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The Maternity Conundrum: One Thing Atul Gawande Doesn’t Get About Health Care Reform

If you’ve been paying any attention to the health care reform conversation in this country, you’ve probably heard of a certain New Yorker article, in which physician Atul Gawande pays a visit to McAllen, TX, the town now infamous for having the most expensive health care in America. With truly exemplary investigative reporting, Gawande explores the factors that have driven the soaring health care costs in McAllen and presents a strong case that this increased spending has not improved the health of the people living there. In fact, he argues, it may be making them sicker. If you haven’t already read the article, please do.

Atul Gawande is not only a world-renowned surgeon and best-selling author, he’s also a MacArthur “Genius Grant” recipient. And rightly so. Among his many other achievements, his analysis of the health care “cost conundrum” is brilliant. So brilliant that President Obama has reportedly made it required reading among his staffers and advisers. I knew the article was something serious when prominent medical blogger Kevin Pho professed on his Twitter feed, “If you only read one health policy article in your lifetime, this one is it.”

I devoured all 8,000 words of it. But, to my astonishment, I found not a single mention of maternity care, despite the fact that hospital charges for maternal and newborn care far exceed those for any other condition, and the clear evidence that there is ample room for cost containment and quality improvement. I wondered how this article got researched, written, and published with such a glaring omission.

Then I remembered something. There’s another article Atul Gawande wrote, this one devoted to maternity care.

In his 2006 article, How Childbirth Went Industrial, Gawande follows a woman — a doctor herself — in labor with her first child. She begins the process hoping for a healthy birth with the least intervention possible. She ends with an epidural, pitocin augmentation, and eventually a cesarean section of her healthy baby after labor fails to progress. Gawande uses this all-too-common story as a backdrop to follow the history of modern obstetrics and to illustrate that, while evidence documents the harms of the routine or liberal use of many obstetric interventions, the “package” of high-tech maternity care nonetheless is responsible for the steep declines in maternal and neonatal deaths we’ve seen since the dawn of obstetrics. Along the way, he argues that broad improvements in maternity care were only possible by reining in the wide variations in obstetric practice that were once commonplace, such as the differences across doctors in the skill and safety with which they performed forceps-assisted deliveries or managed difficult vaginal breech births. Reducing this variation, he contends, required a shift from the “obstetric arts” that were difficult to teach and master consistently to a more measurable, standardized brand of obstetrics. The lamentable but worthwhile result was a rise in the use of cesarean surgery which, according to Gawande and those he interviewed, is “easy to teach,” “comfortable” for obstetricians, can be performed “consistently,” and is a “simpler, more predictable way to intervene.” Today, cesarean surgery is used to accomplish one out of every three births in the United States. (For those interested, Henci has done a more detailed critique of this article.)

Gawande acknowledges cesarean’s risks:

Straightforward as these operations are, they can go wrong. The child can be lacerated. If the placenta separates and the head doesn’t come free quickly, the baby can asphyxiate. The mother faces significant risks, too. As a surgeon, I have been called in to help repair bowels that were torn and wounds that split open. Bleeding can be severe. Wound infections are common. There are increased risks of blood clots and pneumonia. Even without any complication, the recovery is weeks longer and more painful than with vaginal delivery. And, in future pregnancies, mothers can face serious difficulties. The uterine scar has a one-in-two-hundred chance of rupturing in an attempted vaginal delivery. There’s a similar risk that a new baby’s placenta could attach itself to the scar and cause serious bleeding problems. C-sections are surgery. There is no getting around it.

And yet, he concludes, “In the next decade or so the industrial revolution in obstetrics could make cesarean delivery consistently safer than the birth process that evolution gave us.” How do we reconcile Gawande’s cogent plea to curb our over-dependence on medical technology with such a claim?

Granted, one article looks historically while the other comparatively. In How Childbirth Went Industrial, Gawande asks how we wound up with this current style of maternity care. In The Cost Conundrum, he compares McAllen to El Paso, where the population is similar, the costs are lower, and the outcomes are superior. But How Childbirth Went Industrial completely misses the same issues so ably analyzed in The Cost Conundrum even though they were staring Gawande in the face. He gets what is going on in McAllen but not what is going on with U.S. obstetric management, namely that other care models result in better outcomes and that obstetric management is driven by economic self-interest.

