Industry vs. Craft

Thanks, once again, to the wonderful husband, I've been handed an essay that gives some great insight into the world of obstetrics. You'll find the entire piece here, and it's a great one. It is by Atul Gawande, a physician who wrote the book "Complications." The book is another great find, giving amazing insight into the world of becoming a doctor.

The article from the 10/9/06 issue of The New Yorker, is entitled "The Score: How childbirth went industrial." The article summary says, "A piece examines the history of obstetrics and its progression from craft to industry. Weaving in and out of one mother's narrative about resorting to a C-section, the author details the numerous methods that have reduced the chances of death among full-term babies. The discovery in 1933 that two-thirds of maternal deaths were preventable led doctors to standardize childbirth. Anesthesia and labor-inducing drugs became common. Fetal heart-rate monitors gained currency. But it was the Apgar score—a simple measurement of a child's responsiveness immediately after birth—that pushed obstetrics into the realm of "evidence-based medicine."

I want to highlight three areas of the article in this post.

1)I was gratified, though saddened to find that my post on evidence-based medicine, in which I stated my belief that obstetrics didn't follow that path--was accurate.

" Ask most research physicians how a profession can advance, and they will talk about the model of “evidence-based medicine”—the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double-blind randomized controlled trial. But, in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they ignored the results. Careful studies have found that fetal heart monitors provide no added benefit over having nurses simply listen to the baby’s heart rate hourly. In fact, their use seems to increase unnecessary Cesarean sections because slight abnormalities in the tracings make everyone nervous about waiting for vaginal delivery. Nonetheless, they are used in nearly all hospital deliveries. Forceps have virtually disappeared from the delivery wards even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)"

Though the study was in 1978, for many reasons, things have not changed in the area of evidence-based practice.

2) Gawande is able to find a positive to this approach to medicine. He likens OB's to car makers:

"In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked. Whether all the adjustments and innovations of the obstetrics package are necessary and beneficial may remain unclear—routine fetal heart monitoring is still controversial, for example. But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers."

God love him for giving them the benefit of the doubt, but I have to disagree that this "on the fly" approach has not been detrimental. When you choose to give birth in a hospital with an obstetrician, the general modus operandi is going to be that doing something is the benign approach, while wait and see is dangerous. The research does not support this, but it is what is taught, what is observed, and what is accepted. Just google "misoprostol ina mae gaskin" to read about the issues behind a drug OB's say is safe to use off-label, but the research points in the opposite direction.

3) This article cleared up a big issue for me. When it comes down to it, what is the main difference between choosing an MD or a Midwife? Gawande sums up the medical decision:

"The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section."

There it is, my friends, in black and white. And I say this with no sarcasm at all: OB's are factory workers. Things must be standardized so that anyone who wants to be an OB can do them. As a retired doc explained, “Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’"

It reminds me of the old joke, "What do you call a medical student who is at the bottom of his class?"

"Doctor."



I'll be discussing more aspects of this New Yorker article in other posts, because it has so much fascinating information in it. But the key point is this: If you are afraid of worst-case scenarios, no matter what the small likelihood of them occurring, and, you believe you can live with the mindset of "at least you have a healthy baby" no matter how your labor and delivery are handled, then just pick a doc and head for the hospital. (Now obviously I'm being slightly flip here, realizing some medical issues limit women's choices.)

If you want to be treated as an individual, spending time with an artisan who will get to know you, your situation, your body, and your plans, as well as getting outstanding care, then choose a midwife.

Because the main difference between a midwife and an obstetrician is: an OB figures she can fix any problem that comes up, a midwife keeps the problem from coming up in the first place.