At Your Cervix has a post up about doctors who care, reeely care about their patients and take lots of time with them, the so-called "Dr. Wonderfuls" that Barb, on Navelgazing Midwife often goes on about. These are doctors who, according to the econiums on the blogs, try NOT to practice medicine, but behave [the highest compliment!] "like midwives". These are doctors who pay much more attention to their patients' requests than stupid things like evidence-based medicine, so that they take all kinds of risks just to make the patient happy. It all works out very well until the patients begin sueing when there's a bad outcome. Dr. Biter, on the West Coast, has managed to gain an almost fanatical coterie of women who think he's the Cat's Pyjamas, but in only 12 years of practice he has also been named in six lawsuits. One has to wonder why.
But this isn't about "Drs. Wonderful", or "Dr. Grouchy" or any other kind of doctor. It's about communication, or the lack thereof, and time, and patient expectations, and reality.
I'm the last one to deny that most doctors don't have "bedside manners" worth a damn. At Your Cervix has already finished one year of her CNM course [MA, I believe] and until now it's all been about communication. I keep waiting for her to get to midwifery -- I suppose it will show up at some point. Doctors never take courses in how to talk to patients, and to be honest, frank discussions are usually not viable for several reasons. The patient has to trust the doctor, yet he wants the doctor to be somewhat distant and objective, before he can open up and ask "What was that you just said? Can you repeat it in English?" or "Why are you advising this treatment and not that treatment?" because the patient fears the doctor will be annoyed with him for doubting his [the doctor's] pronouncements. [And the doctor, all too often, is. He wants to stay on his pedestal as much as the patient wants him to remain there]. So there is a very fine line in the interaction between patient and doctor. Add to this the fact that in OB the patient is a woman, and the doctor is very often a man, and having a baby is not only emotional but related to sex, and the line can be very fine indeed. One man's compliment can be another man's sexual harassment -- this is the reason all intelligent male doctors will have a female attendant in the room if an internal exam is likely. Females, be they nurses, midwives, or even female physicians, are perceived by the female patient as being less threatening. Those of us in the business know that the most obnoxious doctors [at least as far as their staff colleagues are concerned] can be women, who often need to prove they are tougher than the men, incidentally.
So patients can feel intimidated even when there's no overt intimidation going on, and insensitive doctors can think the patient is entirely satisfied with her treatment unless she signals that she is. The signalling is often misinterpreted as hostility. Trust, and communication, again.
But, the nurses and the midwives, one hears, "listen to me when the doctor doesn't". It depends on what the patient's talking about. It isn't the doctor's job to instruct the patient how to use her glucometer; it is a waste of time to do so, but it is a task the nurse is educated to do. The patient then perceives the nurse as being more interested, more supportive. On a ship, it would be a waste of time for the Captain to shovel coal in the boiler room; he delegates that to the appropriate people. The same thing applies here. The nurse can't determine what the insulin dose should be for a gestational diabetic; the doctor does that, and the nurse shows the patient how to administer it. It's called division of labor.
Now, about time, and reality. Ideally, I would have a half hour with each new patient, to open their pregnancy follow-up card, take a history, chat about the progress of the pregnancy, ask if there are questions, etc. At Your Cervix is interested in bringing the delights [!?] of unmedicated "natural" childbirth to low-income women. Do poor, uninsured women take private midwives? No, they don't. They go to clinics run by teaching hospitals. If a CNM sees a woman, she is a staff midwife, who doesn't pick and choose her patient caseload, she works in a clinic X days a week, or in L&D for X shifts a week. Right away, the one-on-one patient/midwife relationship is compromised. Ms. Hernandez will probably see a number of different midwives through her pregnancy and labor and, because the clinic is almost always crowded, will have only a brief time to speak with one. When doctors are accused of giving their pregnant patients short shrift, the patient doesn't usually know how many patients the doctor has to see within a given time: in my clinic, in a 5 hour stretch, a doctor usually has to see between 40 and 75 women. No time for cozy chats, is there? It's not uncommon for me to be supervising two women having NSTs [fetal monitoring], be teaching a woman about gestational diabetes, and have half a dozen women waiting in the hallway for their BP/weight/urine tests before going in to the doctor. It's a madhouse. And, oh yeah, the phone keeps ringing [usually with asinine questions like "I forgot my pill today but he didn't come inside. Can I get pregnant?" or "I'm 6 weeks pregnant but I'm bleeding and having cramps. I don't have a babysitter. Do I really need to see a doctor?"] The phone queries take more time than anything else.