If Gawande wanted to do some McAllen-style journalism on maternity care, he could have visited Miami-Dade County, Florida, where more babies are born by cesarean than vaginally and one hospital has a 70% cesarean rate. He could have compared costs and outcomes in Dade County with those in, say, one Indian Health Service hospital in New Mexico, where the c-section rate in births at or beyond 35 weeks is below 10%, despite much higher rates of diabetes, pregnancy-induced hypertension, and medically-indicated induction of labor compared with national statistics. (While he was in the neighborhood, he could have checked out excellent outcomes in the rural area nearby where two-thirds of women give birth in a maternity hospital without any surgical or anesthesia facilities at all.) If he was feeling adventurous, he could have crossed the pond to virtually any European country and found lower per-capita costs, far better outcomes, and much less reliance on surgical obstetrics. Not coincidentally, he might also have noticed that had he sat down for dinner with the system’s gate-keepers abroad, as he did with six doctors in McAllen, this time he would have dined mostly with midwives. That’s because in countries with the best outcomes, midwives far outnumber obstetricians, whose specialist expertise and surgical skills are reserved for complicated and high-risk cases.

Gawande saw a fall over time in perinatal and maternal mortality and attributed it to advances in hospital-based obstetrics. But he knows as well as anyone that correlation is not the same as causation. While a few medical advances — oxytocics and ergot derivatives to control hemorrhages, antibiotics to treat infection, and surfactant to treat respiratory distress in premature infants — have certainly prevented deaths, much of the fall in mortality likely comes from basic improvements in public health and hygiene. By looking through the bifocal lenses of medicine and history, Gawande makes an erroneous assumption that, when it comes to giving birth, more technology is inherently better. What he fails to ask is the very question at the heart of The Cost Conundrum: could we get the same or even better outcomes with fewer risky and costly procedures?

So, to all you White House staffers, policymakers, and reform advocates out there, allow me to help answer this question. If you only read two health policy articles in your lifetime, make the second one this.

Milbank Report: Evidence-Based Maternity Care: What It Is and What it Can Achieve

Read this!

Research for Advocacy , , ,

  1. June 28th, 2009 at 17:51 | #1

    Yes, yes, yes, a million times yes. I read his brilliant article and thought the exact same thing. If any specialty needs cost cutting and outcome based analysis of over use of technology, it’s obstetrics.

  2. June 28th, 2009 at 19:05 | #2

    I read and loved the Gawande article on McAllen, and certainly believe that his analysis extends to include maternity care, whether or not he specifically drew the connection. Thanks for the analysis!

  3. June 28th, 2009 at 19:44 | #3

    That’s what happens when a surgeon writes an article about obstetrics. It is funny, when I read the New Yorker article, I was waiting for an obstetric anecdote, but it did not materialize. Thanks for writing this. You took a lot of words right out of my laptop. :)

  4. June 28th, 2009 at 23:04 | #4

    Amy, this is a brilliant article from the title to the very end. I have always taken Gawande’s work with a grain of salt because of his prophylactic-cesareans-for-all argument. This was the first time I’ve read Henci’s critique of How Childbirth Went Industrial and it’s amazing.

    I don’t want to drag this off-topic, but his description of the hospital chief operating officer in the New Yorker article is pretty offensive:

    “She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience.”

    If a young-looking Latina woman (who you can see here) looks more like a school teacher than an influential hospital executive to this man, I can’t help but wonder if women’s issues matter to him at all.

    I will reserve further judgment until I read more about him. I’m not very optimistic.

  5. June 29th, 2009 at 00:11 | #5

    My turn for a wonky hyperlink. Sorry!

  6. June 29th, 2009 at 07:14 | #6

    Fixed! And thanks all for your comments and for helping spread this around the interwebs. I think we were all wondering how OB could have been left out of Gawande’s recent piece. Glad I could thread it all together for us. As for descriptions of women executives in journalism, yep – that is totally a pet peeve of mine. I truly doubt he’d have gotten away with describing a male executive in similar terms (or even thought to try.

