Question about being an OB Resident

[juddson]

I am told repeatedly that whenever there is a "bad outcome" for whatever reason, the chances of getting a letter from an attorney is quite high. Given that "bad outcomes" are a frequent part of life in OB, does that mean that most OB residents will have been sued before they finish up their post graduate years?

I have only limited experience in an OB setting (just two overnights on an L&D floor) and while we didn't have any major bad outcomes among the 7 or 8 deliveries I attended over that weekend, every single deliverly struck me as fairly "touch and go", with one requiring about 5 minutes of CPR. It struck me that the margin between things going OK and things going all to hell is rice-paper thin. How can a resident navigate this gauntlet and emerge unscathed?

Judd

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[Diane L. Evans]

How can a resident navigate this gauntlet and emerge unscathed?

Judd

Most residency programs have protection for residents never allowing a resident to be sued but the attending covering the resident can be sued. While a resident may need to go to court in defense I have not seen this.

 

[mendocino]

Most residency programs have protection for residents never allowing a resident to be sued but the attending covering the resident can be sued. While a resident may need to go to court in defense I have not seen this.

Diane,

I know of two OB-Gyn residents who were sued for bad OB outcomes. Both frivolous cases. Two different states. My program stated up front that it would do everything possible to insure that residents were excluded from a lawsuit but the bottom line is if a plaintiff's attorney decides that your name is the first on the chart and they name you, there is nothing a residency program can do for the resident except keep the med-mal premiums paid and hire a good defense lawyer. I am one of them and it is a friggin nightmare. The other is young attending in my program who was sued as a resident.

I don't see how a program can prevent a resident from being sued unless they have a law in their state granting immunity.
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Not a new member of this forum, name changed to protect the innocent. sorry.

 

[Doula-2-OB]

If you want to reduce the concern about bad outcomes, keep your hands off your patients. Spend some time with a homebirth midwife and look at another perspective of birth before you cement this view of 'highly medical risky' birth. You'll learn a lot, I promise.

 

[3dtp]

If you want to reduce the concern about bad outcomes, keep your hands off your patients. Spend some time with a homebirth midwife and look at another perspective of birth before you cement this view of 'highly medical risky' birth. You'll learn a lot, I promise.

You say you're starting pre-medical school next month. Revisit this topic in 9 years.

Technically you are correct and many obstetricians are doing exactly what you suggest. Keeping their hands off high risk patients or stopping deliveries. all together. Already in some states, a patient with high risk characteristics, must travel to adjacent states for any care at all and any hope of having children.

Patients are considered medically high risk for good reasons, some of them physiological, some anatomical, some for reasons we just plain don't know.

Here's what I suggest. Do a research project, as you are preparing to enter college. I suggest that you do a survey of the childbirth literature. Look at the public health statistics for child and infant mortality from say, 1850 forward. Look at the specific causes of maternal morbidity and mortality and the trends in each of the settings you are familiar with. I recommend you look in the scientific literature, the public health literature and statistics and compare this to other literature. Don't just repeat what the ACOG or RNM or laymidwife literature tell you, for they all might have biases. Do your own work from the original data and trends. It will be good preparation for your premed courses and give you a ready project when it comes time to do your first research project.

I think the information will enlighten you and if you post the results on this board, us as well.

 

[Doula-2-OB]

You say you're starting pre-medical school next month. Revisit this topic in 9 years.

Oh at least! I don't ever want to practice based on assumptions that things don't change. I'll revisit this topic far more often than that.

Technically you are correct and many obstetricians are doing exactly what you suggest. Keeping their hands off high risk patients or stopping deliveries. all together. Already in some states, a patient with high risk characteristics, must travel to adjacent states for any care at all and any hope of having children.

Patients are considered medically high risk for good reasons, some of them physiological, some anatomical, some for reasons we just plain don't know.

