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.

Evidence-based medical practice

I listened to a fascinating podcast from ABC Radio National "The Health Report." If you listen to podcasts at all, "The Health Report" needs to be on your list of ones to listen to.

This podcast was a two-parter focused on Evidence-Based Medicine. Here's the transcript for part one of the two-part series. It was a fascinating view into what Australia is attempting to do to get health practitioners of all varieties; physicians, nurses, naturopaths, etc., to use evidence-based medicine rather than just personal experience, or, my favorite, "It's what my colleagues are doing." Interestingly, the report used stats on the United States to show how many people are harmed or not helped by the way medical decisions are made in the U.S. In other words, we are keeping track of people being harmed, but what about the flip side of the coin?

Making time to read the transcript or listen to the podcast would be beneficial, but until you have the opportunity, here are the three questions suggested by Karen Carey Hazell, who is the Former Chair Health Consumers Council of Western Australia and Member Consumer Health Forum Canberra Perth, WA.


"What are my options?

What are the expected outcomes? And

What's the likelihood of each of those outcomes?

We know from decision making models across a lot of different industries that where probability is involved the minimum amount of data that you need to have is really the answers to those three questions. What are my options? What are the outcomes and what's the likelihood each outcome will occur? And that goes for you know if you're playing roulette at the casino, or you're buying a house, or wherever there's probability, so a lack of certainty, that's the minimum amount of data that you need to know."

The good thing this podcast reminds us is that we are the consumer. It is our responsibility to assure ourselves that our medical partners are giving us evidence-based information. If they are not, then we must do the research ourselves. Actually, even if they are giving us evidence-based information, we still need to be doing the research ourselves.

One final caveat, if you run into a health care partner who does not welcome your questions, encourage your research, and listen when you ask for this information, look elsewhere for a partner, and tell them why you are going to join with someone else. The system will not change until we make it change.

AAFP's stance on VBACs

Thanks to VBAC.com, I just discovered that the American Association of Family has revisited their stance on VBACs. You can read the whole study here, but I am highlighting the part where they diverge from the American College of Obstetricians and Gynecologists on Trial of Labor after C-section (TOLAC.)



What management strategies influence outcomes? (Any emphasis added is mine.)

Recommendation 4: TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes. (Level C)

At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Much of the controversy on VBAC has centered on the management of labor, the timeliness of operative delivery, the risk of uterine rupture and its attendant consequences, and the potential for infant morbidity and mortality. Concerns have been raised about the impact of the immediately available policy on access to VBAC services. One consequence of the immediately available policy appears to be that some hospitals have discontinued VBAC services entirely, forcing women to present late in labor, to travel to another facility that allows VBAC, or to submit to a scheduled repeat cesarean delivery that they may not have wanted. This could result in adverse outcomes for women and babies beyond inconvenience. Some have questioned the assumptions that seem to underpin the immediately available policy. For example, the policy assumes that having a surgical team immediately available will reduce morbidity or mortality from uterine rupture. The AAFP TOLAC Panel felt this was a debatable assumption. Similarly, the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common.

However, it may be argued that, while these other catastrophes are largely not predictable, permitting a TOL in a mother with a previous cesarean is a planned event that may demand a different degree of preparedness.

While adverse consequences of a TOLAC are distinctly uncommon and must be balanced against attendant risks associated with ERCD, current risk management policies across the United States restricting a TOL after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence. The TOLAC Panel found no systematic evidence suggesting that improved outcomes for TOLAC patients resulted from restricting a woman’s ability to undergo a TOLAC based on the availability of resources not usually present for other women in labor, the institutional setting, or the timeliness of operative delivery.

Any effort to limit the accessibility of TOLAC by requiring restrictive conditions during labor is likely to limit access to vaginal delivery for many women. Given the potential negative impact on access to care and the absence of evidence, no recommendations can be made as to whether a difference in intensity of care should be required for patients attempting a VBAC until more definitive evidence is provided demonstrating the benefits of more restrictive services for women undergoing a TOLAC.

Our recommendation significantly differs from current ACOG policy 14 because we could find no evidence to support a different level of care for TOLAC patients. Without good-quality evidence, we believe that different levels of resources cannot be advocated because their potential for unintended harms cannot be evaluated against their purported benefits.



The pdf of this review that I read was published in July, 2005. I just stumbled across it, I certainly did not see it covered in any major news source, as ACOG policy frequently is.

I am not a physician, but if medicine is akin to other professional fields, it is a big deal when one group strikes a stake so significantly different from a peer group. This would be like a group of physics teachers indicating that their peers in the Mathematics department weren't teaching what they should be nor using the methods they should be.

I attempted to search the ACOG website to find reference to this AAFP statement, but was unsuccessful.

One other issue struck me in reading the AAFP paper. Much of the research they found to use was considered only fair-poor based on the criteria they set up to judge a study's value. Much of what I have read and heard has given me the belief that obstetrics is the least well reasearched/evaluated, most based on common practice rather than evidence, area of medicine. This review by ACOG's peers certainly did not alter that belief.

VBAC.com

Thanks to Louisa, the administrator for our local Iowa Chapter of the International Cesarean Awareness Network, I just discovered the website, www.VBAC.com. In perusing that website, I came across at least two important discoveries:

1) The American Association of Family Physicians (AAFP) stance on Elective Repeat C-Section, or most importantly, their stance on whether a surgical team must be “immediately available” as the American Association of Obstetricians and Gynecologists guidelines for VBAC call for. (This important difference will be discussed in another post, along with a link to the AAFP study.)

2) The VBAC.com website is evidence-based, which is a critical factor. I am striving for an evidence-based blog, although I get so intrigued by the human factor side of things I stray down the subjective path. Evidence-based is explained clearly at the VBAC.com website here.

Evidence-based practice is what every woman should be requiring from her health care partner. It means that personal experience and expertise come into play, because we want a health care partner who can generalize experiences, but, and this is a big but, we, as health care consumers have the right to complete information, not just the opinion of the health care partner. There will be more on evidence-based practice in another post.