  7. June 29th, 2009 at 08:49 | #7

    “much of the fall in mortality likely comes from basic improvements in public health and hygiene.”

    That claim has been debunked over and over again.

    Basic improvements in public health and hygeine occured in the late 19th and early 20th Century. The spectacular drop in maternal mortality (99%) and neonatal mortality (90%) occurred between 1940-1980, long after basic advances in public health.

    One of the advances most closely associated with the drop in maternal and neonatal mortality is the development and improvement of epidural anesthesia, making Cesarean section far less risky and far more common.

    I would agree that the C-section rate is far higher than it ought to be, but in order to lower it, we must be honest about its true causes. The cause is NOT physician self interest, since most obstetricians get paid the same amount regardless of type of delivery. The real cause stems from the fact that C-sections are lifesaving operations, patients demand perfection and sue if they don’t get a perfect baby, and the legal system believes that performing a C-section is the only legal defense for anything less than a perfect outcome.

    Conspiracy theories are fun, but they don’t reflect reality. If we want to lower the C-section rate, the first step is to be intellectually honest about what is happening.

  8. June 29th, 2009 at 09:57 | #8

    I have seen Amy Tuter’s name around the blogosphere’s comment sections.

    If what you say is true, Amy, then why don’t you have an “intellectually honest” conversation with European midwives?

  9. June 29th, 2009 at 14:32 | #9

    Hi Amy T.,

    Epidurals decrease maternal and neonatal mortality by making cesareans safer and more common. So epidurals lead to safer cesareans and more cesareans and fewer woman and neonates die as a result. But you also state that there are too many cesareans being performed. Is there a logical step in between there? What is your reason, then, for saying that there are too many cesareans performed? I might have read it wrong because, in your scenario, it sounds like everything is hunky-dory the way it is. I hope you’ll explain it because it’s a really interesting theory.

    So, I’m going to ignore the absolutes, such as:

    No physicians—not a single one—has ever considered that time is money and shortening the birth process to an hour or two could be much more cost effective than hanging around waiting for birth to happen. We know it happens– there are bad apples in every basket.

    All patients—every single one of them—will take their care provider to court to hold them responsible for the outcome of their birth if they are not satisfied.

    The legal system—the whole system and everyone that is a part of it– believes that performing a c-section is the only defense for a bad outcome.

    …and ask if you would agree that the core of defensive medicine is self-interest.

    Defensive “medicine” is aggressive to patients and those who practice aggressively (e.g., with liberal use of prophylactic and unnecessary surgery) make the sweeping assumption that every patient is seeks to be legally aggressive to their doctor. They practice this way out of self-interest, right? A desire to not experience the negative financial ramifications of being sued, a desire to not have to endure the deeply personal accusations of negligence characteristic of malpractice cases, a desire to conform to the pressure of upholding hospital policy and being a good employee, the desire to have an acceptable experience working as a physician that will provide them with a level of personal satisfaction and control with which they are comfortable, etc.

    It’s not pure self-interest. Physicians might have kids that they want to send to college and don’t want their personal savings to be wiped out by an unpredictable birth injury case. Perhaps practicing defensive medicine helps them feel as though they are aiding their hospital financially by keeping potentially expensive litigation at bay. Maintaining the status quo by not practicing differently than peers might make them feel like they are helping with credibility of the profession.

    Patient interests and wellbeing drop to the bottom of the list in the care provider’s decision-making process in the defensive medicine scenario, don’t they?

    It’s probably different since you’re a physician yourself, but have you ever experienced the other side of defensive medicine?

  10. avatar
    Melgirl
    June 29th, 2009 at 19:31 | #10

    In recent decades, the maternal mortality rate has been flat (though, more recently, on the rise), the infant mortality rate has been flat, yet the level of technology and medical intervention has increased dramatically in childbirth. If, as Amy T. suggests, women owe their health and well-being to the machines that go “ping” why aren’t we see that in outcomes? Oh wait, I forgot, it’s because “today’s mothers” are [insert non-evidence based excuse here: too fat, too old, too short, babies are too big, too many diabetics, etc.] How about some actual data
    Amy T.? http://childbirthconnection.org/article.asp?ck=10456&ClickedLink=274&area=27 Amy Romano, keep up your incisive work.

