Article: Failure to Progress: What's Wrong with Hospital Obstetrics? - Mothering Forums

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Old 06-03-2006, 10:42 AM - Thread Starter
 
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Failure to Progress: What's Wrong with Hospital Obstetrics?
http://vermontwoman.com/articles/0606/obstetrics.shtml

A well written, concise article on many of the issues with obstetrics.
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Old 06-03-2006, 03:33 PM
 
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Aggressive management of labor is costing us a fortune. We spend more on birth-related care than does any other country, yet our rate of maternal and fetal deaths remains among the highest in industrialized nations. Malpractice premiums for OB doctors are skyrocketing faster than in any other field of medicine – $100,000 to $250,000 per year for beginning practitioners; still, the main reform called for within the specialty is tort reform – to limit awards for damages.

“The medical world has over-medicalized birth; there is little justification for a cesarean section rate of 30 percent and an induction rate of 30 percent,” said a local OB/GYN who’s been in the field for thirty years. “Yet, the broader U.S. public feels entitled to the ‘perfect baby,’ and when this doesn’t happen, someone is to blame and has to pay for this loss of expectation. So the medico-legal climate has just ruined OB from my point of view.

Until this part is dealt with, aggressive intervention during labor and the c-section rate will only continue to climb. Until a physician can practice medicine without fear of losing everything they have worked YEARS to achieve, they will continue to opt for a c-section at the least sign of a potential problem to cover their own butts, and I honestly cannot say that I blame them.

All it takes is ONE lawsuit with a high enough monetary award to make it impossible for an OB to EVER get malpractice insurance again. That effectively ENDS his or her career, as you can't really practice without malpractice insurance.

One case I distinctly remember was after a VBAC attempt that resulted in rupture and the baby died. The parents sued (um, hello...did you READ the risks or listen AT ALL or read ANYTHING about VBAC prior to trying it?). The doc refused to settle out of court because he truly felt he had done nothing wrong. He had followed ALL of the current recommendations, which at the time said a hospital/doc should be able to perform a c-section within 30 minutes.

This particular baby was delivered by emergency c-section LESS THAN 30 minutes from the first sign of trouble. Well, guess what? The doc lost. And it was a HUGE verdict, but that's the thing. Juries don't like dead babies, and somebody must be at fault cause well, nobody likes to think that sometimes these things just happen. So this doc has no career left when it's all said and done. And he DID NOTHING WRONG.

Then women want to pitch a fit when they can't find a doc or hospital willing to even allow VBAC's at all anymore. Again, can't say that I blame them. Even if the doc and hospital DOES follow every single recommendation from ACOG, they are still likely to lose a malpractice case if it comes down to that point. Why take that risk?

THAT is where this aggressive medical management comes from for the most part. Sure, we've got docs who just want to go play golf, but you better believe that in the back of EVERY practicing OB's mind in the US is the fear that YOUR delivery might be the one that ends their career. They have to intervene early and often if they have a prayer of defending themselves should it come down to it.

Another very real consequence of all the sue-happy folks in the US is that many docs are just no longer delivering babies at all. The malpractice insurance is $100-250K PER YEAR?!?!? for OB's. Drop delivering babies and those rates go down dramatically. They can do GYN stuff all day and not have nearly the risk of being sued. We're going to end up with areas of the country that have no docs who deliver babies or are so full they can't take on new patients. It's already happening in some places.

And midwives won't be immune to the exact same issues over time. I can see a time where they'll be just as interventionist (and some already are) because of fear of being sued. Now, I think most moms who use midwives in the US are less likely to sue because they are more aware of the risks and understand that not all babies are born alive no matter what you do or don't do. But that'll change if more and more mainstream women are forced into using midwives because of a lack of OB's.

The whole thing really sucks, cause ultimately, all the interventions aren't improving the outcomes, but that's not what counts when you get in the courtroom.
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Old 06-03-2006, 03:39 PM
 
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On a funny note, my 4.5 year old twins were looking at the picture of the very pg lady in the article. One says 'MOM! Is *that* what your belly is going to look like with our baby in it?' (I'm almost 12 weeks pg now, and they are fascinated.)

So I say 'Well, yes, it will get very big like that lady's.' Didn't mention it won't look nearly as pretty as the model's.

So the other says 'Well, you're going to need a really big shirt to cover it up then!'