Oh, I agree. I know this as well as you do, even though I practice in another spectrum of birth. I'm not one of those fringe birth folk (even tho I support their right to choose that for themselves) who think that doctors are evil. I think there are bad doctors just as there are bad midwives, etc.- but no, choosing allopathic obstetric care for a normal, low risk pregnancy is not an inherently bad thing. It is incredibly sad for physicians and for patients that OB is being painted into such an obstacle ridden corner. It doesn't bode well for the future of either party.

Here's what I suggest. Do a research project, as you are preparing to enter college. I suggest that you do a survey of the childbirth literature. Look at the public health statistics for child and infant mortality from say, 1850 forward. Look at the specific causes of maternal morbidity and mortality and the trends in each of the settings you are familiar with. I recommend you look in the scientific literature, the public health literature and statistics and compare this to other literature. Don't just repeat what the ACOG or RNM or laymidwife literature tell you, for they all might have biases. Do your own work from the original data and trends. It will be good preparation for your premed courses and give you a ready project when it comes time to do your first research project.

Frankly, I think this is a fabulous idea. I am willing to broaden my perspective, and willing to be wrong or find that I am lacking information where my perceptions are. My original suggestion is based on that principle: looking at things from another perspective and see what there is to learn. This particular resident is looking for ways to 'navigate the paper thin margin' between things being 'ok' and 'hell in a handbasket', and respecting that birth is a natural process that sometimes requires assistance in optimal circumstances, rather than viewing it as an emergency (not saying you are, but it's common), can really make a difference. Did you hear about Helen Sandland, the doc who refused to increase her cesarean rate and was let go from the hospital for whom she worked? I emailed with her for a bit and according to her, her statistics are exemplary, nary a bad outcome to be seen, and yet her hospital was not satisfied with the lack of surgical outcomes and put pressure on her. For what?! (This still pisses me off.)

Another project is to examine why the US is not one of the top ten countries in infant mortality. A large number of European countries have better infant mortality rates than we do- heck, even Cuba has a better (albeit not by much) IM rate than we do. I'd like to know why this is- what are these countries doing so differently? Where do most women labor? What are the cultural mores about giving birth? If we cananswer some of these questions maybe we (collectively) can answer questions like the OP more directly.

I want to also extend an apology to the original poster- because the issue is far too complex for one single trite answer like the one I provided. It would go a long way, however it is not the answer to your question. I don't think there is a simple answer.

I stand by my suggestion that gaining different perspectives on birth is not anything but beneficial to both the student/resident as well as the patient. If the only tool you have is a hammer, everything becomes a nail- and in obstetrics this adage is far too close to home.

I'm going to start looking into your suggestion, I really do think it's a phenomenal idea.

 

[juddson]

Another project is to examine why the US is not one of the top ten countries in infant mortality. A large number of European countries have better infant mortality rates than we do- heck, even Cuba has a better (albeit not by much) IM rate than we do. I'd like to know why this is- what are these countries doing so differently? Where do most women labor? What are the cultural mores about giving birth? If we cananswer some of these questions maybe we (collectively) can answer questions like the OP more directly.

This probably has much to do with the fact that American Medicine (and American attitudes towards such things) make delivery of much much earlier (and, probably much much sicker) fetuses possible. American parents think nothing of spending $100,000 to deliver and apply medical technology to a 30 week neonate. I'm less inclined to suppose our OB/GYN's and neonatologists are systematically killing our neonates.

Judd

 

[Doula-2-OB]

This probably has much to do with the fact that American Medicine (and American attitudes towards such things) make delivery of much much earlier (and, probably much much sicker) fetuses possible. American parents think nothing of spending $100,000 to deliver and apply medical technology to a 30 week neonate. I'm less inclined to suppose our OB/GYN's and neonatologists are systematically killing our neonates.

Judd

Well I don't think anyone is saying that. A lot of what happens in ob is medico-legal, and the other large part of it is just patient driven. Why get sweaty and poop in front of people and scream like you're having the best orgasm in your life in front of a room full of strangers and sweat and grunt and moo like a cow, when you can have a nice 'private' cesarean where there aren't a dozen different people coming in and out, where you can have some fantasy of control over the outcome, and where you can pick the date most convenient for you and your physician? I mean- how would vaginal birth ever compete with that? I'm not even being sarcastic, that's the sad part.