  11. June 29th, 2009 at 20:12 | #11

    I am not a historian and do not profess to know the ins and outs of the epidemiology of maternal and perinatal death. Although I know that many folks who are historians and epidemiologists have come up with the conclusion that I suggested (that basic public health improvements contributed to some if not a significant portion of the drop in mortality.)

    I think that if we are only looking at the timeline of events, there is another plausable explanation for why we didn’t see the astonishing drops in maternal and perinatal mortality until well after basic health and hygiene improvements were widespread in the US. It is possible that while overall health was improving (prior to 1940), obstetricians and hospitals were busy offseting those improvements with harmful care such as the ubiquitous use of forceps and drugs that readily crossed the placenta, leading to birth injuries and respiratory depression after birth, in settings where providers didn’t yet have the skills or drugs to manage these problems (i.e. neonatal resuscitation). Then obstetrics (chiefly, anesthesia techniques such as epidurals) became safer in the second half of the 20th century, and the improvements attributable to better overall health were now visible and quantifiable. But because they occurred after epidurals came on the scene, they are attributed to epidurals. In this scenario, epiduralse may simply have erased the *excess* harm of the management style that preceded it, not the *intrinsic* harm of birth itself. The observed improvements don’t mean that we wouldn’t have been better off without so much of the obstetric management to begin with. And that is the whole point of the Cost Conundrum and my critique of it – in many cases – including in maternity care- we may be better off reducing the amount of technology we use, which may help us achieve the same or even better health outcomes (since technology imposes risks) at a lower cost.

    When we use cesarean more and more, we surpass the rate at which everyone who had one would otherwise have died, lost a baby, or suffered long-term harm, whatever that rate is. So we’re operating on healthier and healthier women with healthier and healthier babies. Some of THOSE cesareans could be safely prevented with lower use of other obsetric management technologies and more supportive, low-tech care.

  12. avatar
    midwife
    June 29th, 2009 at 20:16 | #12

    Amy Tuteur, MD :“much of the fall in mortality likely comes from basic improvements in public health and hygiene.”
    That claim has been debunked over and over again.
    Basic improvements in public health and hygeine occured in the late 19th and early 20th Century. The spectacular drop in maternal mortality (99%) and neonatal mortality (90%) occurred between 1940-1980, long after basic advances in public health.
    One of the advances most closely associated with the drop in maternal and neonatal mortality is the development and improvement of epidural anesthesia, making Cesarean section far less risky and far more common.
    I would agree that the C-section rate is far higher than it ought to be, but in order to lower it, we must be honest about its true causes. The cause is NOT physician self interest, since most obstetricians get paid the same amount regardless of type of delivery. The real cause stems from the fact that C-sections are lifesaving operations, patients demand perfection and sue if they don’t get a perfect baby, and the legal system believes that performing a C-section is the only legal defense for anything less than a perfect outcome.
    Conspiracy theories are fun, but they don’t reflect reality. If we want to lower the C-section rate, the first step is to be intellectually honest about what is happening.

    While the cause of the increase in c-sections may not be directly physician self-interest, I personally see every day physicians who just won’t deal with the potential for a lawsuit…one blip on the monitoring screen, one negative comment by the patient, and they are cut. I’ve been told numerous times “if you don’t cut them and there’s a problem, the question you’ll be answering is why didn’t you just do a cesarean…if you do a c-section, no one can ask that question, because you did everything”. Makes the doctor a hero!

  13. June 29th, 2009 at 20:31 | #13

    Amy R. –

    Also important to note, when birth first entered hospitals, our maternal mortality rate actually ROSE until we had the worst rate in the industrialized world. One of the top causes of death of childbearing women up to the mid-20th century was puerperal (or “childbed”)fever, which was caused by unsanitary practices by doctors, who refused to admit they might be the cause of the infection in the first place. (The book Brought to Bed talks a lot more about this aspect of it.) The maternal mortality rate finally started dropping in the mid-20th century with the implementation of aseptic routine and the invention of antibiotics.

