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Friday
May262006

What Motivates Physicians?

I was asked if the impatience of doctors was why so many interventions occurred. I have my own thoughts and beliefs - I think many will echo others' experiences, but if you think of something I've forgotten, speak up!

I believe medical care happens the way it does for three key reasons:

1. Time
2. Money
3. Liability

The 4th would be arrogance.

Time:

Birth is slow. It can take hours and hours and hours. Doctors used to go to women's homes and sit with them throughout labor. They then figured out how to have nurses do their labor sitting for them and did that for awhile. Once they caught on that if they brought the women into the hospital they would be able to see a slew more women at the same time AND have nurses do the labor sitting, it was off and running. Time being of the essence, you know.

When families started coming into the birth room, nurses were freed to take care of more patients - thereby allowing more women to labor at the same time, too. Then medication - namely, an epidural - helped all of this tremendously. Give an epidural, slow the labor down, augment with pitocin and get the show on the road! tap tap tap on the watch face Oops, not going fast enough - time to cut. If I had a dime for every woman I have stood with who was given a time limit for labor or pushing and threatened with a cesarean - I would be able to buy a whole dress from Nordstom's.

Why are "urgent" inductions done during the week? Why are the majority of "emergency" cesareans done between 9-5? How can doctors, during the business day, disappear to "deliver" a baby, a placenta, and suture and return to the naked woman in room 3 in less than 20 minutes? Why do doctors insist on yanking placentas out when they know damn well it can cause a hemorrhage or prolapse? (because they can FIX it with surgery!)

Time is of the essence. The goal is as many women in and out in as short a time as possible so they can make more money.

Money:

More women = more money. The more expensive the procedure, the more money they make. The more procedures they do - interventions, medications, complications, supplantations they do, the more money everyone gets (hospitals and doctors). Because insurance is a game, billing exhorbitant amounts for every single thing (remember those $20 cotton balls?) gives the max amount possible - they say, to break even. I believe it is to break the bank.

Medicaid pays about $700 for an entire pregnancy, labor, delivery, and postpartum experience. If it is a cesarean, it pays about $1500. Many practices have a limit on the number of welfare clients they will accept. Insurance pays infinitely better, of course.

The more women they can see, the more procedures they can do, the faster they are in and out of the hospital - allowing the next round to begin. Oh, yes... more women = more money.

Liability:

The courtroom has, for at least the last 20 years, (mis)guided "care" by scaring the wits out of doctors and nurses, forcing them into trying to control every second and every aspect of every delivery. Chaos is the enemy in the labor room - the winner in the courtroom. Doctors believe not monitoring is wreckless - there isn't a piece of paper to show the judge or lawyers. Intermittent monitoring? What if something happens between times on the monitors? Despite the dearth of studies showing that continuous monitoring doesn't improve outcomes, the law still believes it is one of the best keys to winning a case proving the doctor acted quickly when fetal issues arose. So what if the woman has to stay put in the bed. So what if she is made incredibly uncomfortable and has a baby stuck trying to rotate through the pelvis. Just break her water and attach a scalp electrode... "then you can move around as much as you want!" Sure. Now the baby is REALLY stuck, been poked in the head, and mom is screaming for an epidural because the pain is overwhelming.

Mission accomplished! We can now speed things up and get it all done faster.

'Round and 'round we go.

(I don't think I need to utter a word about arrogance, do I?)

Reader Comments (3)

I am a medical student and avid reader of your blog. I really enjoy your insight and perspective on birth, and reading this blog will definitely help me question everything I see in my OB rotation. Hopefully, I will hear both sides and have a balanced view. However, I find your view on physicians hard to reconcile.

The most common piece of advice given to any medical student is "whatever you do, stay away from OB." We are told that choosing this specialty would follow up our 8 years of education + 4 years of staying up all night every third night with a career that would involve
- yet more endless call
- being sued an average of 4 times per year (at least in PA, where I live)
- malpractice insurance over $100K/year
- difficulty paying back our loans
- no respect from the medical community

Despite the constant cautions and horror stories, OB/GYN continues to be one of the most popular specialties year after year. The students who choose it say they cannot imagine doing anything else. They are passionate about issues that affect women's health. You say that in four short years, they will complete their residency and turn into monsters that use women in labor for their own greed and gain. I am not in a position to offer evidence to the contrary, but as I said, I find this hard to reconcile.

Thanks for writing this blog; I will continue reading it and thinking about the issues raised.

May 27, 2006 | Unregistered CommenterAnonymous

Anon Med Student: And YOUR words are very helpful to us all, too. It will be good to hear just how much you see an OB up in the middle of the night if he isn't actually delivering a baby.

When I first started doing this work 20+ years ago, the docs and nurses sat together talking at the nurse's station. I don't know if paperwork eliminated any bullshit sessions or discussions of the sort I got to eavesdrop on, but I never see that kind of interaction anymore. I find that sad. More likely, the doc has 1. just come from the office and is heading right back 2. just came from the sleep room 3. just came from the OR - in that order.

It's so hard - the work. I don't deny that AT ALL. I have no more than 3-4 clients in an entire month, rarely more than two months in a row (and then there are fewer clients for a few months before it increases again). (busy) Doctors see hundreds of clients in a week and can deliver 20-40 babies during that same time. It *can't* be easy. I couldn't imagine doing it the way they do.

Knowing how difficult it is, I absolutely see the appeal of inductions. I really do get why they think surgical delivery is a great option, especially if they can foresee things going downhill long before the woman can. Having sat with women for three days, I totally understand why her docs and nurses sigh with relief when she FINALLY accepts medication/an epidural.

I do believe OBs begin very altruistically. I do believe they truly do want to be a part of such a "happy specialty." But, I also believe that along the way, things jump in the way that make it easier to be cynical, to discover ways to limit the need for so much time and personal energy expended. I can't imagine that most people in a high-need specialty, given the opportunity, wouldn't attempt to limit the amount of sweat and tears if there was a safe (enough) way out.

But, it doesn't mean it is right. It doesn't mean that birth should be speeded up, manipulated, twisted into something that barely even looks like having a baby - either in the body, in the physical room, or in the woman's heart.

Birth has become so mechanized, it is no longer recognizable as a pinnacle moment, spiritually and emotionally, in a family's life.

I find that sad.

Thanks, med student, for allowing my stories to give you pause. Yours do the same for me.

May 27, 2006 | Unregistered CommenterNavelgazing Midwife

Barb , I have been there too and many many docs are just what you describe. and I am sorry to anon medical student, I have also met some really dear docs but they are few and far between-
One though family practice medicine still allows for OB practice but tends to be softer folk and are my preference for a provider. Things like treating thrush in a baby also puts it together with timely treatment for mom , not to mention strep and other illnesses in the family also a mom can end up actually knowing the doc better and doc knowing the family better because of increased contact( this lends it'self to continuity of care) .
I also think that medical students are abused, routinely abused and would like to see that changed- there just has to be a better way
take heart and care
anon s

May 27, 2006 | Unregistered CommenterAnonymous

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