You are absolutely right about parents being willing to deliver a preterm baby but the fault does not lie solely with them. I've seen cesareans for Failure to Wait. I've seen docs who induce before their own vacation. I've seen a physician in my own community tell a woman at fourteen weeks that her baby was too large to deliver vaginally and that she'd have to schedule a cesarean. I've seen this same doc walk into a room where a baby was +4/bulging perineam (like a freaking canteloupe was stuck in there) and cross his arms and REFUSE to catch with her in that position. He wouldn't even TRY. I've some positively asinine things out of providers (midwives too, they're not exempt from the ass-hole factor) that I will forever insist endangers outcomes. I saw a homebirth midwife (who, frighteningly, has attended 3500 births in 20 years- which averages out to 20 a month!! That is a scary number of clients to be on call for in a homebirth practice!) give three vaginal exams to a woman who was clearly ruptured within three hours, not using sterile gloves (she pulled them out of a zip lock), and at 4cm she manually dilated the woman's cervix (who was laboring beautifully, I might add) without consulting her or even telling her what she was about to do. She left her with a torn labia that will never properly heal and a torn perineum. @#$@#! I am still pissed at that midwife and think she should be thrown out of what is a truly amazing profession.

My point isn't to bash anyone (specifically), but only to say that providers are human beings with their own biases too, and that they absolutely, unequivocally affect outcomes. Having your doctor push doubt about your ability to birth just because you're too thin or too fat or too short or asian or had a cesarean or whatever- does not HELP women give birth. It's more than science, there's an energy to birthing women that science can not measure and it is the fact that in the US we dismiss this, we ignore it, we don't even acknowledge it and we reproach those who believe it, that leads to the highest 'outcome' that medical providers hope for in a hospital setting is that both mother and baby are alive with all body parts present and accounted for.

I should just stop now.. I'm hijacking and that wasn't my intention. I just want it to be said in black and white that there is far more to birth than just the outcome of the health of the patient, and that when we (as medical professionals) start caring about those other aspects, outcomes will improve. Do I have scientific evidence of that? Not yet. Do I need it to know what I've seen/participated in and the 'outcomes' it's led to? No, I don't. I'm carrying that with me.

 

[Spittz03]

Doula-2-OB, first of good luck in your studies, I hope you get into a good med school and manage to keep your head up through the rough training. I am curious as to how old you are, as you seem to have quite an experience.

Personally as an obstetrician, I would love to see more of low risk deliveries done by midwifes. I try to push many patients towards SVD as this is a natural process for deliveries and for many patients this is the right choice. However, there is a fine point to this, like C/S, SVD carries many risks and complications later in life that a lot of women do not want to deal with given a choice.

I agree with the previous post in regards to the infant mortality rate. Forget the 30 weeker, in US it is the <26 week pregnancies that in other countries would long be dead in utero and thus not counted in statistic... that here in US get the ultimate treatment that many times result in death, failure to thrive, or lifelong disability.

I really doubt that an obstetrician said that a 14 week IUP was too large and needed a C/S as you say. My assumption is that there is more to this story, and as this myth got passed from one person to the other, it lost a lot of detail. Let's say a patient had a history of diabetes and large babies born during previous deliveries, I can see how a discussion might have taken place planning for C/S even as early as 14 weeks. This does not mean that a C/S was done at 14 weeks, and it does not mean that this course was ultimately taken.

Part of the trouble with Doula training, is an incomplete knowledge and a lot of bias passed on from one person to the other. There are a lot of deliveries done in this country in a given year, and if you concentrate on few exceptions, you might miss the whole picture I hope you get the needed training and become a great physician that will be true to your patient needs while passing on a non-biased earned knowledge.