    The history of obstetrics is not so much one of doctors saving women from nature as it is doctors saving women from their own experiments, with a few serendipitous discoveries thrown in.

  14. June 29th, 2009 at 20:37 | #14

    @Emily Jones

    sorry, got my books mixed up. I meant the book “Lying-In.”

  15. avatar
    Jim Bob
    June 30th, 2009 at 00:37 | #15

    I think you’ll find that Gawande left obstetrics because his statistics were relying upon publicly available Medicare payments, generally a somewhat older population than the childbearing.

    And on the public health front from Gawande’s article on obstetrics:
    http://www.newyorker.com/archive/2006/10/09/061009fa_fact

    “But in 1933 the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; newborn deaths from birth injuries had actually increased. Hospital care brought no advantages; mothers were better off delivering at home. The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better.

    “The two reports brought modern obstetrics to a turning point. Specialists in the field had shown extraordinary ingenuity. They had developed the knowledge and instrumentation to solve many problems of child delivery. Yet knowledge and instrumentation had proved grossly insufficient. If obstetrics wasn’t to go the way of phrenology or trepanning, it had to come up with a different kind of ingenuity. It had to figure out how to standardize childbirth. And it did.

  16. avatar
    Natalie
    June 30th, 2009 at 08:25 | #16

    “All patients—every single one of them—will take their care provider to court to hold them responsible for the outcome of their birth if they are not satisfied.”

    Not true- I did not take my OB to court to sue for my prophylactic cesarean…after I was coerced into an induction at 40 weeks, 1 day (I did have the sense and strength to fight the induction at 39 weeks- when she first wanted to do it)
    How do you sue for documenting arrest of labor after 2 hours at 9 cm- “Due to failed dilatation, she is determined to be a good candidate for operative delivery.”

  17. June 30th, 2009 at 10:26 | #17

    You know, I saw this and optimism was restored. It seems odd to me that he threw obstetrics in the same bucket with phrenology and trepanation– them’s fighting words for a skeptic.

    So it comes back to the same basic question– standardization of childbirth… good, bad or somewhere in between?
    @Jim Bob

  18. June 30th, 2009 at 10:26 | #18

    @Jill–Unnecesarean

    Dang it! That was a reply to @Jim Bob (#15).

  19. June 30th, 2009 at 11:37 | #19

    @Jill–Unnecesarean

    How do we know that too many C-sections are being performed?

    All treatment decisions are governed by the law of diminishing returns. This is a principle first described in economics that applies to many other areas as well. It must be taken into account when determining what C-section rate is appropriate. The following is a hypothetical example of how the law of diminishing returns works, which will help us identify the issues raised by the rising C-section rate.

    Imagine a hypothetical first world country that has 1 million births per year. In this hypothetical country, we are able to analyze the number of lives saved by C-sections and we are able to analyze it in hindsight so that we know which C-sections were necessary. As the C-section rate rises, the numbers of lives saved drops off (diminishing returns). In our hypothetical country, we can chart how many lives are saved for each percentage point of the C-section rate. Each percentage point of the C-section rate represents 10,000 C-sections. Our chart might look something like this:

    C-section rate lives saved/10,000 C-sections
    0-5%% 20,000 (every mother and baby)
    6-10% 10,000 (every baby)
    11-15% 5,000
    16-20% 500
    21-25% 50
    26-30% 5
    31-35% 0.5
    36-40% 0.05

    We can see the law of diminishing returns in action here. At a C-section rate from 0-5%, every C-section is necessary, and every C-section saves the life of both mother and baby. From 6-10% every C-section is necessary and saves the life of the baby. From 11-15% half the C-sections are necessary, resulting in a savings of 5000 lives. At rates higher than 15%, retrospective analysis reveals that far fewer C-sections are life saving. By the time a C-section rate of 35-40% is reached, only one additional baby will be saved every other year.