I really am enjoying them being old enough to 'get it', as they were only 13 months old when #3 was born. This is a whole new experience for us.
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Old 06-03-2006, 10:51 PM
 
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This is a great article, thanks for sharing it! I'm going to pass it along to the Unbelievers
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Old 06-04-2006, 01:16 AM
 
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Originally Posted by wifeandmom
Until this part is dealt with, aggressive intervention during labor and the c-section rate will only continue to climb. Until a physician can practice medicine without fear of losing everything they have worked YEARS to achieve, they will continue to opt for a c-section at the least sign of a potential problem
Very true.

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He had followed ALL of the current recommendations [...] And he DID NOTHING WRONG.
Hmm... just because he followed the recommendations doesn't mean he didn't do anything wrong. Sometimes the recommendations themselves are wrong.

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Then women want to pitch a fit when they can't find a doc or hospital willing to even allow VBAC's at all anymore. Again, can't say that I blame them. Even if the doc and hospital DOES follow every single recommendation from ACOG, they are still likely to lose a malpractice case if it comes down to that point. Why take that risk?
Because not to -- in other words, to mandate non-emergency surgery with its attendant risks -- is unethical.
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We're going to end up with areas of the country that have no docs who deliver babies or are so full they can't take on new patients. It's already happening in some places.
Who is delivering these babies, then? Regardless of shortages, women still seem to be able to find doctors...

Anyway, assuming it will happen, hopefully it will wake people up to the need for malpractice reform. Something has to give.
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Old 06-04-2006, 03:52 AM
 
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Originally Posted by fourlittlebirds
Very true.



Hmm... just because he followed the recommendations doesn't mean he didn't do anything wrong. Sometimes the recommendations themselves are wrong.
Obviously I wasn't there for the trial, but DH and I both read extensively during the time it was going on and afterwards all about the exact details of what happened during this particular birth. I read with fascinated horror to be honest, because from the MOMENT this baby showed a single.solitary.blip. on the EFM strip til the MOMENT the baby was delivered was less than 30 minutes. There WERE no other outward signs of rupture except the non-reassuring heart tones.

At the time, ACOG recommended a c-section be performed within 30 minutes of detecting rupture. If the doc cannot go by ACOG recommendations, what exactly *should* they be going by? As it is, these very recommendations changed to 'immediate' ability to perform a crash c-section, and the result has been a sharp decline in hospitals that will allow a VBAC attempt at all. They simply cannot conform to the 'immediate' part of ACOG's standard, which means they WILL lose a lawsuit if it comes down to it.

This particular doctor had an outstandig record and impeccible reputation when this occurred. It was all very sad.


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Because not to -- in other words, to mandate non-emergency surgery with its attendant risks -- is unethical.
If it comes right down to it though, because of very real legal repercussions, if the choice is between losing your ability to practice medicine vs. doing the so-called 'right' thing...well, non-emergency surgery is going to be accepted in mainstream America as necessary afterall.

Not to mention the fact that many malpractice carriers are outright refusing to cover docs who do VBACs period. Ethical or not, they can't very well attend births that they have no insurance coverage for.


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Who is delivering these babies, then? Regardless of shortages, women still seem to be able to find doctors...

Anyway, assuming it will happen, hopefully it will wake people up to the need for malpractice reform. Something has to give.
From what I've read and heard, some women are having to travel several hours to reach the nearest teaching hospital that has staff docs who will do OB. Some are seeking alternative birthing options, which is great, but the fact remains that when/if midwives begin to see a larger percentage of pg women in this country, they too will face more malpractice suits cause we expect a live baby at the end of pg, and if that doesn't happen, we tend to place blame whether or not the problem could have reasonably been avoided.