 

[Doula-2-OB]

Doula-2-OB, first of good luck in your studies, I hope you get into a good med school and manage to keep your head up through the rough training. I am curious as to how old you are, as you seem to have quite an experience.

I'm 29, I've been a doula for three years. I don't even work in a city, I live an hour out of Seattle so I admit I haven't seen a lot of things that the city doulas have seen.

Personally as an obstetrician, I would love to see more of low risk deliveries done by midwifes. I try to push many patients towards SVD as this is a natural process for deliveries and for many patients this is the right choice. However, there is a fine point to this, like C/S, SVD carries many risks and complications later in life that a lot of women do not want to deal with given a choice.

Well, just to point out an obvious truth: birth is risky. There's no such thing as a 'safe' birth. You're taking your chances with elements that are out of anyone's control, and doing your best to reduce your risk. American women are NOT taught that birth is naturally risky, they are taught to think that by managing/having technology at their fingertips they are eliminating risk. They think cesareans are w/o risk. It's just a complete lack of birth culture.

I really doubt that an obstetrician said that a 14 week IUP was too large and needed a C/S as you say

I too have my doubts that this is the whole story - I was given this scenario by the mother herself, a primip (a teen, actually), and her mother who attended the appointment. They absolutely believed 100% that he was right, telling them the truth- this isn't one of those random 'rogue doc' tales that of course we doulas do admittedly pass around. LOL It's absolutely possible that they misunderstood, however this doc does indeed go out of his way to cut women off at the 'pass', so to speak, and head for surgery. If I needed a cesarean I might consider him since he's so experienced at it. He absolutely sucks at vaginal birth. LOL

This does not mean that a C/S was done at 14 weeks, and it does not mean that this course was ultimately taken.

No no, that isn't what I meant. He told her at 14 weeks that she would ultimately need a cesarean when she was full term because her baby was already measuring large, not that she needed one at 14 weeks.

Part of the trouble with Doula training, is an incomplete knowledge and a lot of bias passed on from one person to the other.

I ask curiously, not antagonistically, if you've attended a doula training? The trainings in the Seattle area (the largest doula community in the country, I daresay) are evidence based emphasis. That doesn't mean they're perfect, there aren't studies that show that the hip squeeze will be enough to get a woman through labor w/o pain meds, but anecdotally we pass those things on, for sure. But when we dispense information to clients, alternatives, other routes, etc. (NEVER *advice!!*), we are taught not only in our training but it is emphasized at every conference, seminar and workshop, and by our peers at large, to be evidence based. Now, I grant that I don't know many doulas who have a lot of experience in reading studies as they are published, how to determine fact from... well.. bullcrap... and I see all sides using any study whether it's well done or not, to serve their own agendas. Physicians and midwives are not innocent of this, either.

My goal is to be a physician who works with what evidence there is, who remains open to what is unknown, and who encourages women to trust their bodies, to treat them respectfully. My goal is to be a physician who protects birth as a rite of passage and does not medicalize it unnecessarily. That's REALLY hard, given the climate. That's almost impossible, given all that OBs are up against. I still think it can be done. If it can change into the climate we're in today, it can surely change into something else.

There are a lot of deliveries done in this country in a given year, and if you concentrate on few exceptions, you might miss the whole picture I hope you get the needed training and become a great physician that will be true to your patient needs while passing on a non-biased earned knowledge.

Thank you, I really appreciate that- I mean it. I hope the same thing for myself, that I don't lose sight of what brought me on this path somewhere as I navigate it.

 

[3dtp]

Oh at least! I don't ever want to practice based on assumptions that things don't change. I'll revisit this topic far more often than that.



Oh, I agree. I know this as well as you do, even though I practice in another spectrum of birth. I'm not one of those fringe birth folk (even tho I support their right to choose that for themselves) who think that doctors are evil. I think there are bad doctors just as there are bad midwives, etc.- but no, choosing allopathic obstetric care for a normal, low risk pregnancy is not an inherently bad thing. It is incredibly sad for physicians and for patients that OB is being painted into such an obstacle ridden corner. It doesn't bode well for the future of either party.