    That’s not all we have to take into account. Though the risk of maternal death from a C-section is low, it is not zero. As greater numbers of C-sections are performed, maternal deaths will become an every greater issue. Let’s assume that the maternal death rate solely attributable to C-section is 1/10,000. At low C-section rates, where almost all C-sections are lifesaving, a maternal death rate of 1/10,000 seems very small. As the C-section rate begins to rise, look what happens. For C-section rates from 11-15%, 5000 babies will be saved per 10,000 C-sections, and 1 mother will die. From 21-25%, 50 babies will be saved per 10,000 C-sections, 9,950 unnecessary C-sections will have been performed and 1 mother will die. By the time you reach 31-35%, only 1 baby will be saved every other year per 10,000 C-sections. 9,999/10,000 C-sections are unnecessary and 1 mother will die. A C-section rate of 36-40% would save only 1 baby every 10 years, almost every C-section is unnecessary, and 1 woman would die per 10,000 C-sections.

    Although the decision to perform a C-section is made on a case by case basis, analysis of C-sections in the aggregate show us that the C-section rate CAN be too high. When you get to the point that you are saving 1 baby every 10 years, but killing 1 mother every year, the C-section rate is clearly too high. Why has the C-section rate risen so high in first world countries? The reason is that a tremendous premium has been placed on the life of each and every baby. That societal value is directly reflected in the rising number of lawsuits and monetary judgments for babies who die or are disabled during birth. That societal value is reflected in the fact that our judicial system operates as if we believe that if a C-section had even a remote chance of preventing the death or disability, that C-section should have been done, and because it wasn’t done, the parents should be compensated.

    Is that what we really believe? Is any number of unnecessary C-sections justified to save the life of one baby every decade or every century? How many maternal deaths are justified to save the life of one baby every decade or every century? Personally, I think the standard should be different. The number of unnecessary C-sections done to save one baby every decade is NOT unlimited. The number of maternal deaths is certainly not unlimited, and it is not even one to one. The standard for determining fault in an obstetric malpractice case should NOT be to show that a C-section could have prevented the baby’s death or disability; the standard should be that the doctor could have reasonably foreseen (based on the evidence available) that a C-section was NECESSARY to prevent the baby’s death or disability.

    C-sections come with costs. We have not even talked about the financial costs, because, in my judgment, these are secondary. However, massive numbers of unnecessary C-sections cause unnecessary complications and unnecessary deaths. As the C-section rate rises, these unnecessary complications and unnecessary deaths rise from relatively trivial occurences, to occurences that far outweight the number of babies’ lives saved. We, as a society, need to think about where we draw the line, because we, as a society, through our punishments and incentives, determine how high the C-section rate should be. Doctors are merely responding to society’s wishes as expressed through our values and our legal system.

  20. June 30th, 2009 at 11:46 | #20

    Natalie :
    How do you sue for documenting arrest of labor after 2 hours at 9 cm- “Due to failed dilatation, she is determined to be a good candidate for operative delivery.”

    Along the same lines, the gold standard for obstetric litigation in this country is not having died. It would be almost impossible for a woman to sue a doctor and win for having performed an unnecessary c-section, since both mother and baby apparently survived.

  21. June 30th, 2009 at 22:08 | #21

    …Another Amy, Amy Romano, wrote a blog post in which she questions the lack of attention to the maternity care situation in an article written by Dr. Atul Gawande. In her blog post, she says…”

  22. avatar
    Natalie
    July 1st, 2009 at 08:40 | #22

    It IS impossible to sue a doctor for an unnecessary cesarean. I wouldn’t want to do it anyway. Lawsuits are overused.

    Emily’s comment did remind me of Atul’s other article “The Score,” about the history of the Apgar score, and the fact that there is nothing like it in other areas of medicine. He says, “we have no score for how the mother does, beyond asking whether she lived or not- no measure to prod us to improve results for her, too. Indeed, we need an Apgar score for everyone who encounters medicine…”

  23. July 1st, 2009 at 09:19 | #23

    @Amy Tuteur, MD

    I have never seen the law of diminishing returns used in anything but economics. I like it in this context a lot. It makes me think of the 2007 WHO study on cesareans and maternal mortality which said identified a strong inverse association between c-section rates and maternal/neonatal mortality. For some reason, I also remember you finding flaws in the methodology of that study?