You are *absolutely* right that *something* has to give. The birthing climate in the hospitals DH works in is appalling. Absolutely sickening really, but most everyone seems so complacent about it.
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Old 06-04-2006, 05:05 AM
 
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Old 06-04-2006, 05:12 AM
 
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I don't know that it is true that one jury award=no insurance. I worked L&D for 5 years and certainly knew OB's that had been sued and had judgements against them and were still in practice. The truth is the vast majority are settled before they ever see a courtroom, sometimes paying out big, but they are still in business. The OB's who seemed to stop doing deliveries or closing their practices were not those who had been sued, but those who weren't doing the volume to justify paying out the high premiums for malpractice insurance. But the high premiums were being seen all around, not just those who had been sued and lost or settled.
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Old 06-04-2006, 01:12 PM
 
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Originally Posted by wifeandmom
Obviously I wasn't there for the trial, but DH and I both read extensively during the time it was going on and afterwards all about the exact details of what happened during this particular birth. I read with fascinated horror to be honest, because from the MOMENT this baby showed a single.solitary.blip. on the EFM strip til the MOMENT the baby was delivered was less than 30 minutes. There WERE no other outward signs of rupture except the non-reassuring heart tones.
That's not the part that concerns me. What I'd like to know is, what did the OB do during labor that would make a VBAC rupture more likely? There are several possibilities that immediately come to my mind. As far as this goes, those in the medical community (in general) have their heads up their asses. It's all about how fast we can cut a woman open, not about what creates a dysfunctional birth in the first place. It is so upside-down.

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As it is, these very recommendations changed to 'immediate' ability to perform a crash c-section, and the result has been a sharp decline in hospitals that will allow a VBAC attempt at all. They simply cannot conform to the 'immediate' part of ACOG's standard, which means they WILL lose a lawsuit if it comes down to it.
A woman can rupture even if she hasn't had a previous cesarean. So what now, are they going to ban *all* births? Of course not. Yes, I know that rupture is statistically more likely to occur after a VBAC (especially when induced.) But death is more likely to occur with cesarean section than vaginal birth, yet no one is talking about banning elective c-secs. It's a nonsensical double standard.

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This particular doctor had an outstandig record and impeccible reputation when this occurred.
<shrug> That doesn't mean much to me. I was delivered by a doctor who delivered 5000 babies in his lifetime and was revered in the medical community. During her labor, my mother was left alone for the most part, confined to bed, for 19 hours with no food or water, when an x-ray was finally done to determine I was breech, of course necessitating "emergency" sugery which left her so ill she couldn't care for me for the first week of my life. We lived though, so I guess that was regarded as a total success. The standards by which medical professionals are judged are relative, and reflect the medical establishment's biases, as well as those of our culture.
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Old 06-04-2006, 01:16 PM
 
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Originally Posted by mom2seven
I don't know that it is true that one jury award=no insurance. I worked L&D for 5 years and certainly knew OB's that had been sued and had judgements against them and were still in practice.
Where I live it was the *hospital administration* that banned VBACs, against the wishes of several of the doctors practicing there, and I'm assuming the reason is that the malpractice insurance was being paid by the hospital?
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Old 06-04-2006, 01:56 PM
 
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Originally Posted by mom2seven
I don't know that it is true that one jury award=no insurance. I worked L&D for 5 years and certainly knew OB's that had been sued and had judgements against them and were still in practice. The truth is the vast majority are settled before they ever see a courtroom, sometimes paying out big, but they are still in business. The OB's who seemed to stop doing deliveries or closing their practices were not those who had been sued, but those who weren't doing the volume to justify paying out the high premiums for malpractice insurance. But the high premiums were being seen all around, not just those who had been sued and lost or settled.

I didn't mean that losing one case makes you uninsurable. It typically depends on HOW LARGE the loss is. I cannot for the life of me remember what the actual 'typical' number was back when this particular case was going on that meant you were basically uninsurable. Something like $5 or 10 million maybe? And once you crossed that threshold, you were SOL for malpractice insurance.

We pay premiums out of pocket for DH's malpractice insurance when he works PRN at various hospitals. It is not pretty, and he's in the 'best' category with several years of experience and no 'losses' thus far. If he had an award against him over a certain amount, we'd have to go with a 'high risk' company, but even those companies have limits to who they'll insure.

Plus, much like car insurance, it's not only the fear of losing coverage altogther, but the fear of your premiums doubling or tripling. Do you have any idea how many patients you have to see just to cover the insurance if it costs you $250K or more per year? That's JUST for malpractice insurance. It's mind boggling really.
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Old 06-04-2006, 02:07 PM
 
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My understanding is that though many claims are filed (the average OB these days has 3 filed against them, up from 1 20 years ago), few get settlements, even fewer go to court, and most cases file in favor of the defendant. The whole "litigous society" argument has a very limited play in this, I believe. What is happening is that insurance companies are hyping the fear of the litigous society to openly steal money, hand over fist. Doing a damn fine job, I might add since here we are hearing this one case that got some kind of settlement and it's used over and over as a demonstration of how much insuring doctors costs. We're supposed to feel sorry for insurance companies. Meanwhile women are being raped and abused by docs (willingly, I might add) trying to cover their asses or to streamline a natural process. It's almost like when the U.S. Forest Service hypes logging as a means of protecting forests from wildfire. Thanks corporate lobby!