Thanks. In my former program I had the pleasure of working with doulas in the academic hospital setting. So, I have had exposure to your "spectrum." Thank you for understanding that we are not all evil. Sometimes I wonder...

Frankly, I think this is a fabulous idea. I am willing to broaden my perspective, and willing to be wrong or find that I am lacking information where my perceptions are. My original suggestion is based on that principle: looking at things from another perspective and see what there is to learn. This particular resident is looking for ways to 'navigate the paper thin margin' between things being 'ok' and 'hell in a handbasket', and respecting that birth is a natural process that sometimes requires assistance in optimal circumstances, rather than viewing it as an emergency (not saying you are, but it's common), can really make a difference. Did you hear about Helen Sandland, the doc who refused to increase her cesarean rate and was let go from the hospital for whom she worked? I emailed with her for a bit and according to her, her statistics are exemplary, nary a bad outcome to be seen, and yet her hospital was not satisfied with the lack of surgical outcomes and put pressure on her. For what?! (This still pisses me off.)

Thank you. Please let me know if I can help, review articles or in any other way lend assistance. Others have already suggested a possible explanation for lowered US infant mortality statistics. One might review those studies and do gestational age corrected statistic for all countries. Then we could really see what's going on eh? I agree that sometimes many hospitals act in their own financial best interets and this is unfortunate for all.

I'm going to start looking into your suggestion, I really do think it's a phenomenal idea.

Again thanks and certainly feel free to PM me for any suggestions assistance or other ideas.

 

[hilseb]

You say you're starting pre-medical school next month. Revisit this topic in 9 years.

Technically you are correct and many obstetricians are doing exactly what you suggest. Keeping their hands off high risk patients or stopping deliveries. all together. Already in some states, a patient with high risk characteristics, must travel to adjacent states for any care at all and any hope of having children.

Patients are considered medically high risk for good reasons, some of them physiological, some anatomical, some for reasons we just plain don't know.

Here's what I suggest. Do a research project, as you are preparing to enter college. I suggest that you do a survey of the childbirth literature. Look at the public health statistics for child and infant mortality from say, 1850 forward. Look at the specific causes of maternal morbidity and mortality and the trends in each of the settings you are familiar with. I recommend you look in the scientific literature, the public health literature and statistics and compare this to other literature. Don't just repeat what the ACOG or RNM or laymidwife literature tell you, for they all might have biases. Do your own work from the original data and trends. It will be good preparation for your premed courses and give you a ready project when it comes time to do your first research project.

I think the information will enlighten you and if you post the results on this board, us as well.

I found this thread by searching "homebirth". I was coming on to post about homebirth and out of hospital birth. I trained as a midwife and am starting medical school in the fall. I just bought a book called "Birth in Four Cultures" and it is on its way to my house. One of the cultures in that book is Holland, where they have the vast majority of their births at home. I plan on starting a new thread about what I read.

In the meantime, someone suggested on another thread that out of hospital birth was illegal for physicians. I know of two husband OB/ Wife CNM teams that run birth centers in Florida. Maybe the wife is the attendant legally at all out of hospital births? (The husbands also have hospital attending rights and do hospital births, also). Does anyone know if it is expressly illegal to attend birth clinic or homebirths, or is it just not "standard of care" and leaves you open to litigation? Is it state by state?

I should start a new thread for it, huh?

 

[stiffany]

Does anyone know if it is expressly illegal to attend birth clinic or homebirths, or is it just not "standard of care" and leaves you open to litigation? Is it state by state?

I should start a new thread for it, huh?

It's not illegal, but it would be opening up a physician for malpractice should something unfortunate happen since the normal "standard of care" has been violated.

There's a good book that just came on the market in paperback called "Birth" that goes through the history of birthing starting in the middle ages. It's a little heavy handed against doctors sometimes in my opinion, but it does provide a very interesting insight. Ultimately, the author herself states that she would prefer a hospital assisted birth "just in case." If you actually look at the anatomy and the tight squeeze and flips involved, it's pretty amazing that so many people have "normal" births.