    We, as a society, need to think about where we draw the line, because we, as a society, through our punishments and incentives, determine how high the C-section rate should be. Doctors are merely responding to society’s wishes as expressed through our values and our legal system.

    Until these final sentences, I was applauding. They sound so certain and absolute but yet they’re so very vague. I like this style of leaving readers hanging and wanting more clarification.

    Here’s where I get hung up and I’m pretty sure a lot of doctors might object. Are doctors merely pawns, passively carrying out what they perceive to be the wishes of their society as a whole? Did you really feel that way when you practiced? I watched my friends that became physicians grow into autonomous (or autonomous-ish) decision makers during their residencies. I can see the ideals of the dominant society affecting public policy and the legal system and personal values which in turn affect businesses which affect hospital policy which influences how doctors can practice, but do they completely rob them of all autonomy?

    When the onus is taken completely off of doctors and their years of school, training and practice are reduced to merely responding to the wishes of society, what is left? A puppet who has been martyred by society and has no choice but to perform “medicine” as dictated by the masses? A surgery-performing robot with a prescription pad and illegible handwriting? Do you really feel like that is what your profession has become?

    Hearing that my doctor responds first and foremost to society’s wishes and not to any sort of evidence or even his own personal judgment makes me sympathize with his disenfranchised position. It also now makes me, the patient, want to keep very far away from him. Good thing for me that my GP, Dr. Nguyen, does not just respond to society’s wishes and actually practices medicine. His decisions might be affected directly and indirectly by society’s wishes and ideals but, ultimately, he calls (and orders) the shots.

    As for your call for intellectual honesty, YES! Please! Wouldn’t you like to see some interpersonal honesty with patients about why doctors are recommending cesareans and inductions? The reason I asked if you’ve ever been on the other side of defensive medicine is because watching multiple doctors (in clinic and in labor) try to build a case for why I needed a cesarean was a series of the most awkward and uncomfortable moments in my life. It’s sad to watch someone lie and rely purely on anecdotes to explain their decision and even sadder to realize that you’re a week away from letting these people catch your baby. Scarier is that new doctors might have been educated to actually believe that these lies are actual medicine and not defensive medicine. Watching (and experiencing) defensive medicine in action is enough to convert a believer in the medical process into a bona fide into a skeptic of OB.

  24. July 1st, 2009 at 12:03 | #24

    @Jill–Unnecesarean

    “Are doctors merely pawns, passively carrying out what they perceive to be the wishes of their society as a whole?”

    When it comes to value judgments, don’t we want doctors to respond to the beliefs and desires of their patients?

    A doctor is an authority on medical knowledge, but he or she is not an authority on values and beliefs. That’s why it is imperative that doctors respect and respond to the values and beliefs of their patients. For example, a doctor can tell you that the chance of a comatose patient recovering is pegged at a certain percentage, but he or she cannot tell you that you should turn off life support now or that you should never turn off life support.

    Similarly, I can tell you the risks of C-sections, but I cannot tell you how society as a whole should balance various risks. Americans have made it exceedingly clear that they consider virtually any risk to babies to be unacceptable. Doctors are responding to that value judgment.

  25. July 1st, 2009 at 13:17 | #25

    “convert a believer in the medical process into a bona fide into a skeptic of OB.”

    Also, I am very skeptical of proofreading as seen in the last sentence of the previous comment. Grammar is the true conspiracy.

  26. July 2nd, 2009 at 01:28 | #26

    @Amy Tuteur, MD

    I didn’t notice Comment #24 earlier for some reason. I think I returned to the window without refreshing it, then submitted another comment.

    Nevertheless, reading absolute statements makes me compulsively want to fill in the gaps with anecdotal information on every possible nuance and exception to the statement. I am such a sucker.