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Old 06-04-2006, 02:08 PM
 
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Originally Posted by fourlittlebirds
Where I live it was the *hospital administration* that banned VBACs, against the wishes of several of the doctors practicing there, and I'm assuming the reason is that the malpractice insurance was being paid by the hospital?
The hospitals have their own insurance, but the doctors practicing there must have their own indiviual coverage as well.

In a lawsuit, even if it is the doctor who is CLEARLY at fault, the hospital will be named in the lawsuit as well. It's two separate insurance policies.

The only time I've heard of the hospital providing malpractice insurance for individual docs is when the docs are ONLY working at the hospital and not in private practice.

For example, if DH worked for a hospital, malpractice insurance is typically part of the salary package. If he worked for an ansesthsia group, the group itself pays for malpractice insurance. If he was in solo practice, obviously the premiums would come only from him.

Most OB's don't work for the hospital though, thus the premiums must come from their particular group/practice.

The biggest reason hospitals are banning VBACs altogether has much to do with anesthesia coverage. ACOG now says hospitals must staff both surgeons and anesthesia staff 24/7 to handle VBACs safely.

To hire an anesthetist, the hospital will pay $100-150 PER HOUR just in wages for someone to sit there waiting to see if something goes wrong or if the woman wants an epidural. Unless there are LOTS of women wanting an epi, the hospital is going to lose their butt paying that kind of money, but that's the going rate.

If they hire someone full time, they've got to hire 3 such people to cover 24/7. Salary alone ranges from $100-220K per year PER provider, and this is for anesthetists, NOT for anesthesiologists (which can easily make twice these figures per hour or per year). You can easily add in another $50-100K per year PER provider for benefits such as health insurance, 401K match, bonuses, vacation time, etc. That's a lot of money for small hospitals that don't deliver lots of babies.

Even when the recommendations were to have access to a crash section within 30 minutes, thus anesthesia folks could just carry a beeper...that runs you $25-100 PER HOUR for someone to carry a beeper. Lots of anesthesia providers, my husband included, now refuse to carry a beeper for L&D. They'll ONLY do 'in-house' call where they are actually present at the hospital (and thus getting paid a lot more money). It's not the extra money that's causing this though. Carrying a beeper for $50 an hour was super sweet, but it put DH at risk should disaster strike and he got caught in traffic or something. So many of his co-workers will now either outright refuse to cover L&D OR they will only do it if the hospital will pay for them to be AT the hospital during their call time.

This conversation usually turns to 'Why are they getting paid so much?' at this point, which is a relevant question for sure. First, consider we are paying out of pocket for that pesky malpractice insurance, so that $100-150 per hour isn't nearly as much after paying for insurance. Second, he graduated with over $100K in student loans, as do most people who have been in school for 8-12 years AFTER high school. Our student loan payments are more than many people's mortgage payments.
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Old 06-04-2006, 02:10 PM
 
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Our student loans will be that much too, but my DH will be a PhD, not a MD and won't make nearly as much money as yours, so I hardly feel sorry for the docs and their student loan debt. Everyone has a mountain of it these days. It's the price of voting republican.

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Old 06-04-2006, 02:21 PM
 
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Originally Posted by fourlittlebirds
That's not the part that concerns me. What I'd like to know is, what did the OB do during labor that would make a VBAC rupture more likely? There are several possibilities that immediately come to my mind. As far as this goes, those in the medical community (in general) have their heads up their asses. It's all about how fast we can cut a woman open, not about what creates a dysfunctional birth in the first place. It is so upside-down.
That's what I am telling you though, he didn't DO anything that was not accepted as standard of care for VBACs at the time. Now, of course, all that has changed and recommendations are a lot stricter. But even today, how many women do we see that are induced even though they are a VBAC? I wouldn't touch a VBAC with pitocin for a million bucks. You WILL LOSE in court if you've got mom on pit and she ruptures. The end.

