment I just want to clarify something. When you talk about "fundal massage" are you talking about actively rubbing the fundus before there are signs of placental separation?
I'll comment further when I'm sure we're talking about the same thing.


No, that's not what I'm talking about at all. Fundal massage prior to placental separation can cause partial separation of the placenta which can actually increase bleeding. Only massage the fundus after the placenta has been delivered. But I'm sure you already knew that. :)

 


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#199 of 229 Old 04-16-2012, 08:29 PM
 
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That's your interpretation, but that's not what was said.

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unless you want to lose an uncommon amount of blood, pretty much sounds like a gaurantee - that I will pph and/or want to.

 



 


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That's your interpretation, but that's not what was said.



 




No...I think any reasonable person would say that is pretty much what you were saying there. I can't think of many other ways that could be interpreted. Or really even one other way.


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Originally Posted by holly6737 View Post



Fundal massage is standard protocol, and should be done in all births. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood. It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.


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That's your interpretation, but that's not what was said.

 


Ok. I guess on top of having extremely different views of birth and the ncb community, we are also speaking different languages.

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Nope. Not what I said. You can read into what you will, but that's not what I said. I will never concede that point as I would never say that. It's a ridiculous assertion and I don't make ridiculous assertions. ;)

 

You should get fundal massage if you don't want to hemorrhage, as fundal massage prevents PPH. It's a simple concept. Fundal massage prevents PPH. If you dont' want a PPH, you should get fundal massage. That does not mean 100% of people without fundal massage will PPH.

 

You are focusing on this part of the argument in order to distract from the greater issue, which is the fact that fundal massage is recommended by every major medical organization as a part of active management of third stage and is evidence-based practice. (What you are doing is called a red herring. It's a logical fallacy and I'm not going to waste my time on it further.)
 

 

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No...I think any reasonable person would say that is pretty much what you were saying there. I can't think of many other ways that could be interpreted. Or really even one other way.



 


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Why should they be able to bill medicaid and Tricare for such services? Standards are important. Education is important. When you say it's not, you're making yourselves look like anti-intellectualists.



CPMs can't bill Tricare. They aren't authorized providers.

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But no one said you weren't allowed to birth at home with anyone you wish in attendance. No one wants to get the laboring woman in trouble. The laboring woman can do whatever she wants. It's the dangerous "provider" that should be regulated and fined for pretending to be something they are not.



 



Have you any idea how paternalistic this sounds? You're essentially saying that the poor, pitiful, laboring women are essentially too dumb to be active participants in something you think is wrong. It's like the old idea of jailing abortion providers, but not the women who get the abortions. Well, it's nice and all that you don't want to punish pregnant women - I appreciate the sentiment - but the idea that it's only the providers at fault really DOES suggest that the women were gullible and stupid. If midwives don't misrepresent themselves, then the women know what they are getting. If they do, then that's another issue entirely, and surely worthy of punishment, but if they don't, then why should they be punished over the women? Honestly. I know this is a difficult idea for people to wrap their minds around, because it sounds so nice, and friendly, and caring to not punish the poor, pitiful, pregnant women, who were just too dumb to know better, but the fact of the matter is that if a woman knowingly hires a midwife with whatever background, then that woman is complicit in whatever "crime" you think it is that the midwife is committing. If you disagree, you are essentially assigning the mentality of children to pregnant women - saying they aren't intelligent enough to know better. You really can't get more paternalistic than that. (And remember, I specifically stated that this applies only when women are well aware of their midwife's particular background, education, etc. It's a different story when a midwife misrepresents herself, so please don't try to conflate the two issues and pretend that they're all the same. They aren't.)

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#205 of 229 Old 04-16-2012, 09:35 PM
 
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If there were a man going around calling himself a "lay surgeon", removing the appendix's of people in your neighborhood in their living rooms, do you think he should be charged with practicing medicine without a license?

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Have you any idea how paternalistic this sounds? You're essentially saying that the poor, pitiful, laboring women are essentially too dumb to be active participants in something you think is wrong. It's like the old idea of jailing abortion providers, but not the women who get the abortions. Well, it's nice and all that you don't want to punish pregnant women - I appreciate the sentiment - but the idea that it's only the providers at fault really DOES suggest that the women were gullible and stupid. If midwives don't misrepresent themselves, then the women know what they are getting. If they do, then that's another issue entirely, and surely worthy of punishment, but if they don't, then why should they be punished over the women? Honestly. I know this is a difficult idea for people to wrap their minds around, because it sounds so nice, and friendly, and caring to not punish the poor, pitiful, pregnant women, who were just too dumb to know better, but the fact of the matter is that if a woman knowingly hires a midwife with whatever background, then that woman is complicit in whatever "crime" you think it is that the midwife is committing. If you disagree, you are essentially assigning the mentality of children to pregnant women - saying they aren't intelligent enough to know better. You really can't get more paternalistic than that. (And remember, I specifically stated that this applies only when women are well aware of their midwife's particular background, education, etc. It's a different story when a midwife misrepresents herself, so please don't try to conflate the two issues and pretend that they're all the same. They aren't.)