I would also caution the doulas and midwives of the world to lay off on the doctor bashing just as I personally feel that as a future obgyn I may not always have the "best" solution for every patient. Not all obstetricians are "bad" or are too worried about their time to wait out a labor instead of quickly cutting. Furthermore, by assuming that many obstetricians are against "natural" delivery in cases where it's warranted, you're automatically creating a defensive barrier against further discussion about when it's ok for different parties to step in and help the woman delivering. In addition, part of the shift against home deliveries in recent years has come as a result of hopes for pharmacologic pain relief that are not available without licensed presence and even an increase in desires for "scheduled" births that fit in with women's lives.

 

[Doula-2-OB]

I would also caution the doulas and midwives of the world to lay off on the doctor bashing just as I personally feel that as a future obgyn I may not always have the "best" solution for every patient. Not all obstetricians are "bad" or are too worried about their time to wait out a labor instead of quickly cutting. Furthermore, by assuming that many obstetricians are against "natural" delivery in cases where it's warranted, you're automatically creating a defensive barrier against further discussion about when it's ok for different parties to step in and help the woman delivering. In addition, part of the shift against home deliveries in recent years has come as a result of hopes for pharmacologic pain relief that are not available without licensed presence and even an increase in desires for "scheduled" births that fit in with women's lives.

I definitely wanted to respond to this comment.

I agree that there is a tremendous amount of bashing going on. Who is doing more- docs or doulas/midwives? I can't say for sure. I can say that there are doulas who will refuse to work with certain clinics, or hospitals, given bad experiences there. I know there are also clinics who will not 'allow' their patients to have doulas as well. It's VERY sad for all involved. I have learned a tremendous amount just visiting these boards about not only the good intentions behind some of the actions that don't seem to have obviously rational explanation (at first), but also that medical students and docs are hardly oblivious to bias and reacting due to trauma. We are all in the same boat, we're just paddling against each other, if you ask me. The intention is to try to give women the best care we can, we just can't find a way to agree how that should happen. There's too much at stake for everyone. If we agreed that low risk women could safely give birth at home, someone is at risk to be sued. If we say that all women should give birth in the hospital, someone is at risk to be sued.

I am NOT anti-doc anymore. I admit I was when I started, I am human and had some major biases. Having been working in the birth world for five years and seen absolutely amazing docs with infinite patience and a true trust in the process, and docs who were so traumatized by bad outcomes and having been sued that they wanted absolute control and therefore had unjustifiable cesarean rates-- and let me tell you, I've seen the SAME with midwives and doulas. I've seen doulas walk out on clients who got epidurals, doulas 'fire' a client who wanted to work with a certain doc or have a certain experience, and midwives take advantage of their exalted status among the unmedicated birthers to abuse women in terrible, criminal ways. I have seen the opposite, brilliant, loving care, respect of the family as a family, informed consent to levels I never could have fantasized about.

It's not a perfect system. I want to go into it to make it better, not fix it. There are no right answers to how to make it 'right' for everyone, but I have to believe that going in with a healthy perspective, hopefully having experienced many 'styles' of birth (home, birth center, water, cesarean, induction, etc) and seen the different emotional needs of the women having these birth, and coming to understand that the first priority is the health and welfare - not JUST the physical health- of the mother and baby, is the highest priority. Not our desire to not be on call at Christmas or to miss a flight or to make bad calls because we're tired and don't feel like dealing with something (I'm not even pointing fingers, these same things affect us all in the profession). We do NOT come first. I think if that concept could permeate med school with regard to obstetrics, birth could truly change and be not only safer, but better all the way around.

Down with doctor bashing! Down with doula and midwife bashing too. We may not all agree but there is room for us all at the table. Not implying that doulas have the level of responsibility that providers do, but we are thrown into the mix by being in the room as professionals - and we are definitely thrown under the bus just as often as anyone else.