Now, VBACs are only recommended if mom has had ONE previous section, but how many VBA2C do we still see? Not a lot, but there ARE docs/hospitals out there that will do it....with pit no less. I wonder what on earth these docs are thinking?

As for sticking mom in bed on continuous EFM, thus screwing up the body's natural rhythm of laboring, there's no way to defend NOT doing continuous monitoring though. If something goes wrong, all the lawyer has to say is 'What if they'd actually been monitoring this baby? Maybe he or she wouldn't be dead today.'

I KNOW that research doesn't support continuous EFM, but that is not going to matter one iota to a jury of normal adults in America. As for settling out of court, the reason we see most of that is cause docs are terrified (or their malpractice carriers are) of putting a case in front of a jury *no matter how good the care provided was* cause juries DON'T LIKE DEAD BABIES and *someone* has to be held responsible. So they settle and cut their losses while they can.



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A woman can rupture even if she hasn't had a previous cesarean. So what now, are they going to ban *all* births? Of course not. Yes, I know that rupture is statistically more likely to occur after a VBAC (especially when induced.) But death is more likely to occur with cesarean section than vaginal birth, yet no one is talking about banning elective c-secs. It's a nonsensical double standard.
Absolutely. And my fear is that the time will come when only large hospitals with 24/7 OB and anesthesia coverage will be able to afford to offer deliery services for ANY birth. As it has been pointed out repeatedly, there are SEVERAL other things that are MORE LIKELY to go wrong during the course of a normal L&D than rupture, yet we don't see the recommendation for 24/7 coverage across the board. I am afraid that might just be what is coming in the next 10+ years.
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Old 06-04-2006, 02:26 PM
 
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Originally Posted by annakiss
Our student loans will be that much too, but my DH will be a PhD, not a MD and won't make nearly as much money as yours, so I hardly feel sorry for the docs and their student loan debt. Everyone has a mountain of it these days. It's the price of voting republican.
I have no doubt other people have $120K+ in student loans that don't make the money we do. I personally cannot fathom taking out that much in loans if the income potential is not there, simply because it is a big budget item to pay the things back over the next 30 years.

And I don't expect, nor want, anyone to 'feel sorry' for our student loans, as we'd take it out all over again. It is worth making that payment every month when we look at the salary difference between what he was making with just his Bachelor's degree vs. now.

I do disagree that 'everyone has a mountain of student loan debt' though. Some article recently published said the average student graduates with what...$20K in debt? It wasn't 'a mountain', whatever the number was. I handled $20K in student loans as a school teacher, so that's not a huge amount IMO.

And I'm not sure what 'voting Republican' has to do with borrowing money for college. Has college been free when Democrats are in office? Heck, I was in college when Clinton was in office, and I have the loan book to prove otherwise.
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Old 06-04-2006, 02:27 PM
 
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Originally Posted by wifeandmom
So this doc has no career left when it's all said and done. And he DID NOTHING WRONG.

Even if the doc and hospital DOES follow every single recommendation from ACOG, they are still likely to lose a malpractice case if it comes down to that point. Why take that risk?

THAT is where this aggressive medical management comes from for the most part.
This doesn't seem like a chicken and egg situation to you at all? I just see it from the opposite angle. It seems to me that the people have mostly been brainwashed by a very aggressive medical industry to believe that it is always better to do something than to do nothing. Hence the need to do every intervention, follow every recommendation. If an OB can't perform a c/s fast enough, they are sued and lose. But if that same doc does an "emergency c/s" and baby or mom dies or suffers long-term problems, does anyone really look into whether or not that C/s was necessary? or if there was some alternative to try? Isn't the prevailing attitude (REALLY generalizing here) "The doc did everything he could, and couldn't save them. Such a tragedy. Oh well..."? But I don't see anyone considering that the best thing might have been to keep everybody's fingers out of the pie, so to speak, and awarding claims on that basis. So from this perspective, it seems to be the agressive attitude of doctors in general that have brought about a system where people are more likely to condemn a doctor for not being aggressive or active enough. Looking at the activities and mentalities of say, western European nations, their medical systems are not nearly as agressive, and the legal repercussions dealt out to the professionals in those systems appears to reflect that...
It has always seemed to me that a great deal of the American medical and legal climates have been largely based on some cultural biases