 


CNM mama.

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#206 of 229 Old 04-16-2012, 09:45 PM
 
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Performing surgery is not the same as attending vaginal births, and you know it....or maybe you don't. I have no idea. I kind of assume you do, since you know damn well your training, which is sufficient to prepare you to attend births, is not sufficient to prepare you to perform c-sections. However, if people are silly enough to have some neighborhood dude removing their appendixes, and they know he's not a real doctor and isn't licensed, etc., etc.,, then you either punish them ALL or punish no one. Otherwise, you are saying that the people who use him are morons, too stupid to understand what they're doing, and were therefore tricked. What you are saying right now is that EVERY woman who has ever used an unlicensed midwife in this country was too stupid to understand what she was getting, and therefore, while the midwife should surely be punished, the woman, who was obviously not intelligent enough to be considered an active participant in a crime, should not. She's essentially not mentally fit to stand trial for her participation in said crime.

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#207 of 229 Old 04-16-2012, 09:49 PM
 
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Why is it that, in every other scenario, we punish BOTH parties involved in crimes? What's so different about buying drugs, for instance? If I go buy crack from some dealer on the corner, the cops don't assume that I was tricked. The law says I'm a criminal, too, because I was willfully engaged in criminal behavior. We prosecute johns just like we prosecute prostitutes. We don't say one was less guilty than the other (short of women who've been forced into prostitution). We assume that BOTH parties were mentally fit. However, when it comes to any sort of treatment of our health and/or bodies, suddenly all us patients are just idiots? We can't be guilty of anything because we're too stupid to know better? How come I'm smart enough to know whether I should buy crack, but I'm not smart enough to know whether I should use an unlicensed midwife? Makes no sense.

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#208 of 229 Old 04-16-2012, 10:38 PM
 
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Not to stick my head into a hornet's nest here, but those laws regulating medical providers are because the state has an interest in making sure medical providers fulfil our duty to the public. As a medical provider, I am bound by certain laws if I want to continue legally practicing in my state, and I am subject to action if I break those laws. Patients are subject to no such laws, nor should they be. The "both parties to a crime" discussion isn't really relevant because patients are not legally held to any particular standard of conduct in an interaction with a medical provider that they aren't in other situations. The "crime" in question is committed by a medical provider who violates the rules of his/her profession, or by someone who hasn't met the standards to be called a medical provider but calls him/herself one anyway. Part of the reason that non-providers can't misrepresent themselves as providers is because they could do so in order to fool patients. The issue of whether a particular patient chooses that situation fully aware of the non-provider's qualifications isn't really relevant, because the legal smackdown is not about the patient, it's about the person who's calling themself a provider.

 

There are all sorts of instances along these lines where someone who is operating in a particular way has to obey particular laws, while those who use their services don't. If I own a restaurant and you come to eat there, then I get shut down for health code violations, you can't get in trouble for having eaten at my restaurant, even if you knew I was violating the health code and chose to eat at my restaurant anyway. That's because the law regulates me as the restaurant owner but not you as the customer. Etc.

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#209 of 229 Old 04-16-2012, 11:54 PM
 
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“Evidence-based medicine is a systematic process of appraising and using current research findings. It is a step-by-step process that includes: formulating a clear clinical question of patient needs; searching the current literature; evaluating the literature, deciding which studies are valid and useful to the patient; applying the findings to the patient's care; and then evaluating the outcome.http://library.hsc.unt.edu/content/library-glossary (bolded mine).

 

I  have a hcp that follows this definition of evidence based medicine. I feel pretty lucky to have someone who can read the original research (not just meta-analyses and recommendations), understand it and together we can make a decision of care based on me. If my only choice was to be attended by someone like you, I would UC. I am glad I have a choice. I always think about women who don’t and it makes me sad.

 

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#210 of 229 Old 04-17-2012, 05:00 AM
 
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Quote:
Originally Posted by lilikoi View Post

“Evidence-based medicine is a systematic process of appraising and using current research findings. It is a step-by-step process that includes: formulating a clear clinical question of patient needs; searching the current literature; evaluating the literature, deciding which studies are valid and useful to the patient; applying the findings to the patient's care; and then evaluating the outcome.http://library.hsc.unt.edu/content/library-glossary (bolded mine).

 

I  have a hcp that follows this definition of evidence based medicine. I feel pretty lucky to have someone who can read the original research (not just meta-analyses and recommendations), understand it and together we can make a decision of care based on me. If my only choice was to be attended by someone like you, I would UC. I am glad I have a choice. I always think about women who don’t and it makes me sad.

 

Thank you for posting this.

 

 

Quote:
Evidence-based practice involves the active participation of patients in making decisions about their care. Though foreboding in concept, the premise is simple: evidence-based decision-making requires that consumers comprehend their diagnosis and engage in a reasoned assessment of available treatment options and the benefits and risks associated with each.

I don't see how this is much different than the Marsden Wagner quote.

 

 Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other.

 

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