    If you’re willing to clarify…

    Society places value on the perfect baby. Women carry this value with them to their doctors and demand a perfect baby. The doctor responds to their values and beliefs by _________. What is the conclusion? Cesarean? Giving them a perfect baby? The illusion that everything possible was done to give them a perfect baby?

    I really can’t believe that the locus of control lies that far outside of (all, most, some) physicians. If that was your experience, I’ll take your word for it. Is this theory based on any studies or is it opinion/experience?

    The “perfect baby” concept comes up in a lot of discussions. It is pretty complex and transverses a lot of disciplines. The concept is at the core of most discussions about maternity care in the U.S. whether people realize it or not.

  27. avatar
    Linda J. Smith
    July 15th, 2009 at 15:45 | #27

    RIGHT ON!! Thanks, Amy.

  28. avatar
    Anne Wright
    July 15th, 2009 at 17:24 | #28

    I am a very strong advocate for the Lamaze philosophy of Childbirth, and I found Gawande’s article, “How Childbirth Went Industrial” to be extremely valuable. “Science and Sensibility” presents just one perspective on the article. I would strongly encourage all of you to read it article for yourselves. I had a very different perception of Gawande’s assertion; I did not perceive that he was advocating for increased use of technology, but rather analyzing the very complicated web of causes that have led to our current results. I think it’s important for all of us to understand that the problems we are currently facing in maternity care are very complex and multi-faceted. Until we understand this, the solutions and advocacy we offer may be too simplistic and superficial, and is unlikely to achieve our desired outcome of normalizing birth in any significant way. Let us first seek to understand, and then be understood.

  29. July 16th, 2009 at 07:27 | #29

    Dear Amy:
    Excellent, excellent, excellent. Can you please send your article to someone in the current administration. Modern obstetrics no longer exists. I know because I’ve been in this area for almost 40 years. The art of Obstetrics is being replaced by the technology of the surgeons who think they are practicing Obstetrics. They are not. They have become what I call “Sectionists”, because they too often and for no good indication, perform C/Sections because of fear of litigation, expediency or maybe because they just don’t know what else to do.
    It is very, very sad and very, very dangerous for mothers, babies and families. It will be years before the true cost of this “Sectionist” movement becomes apparent, but it will be too late, I’m afraid, for the many moms who will have lost their uteri, had other internal injuries, suffered difficult recoveries or worse, lost their lives because of repeat Cesareans and their increasing risks.

  30. avatar
    Lisa Donigian
    July 16th, 2009 at 07:29 | #30

    One thing is certain …. allowing government elected officials with NO health care experience to make the overhaul of health care, based on a rush-rush-hurry-hurry decision, before the August recess will only make things worse. We have problems, but we also have a health care system that the rest of the world envy’s. Based on everything else the government handles (Post Office, VA, Medicare/Medicaid, Social Security, etc) there is NO indication they can do this more effectively or cheaper. It will become a maze of government red tape and high level pay-offs, fraud and abuse (like everything else they run) …. all on the backs of the American citizens.

  31. avatar
    Elaine Germano
    July 17th, 2009 at 09:26 | #31

    To Amy R- Will you please send your article as a “Letter to the Editor” of the New Yorker in response to Gawande’s article? Your response needs a wider audience. If policy makers are using Gawande’s article for decisions regarding health care reform, they also need to hear your rebuttal of it. Thank you for writing your rebuttal, and please do whatever you can to get it in the hands of our policy makers.

  32. December 7th, 2009 at 04:45 | #32

    I got it!! thanks for enlighting me. Good post..

  33. April 24th, 2010 at 11:51 | #33

    Interesting dialogue here. I wouldn’t characterize Amy’s post as a rebuttal of Gawande, just an illustration of another aspect of the same issue, that Gawande never even addressed.

    To comment on A Tuteur’s thread, I think that physicians are in great part responding to outside influences, other than what they think is best medicine. A lot of decisions get made with the thought “if this goes badly how will this look in retrospect?”.

    At the same time, I argue with the idea that every patient will sue for every bad outcome. I think with a good doctor patient relationship and good communication after a bad event, a lot of patients will not choose to take legal action.

  1. June 28th, 2009 at 18:01 | #1
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