My very own $.02,
Rachele
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Old 06-04-2006, 02:42 PM
 
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Originally Posted by Qalliope
This doesn't seem like a chicken and egg situation to you at all? I just see it from the opposite angle. It seems to me that the people have mostly been brainwashed by a very aggressive medical industry to believe that it is always better to do something than to do nothing. Hence the need to do every intervention, follow every recommendation. If an OB can't perform a c/s fast enough, they are sued and lose. But if that same doc does an "emergency c/s" and baby or mom dies or suffers long-term problems, does anyone really look into whether or not that C/s was necessary? or if there was some alternative to try? Isn't the prevailing attitude (REALLY generalizing here) "The doc did everything he could, and couldn't save them. Such a tragedy. Oh well..."? But I don't see anyone considering that the best thing might have been to keep everybody's fingers out of the pie, so to speak, and awarding claims on that basis. So from this perspective, it seems to be the agressive attitude of doctors in general that have brought about a system where people are more likely to condemn a doctor for not being aggressive or active enough. Looking at the activities and mentalities of say, western European nations, their medical systems are not nearly as agressive, and the legal repercussions dealt out to the professionals in those systems appears to reflect that...
It has always seemed to me that a great deal of the American medical and legal climates have been largely based on some cultural biases

My very own $.02,
Rachele
Yup, I completely see what you are saying. Obviously doing SOMETHING is not always preferable to doing NOTHING, however that's not the culturally accepted norm in our country. We expect docs to do SOMETHING, and the only hope they have of defending themselves is if they DID do 'everything' medically possible to save mom and baby.

Afterall, docs generally don't get sued for DOING a section, rather for NOT DOING one fast enough. This is the framework that current OB's practice within, and where it came from or how long it has been this way is really not the point when it comes to day to day practice. To 'buck the system' carries the very real possibility of something going wrong and the doc will be found to have 'not performed emergency surgery quickly enough' blah blah blah.
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Old 06-04-2006, 02:54 PM
 
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Honestly, OBs learn very fast that the only section you'll be sued for is the one you don't do. It's this sense among most Americans that everyone has a right to a perfect baby (whatever that means, and however impossible that would be) and when there isn't a perfect baby, someone has to be the goat. It's never just that sometimes moms or babies die, or are injured, but that someone must be to blame.

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Old 06-04-2006, 03:21 PM
 
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Originally Posted by wifeandmom
I have no doubt other people have $120K+ in student loans that don't make the money we do. I personally cannot fathom taking out that much in loans if the income potential is not there, simply because it is a big budget item to pay the things back over the next 30 years.

And I don't expect, nor want, anyone to 'feel sorry' for our student loans, as we'd take it out all over again. It is worth making that payment every month when we look at the salary difference between what he was making with just his Bachelor's degree vs. now.

I do disagree that 'everyone has a mountain of student loan debt' though. Some article recently published said the average student graduates with what...$20K in debt? It wasn't 'a mountain', whatever the number was. I handled $20K in student loans as a school teacher, so that's not a huge amount IMO.

And I'm not sure what 'voting Republican' has to do with borrowing money for college. Has college been free when Democrats are in office? Heck, I was in college when Clinton was in office, and I have the loan book to prove otherwise.
20K is a lot of money. It's not 100K, but it's a lot of money. When you're making 30K a year, it certainly looks like a mountain. The salary after graduation is not remotely a primary reason for getting a degree that costs a lot in student loans. You're making docs sound as money-grubbing as stereotypes make them out to be.

It was Regan who originally started moving away from grant-based financial aid to loan-based. It's continued. Clinton was that new breed of conservative democrat, so I'd hardly consider him to be a boon to college students anyway or poor people or black people or gay people, etc.

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Old 06-04-2006, 04:50 PM
 
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Who is delivering these babies, then? Regardless of shortages, women still seem to be able to find doctors...
I can answer that.

I'm an RN, and I once worked in an area of the country where this is happening, and in the particular city I worked in, the OBs were not accepting any patient who didn't have a solid insurance plan. No uninsured, no "self pay", no marginal medical deductible program plans, etc.

The uninsured people would present to the emergency department, where I worked, for their "prenatal care"... About every month or two, the women would present with a non-serious complaint (made up) - i.e., cough for two days, low back pain. Generally, as part of the evaluation for a pregnant woman, we would check blood pressure, do FHTs, and depending on the complaint, a urine dip. All most women wanted was to hear that "The baby's okay" and so was their throat and back. Most of the staff knew the situation and we would accommodate this; what else can you do?

Then, about halfway through their pregnancies, women would present to the ED complaining of severe abdominal pain or cramping/bleeding/tightness, etc. Part of that evaluation generally included a complete OB ultrasound, much like most American women get around 20 weeks. Upon completion of a typically normal ultrasound (where most found the gender of their babes), they would feel "better" and be able to be discharged home.

Then, when the women began to labor, they would again present to the ED. We would naturally triage them up to the OB unit, where whoever was on call would be called in to deliver their babies.

Post-delivery and post-hospital discharge, when the OBs again wouldn't see them without their insurance, they would present to the ED for evaluation of their lochia, perineal swelling, etc., and prescribe birth control when asked (which was frequently).

And, that, my friends, is, in a nutshell, why emergency department care costs so much.

It's a rotten system, and I can't blame the patients. It's all money-driven, and when you don't have the money, you don't get to make the choices.

Mama to A 8/05 and S 11/06
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Old 06-04-2006, 04:54 PM
 
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Oh, and I just wanted to add... this is a great discussion. I don't want to hijack by focusing on one aspect of one post, but I couldn't not respond. It's particularly fascinating looking at it from the physician's point of view, since that isn't often represented on MDC.

Carry on with your regularly scheduled discussion, please!

Mama to A 8/05 and S 11/06
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Old 06-04-2006, 06:05 PM
 
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20K is a lot of money. It's not 100K, but it's a lot of money. When you're making 30K a year, it certainly looks like a mountain. The salary after graduation is not remotely a primary reason for getting a degree that costs a lot in student loans. You're making docs sound as money-grubbing as stereotypes make them out to be.

It was Regan who originally started moving away from grant-based financial aid to loan-based. It's continued. Clinton was that new breed of conservative democrat, so I'd hardly consider him to be a boon to college students anyway or poor people or black people or gay people, etc.
I'd be hard pressed to recommend ANYONE take out $100K+ in student loans if the salary potential for the chosen degree path is less than $50K per year.

Let's say you bring home $3000 per month after taxes and such, not a piddly amount of money by any means. But let's say you have the student loan debt that DH and I have, which currently amounts to approximately $700 per month. That amount will go up again in a few years, finally topping out at about $900 per month for the next THIRTY YEARS.

Ok, so if you're bringing home $3K per month and forking out $700 in student loans, to me that spells trouble. That's nearly a fourth of your take home pay, what many wise financial planners/advisors will tell a couple is an appropriate amount for their HOUSING costs.

I'm not saying people absolutely should not even CONSIDER pursuing a very expensive degree when they know they won't make much money with that degree, but come on, let's be realistic here. It makes little sense to dig yourself into this huge hole financially before you've ever even gotten started. Or at least that's how *I* look at it.

I have no doubt that we are incredibly blessed that DH *wanted* to do something that makes good money. He LOVES what he does, he's a quiet kind of guy, loves the solitude of passing gas all day. But honest to goodness, we would have never taken on that kind of debt if he was going to make $50K a year when he was done. That just doesn't make financial sense to me.

My theory is that your final loan amount ought to be a bit less than what your salary potential would be. When I taught school, I made just under $30K and wasn't intimidated by $20K in loans. With DH's current salary, his loans aren't intimidating to us financially. I don't like paying them, but they don't break the bank every month.
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Old 06-04-2006, 11:32 PM
 
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Sorry for the derailment everyone.

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Old 06-04-2006, 11:42 PM
 
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wifeandmom, do you think that tort reform is the answer? The article seems to scoff at that solution.

also, I find this really odd:
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A Vermont-trained OB doctor practicing in New York agreed, saying, “I cannot practice the kind of medicine I was trained to do.” These physicians are part of an unhappy chorus of practitioners who feel that their ability to care for patients is restricted by the fear of legal action, pushing them toward aggressive management of delivery, and more and earlier interventions.
What exactly is the kind of medicine they were trained to do? Because what OB sees natural birth in med school?

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Old 06-04-2006, 11:43 PM
 
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Sorry for the derailment everyone.
I think most of the women here are perfectly capable of carrying on a discussion about a fascinating topic/article and all the many issues surrounding that topic without much trouble.
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Old 06-04-2006, 11:58 PM
 
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Another interesting quote from the article:
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Doctors who are pushed into action by managed care, utilization review, and fear of litigation find it difficult to justify letting a laboring woman remain in the hospital for a day and a night without the benefit of some documented, billable procedure
It really is all about money, isn't it?

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Old 06-05-2006, 12:15 AM
 
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I KNOW that research doesn't support continuous EFM, but that is not going to matter one iota to a jury of normal adults in America. As for settling out of court, the reason we see most of that is cause docs are terrified (or their malpractice carriers are) of putting a case in front of a jury *no matter how good the care provided was* cause juries DON'T LIKE DEAD BABIES and *someone* has to be held responsible. So they settle and cut their losses while they can.
Let's not forget that the average juror is WAY less informed on these issues than your average MDC poster. Therefore, they are at the mercy of the lawyers' witnesses to get the information needed to pass judgement. And we all know how trustworthy some prosecutors are... I agree with annakiss that the ins. companies are hyping this issue in order to make more money; however, we should remember also that it's the dishonest lawyers who win cases that should not be won.

This issue is far more complicated than "Let's blame ___!" There is the ignorance and fear of the public at large regarding birth; there is the greed of insurance companies, lawyers, and doctors; there is the general tendency to regard doctors as authority figures or (dare I say) demigods and blindly trust everything they say...I could go on. I don't see how this problem can be fixed unless some serious societal attitudes begin to change.
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Old 06-05-2006, 12:18 AM
 
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It seems to me that the people have mostly been brainwashed by a very aggressive medical industry to believe that it is always better to do something than to do nothing. Hence the need to do every intervention, follow every recommendation. If an OB can't perform a c/s fast enough, they are sued and lose. But if that same doc does an "emergency c/s" and baby or mom dies or suffers long-term problems, does anyone really look into whether or not that C/s was necessary? or if there was some alternative to try? Isn't the prevailing attitude (REALLY generalizing here) "The doc did everything he could, and couldn't save them. Such a tragedy. Oh well..."?
It's an interesting conundrum. I think it plays into the same thing I just mentioned: that doctors are seen as some sort of godlike saviours, which becomes a dual-edged sword: On the one hand, we look to them to "handle" the situation (birth), which is why women accept intervetion-filled births without batting an eyelash...but when the doctors appear to fail, we are merciless. "Obviously the baby died because of the doctor's action/inaction, because he is in control of the situation, so if it goes wrong, it can't be anyone else's fault or just bad luck!" (Unless of course he did do surgery, which is seen as The Big Baby-Saver...sheesh...) Maybe docs should start discouraging pedastal-placement for their own good...
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Old 06-05-2006, 12:40 AM
 
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Let's not forget that the average juror is WAY less informed on these issues than your average MDC poster. Therefore, they are at the mercy of the lawyers' witnesses to get the information needed to pass judgement. And we all know how trustworthy some prosecutors are... I agree with annakiss that the ins. companies are hyping this issue in order to make more money; however, we should remember also that it's the dishonest lawyers who win cases that should not be won.

This issue is far more complicated than "Let's blame ___!" There is the ignorance and fear of the public at large regarding birth; there is the greed of insurance companies, lawyers, and doctors; there is the general tendency to regard doctors as authority figures or (dare I say) demigods and blindly trust everything they say...I could go on. I don't see how this problem can be fixed unless some serious societal attitudes begin to change.
I certainly agree that insurance companies are not the only ones to blame. I blame the public's ignorance, doctors, history, the oppression of women, medical associations, the corporate lobby, technology, nurses, television, the FDA, hospital administrations, the for-profit health industry, etc. etc. etc.

I'm confused though about this:
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Originally Posted by AndiB
we should remember also that it's the dishonest lawyers who win cases that should not be won.
Do you mean as in the instance wifeandmom mentioned? I just finished reading The American Way of Birth and from what it says, this just isn't true in general. Some cases are won, sure, but very few. Most don't even go to court. Unless you're talking about the dishonest lawyers defending OBs who may skew what normal and abnormal birth are.

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