Whether a woman gives birth in hospital or home, if she retains a private midwife, of course she gets a great deal more attention. She's paying for it [or in some cases, her insurer is]. Most CNMs who don't work in hospital work with a medical group, and depending on how much overhead there is, and how much profit her medical partners want to make, her caseload can be extensive. It often presents a dilemma. Whereas a doctor can relinquish on-the-spot care to the L&D nurses and only get to the hospital when the patient is nearing delivery, or will briefly pop in from time to time, thus being able to manage his office hours as well, the CNM is expected to accompany her patient, acting more as a doula than as a doctor, especially in early labor. Meanwhile, her clinics for her antenatal patients must be cancelled and all the patients rescheduled. The patients really love this, believe me. [Or the practice has several midwives, who cover for each other, which patients, used to seeing a particular midwife, also dislike]
Homebirth midwives make a big point of describing the huge amounts of attention they give their patients. Well, that's because of the infinitesimal number of patients they deliver. Two deliveries a week, 100 a year, is a really heavy caseload for a midwife delivering babies at home, and a midwife with a caseload like that is a physical wreck pretty soon, from exhaustion. Two deliveries a month is more like it, and while sometimes she might have a busy month, with four or five deliveries, she is also likely to go several months without a delivery. Most homebirth midwives can't make a living from this, no matter what they charge, and also work as instructors or doulas [or their partners support them].
So the bottom line is that although a midwife ought to be [1] a CNM, [2] carry a reasonable caseload which allows at least half an hour for each patient, [3] be linked to a major medical facility or have medical back-up which is sympathetic to the idea of promoting the midwife's ideology for birth, [4] has an income commensurate with her education and committment -- the chances are that it's all a long way off. Noticed any flying pigs in the neighborhood recently?
In the present, you do what you can. When I have an obviously distressed patient, I shoo everyone out and close the door, even occasionally lock it [but that doesn't stop patients banging on it anyway] and try to disconnect the phone [but the switchboard operators get antsy with the secretaries because they can't put "emergency" calls through] and give some quality time to the patient. But as the saying goes, until you've walked a mile in a man's shoes, don't judge him -- wait until you're in practice, At Your Cervix, before you make judgements on how patients are treated by their Health Care Providers. BTW, hope the day you begin your new career isn't far off.
ANTIGONOS' BRAIN
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6 comments:
You remind me of my Ob clinical instructor from nursing school. She, also, was part of a very large, busy group of Nurse Midwives and OB/GYN physicians and she voiced similar to yours opinions. I'm just a regular RN, and I don't work in OB, so this would be from a patient's perspective. I think you're right about things being busy, but I think what At Your Cervix is referring to is the simple humane way of approaching laboring women, instead of the efficient factory of deliveries you're talking about. I think the reality of what both of you are saying is that there needs to be a middle somewhere, where the delivery goes well (so physician/midwife is happy), both mom and baby are healthy (then happy!) and the patient is satisfied. I think in US there is such a stigma for "self-satisfaction" and (you're totally right) people rate physicians based on how long they talk to them or how little they have to sit in the waiting room instead of how well he/she treated their condition. Personally, I changed my OB doc because he asked me out for coffee... all during a pelvic exam. I prefer the professional distance between my OB and I, although in times of distress, I guess personalization of the situation is nice. But not every time, please.
I think there is a great gap between what the patient wants from her doctor [or HCP] and what we think she ought to want. A certain population with which I deal chooses its medical care provider ENTIRELY on the basis of gender instead of professional ability -- they will turn down a male professor [here this means a top specialist] if they can go to a woman who hasn't read a book since medical school. I think this is nuts. They don't. When I see a guy like Dr. Biter, whose YouTube video I watched yesterday, I see a catastrophe waiting to happen [indeed, with 6 current lawsuits against him, it has] yet he has mesmerized a large group of patients into believing that there is no doctor to match him. I find it scary. When I think of "Birdie's Mama", secure -- right up to the intrapartum death of her baby -- in the knowledge that her internet research made her an expert in OB, I find it scary. Whatever happened to simple common sense? Yes, the patient's wishes deserve to be heard, and yes, it's my responsibility to teach and explain, but the bottom line is that I'M the professional, and she isn't, and my responsibility to her is not to give her a beautiful experience but to give her and her baby the best care I can. [Sometimes the two coincide]. I think most women prefer doctors who maintain a certain detachment, although I know one who was immensely successful, and when asked what his secret was, he said that when he saw his patient, waddling toward him with a belly out to the wall, he ALWAYS made a point of complimenting her on her appearance and telling her how well she looked. It worked wonders.
I think it all comes down to people wanting to be treated as a whole, not only by the specific bits of anatomy involved in medical professionals' areas of specialty. For many women, birth doesn't have to be a highly medical, deeply skilled event, so what is wrong with making the birth as good of an experience as possible for those women?
You are right though, that women should chose their care provider based on more than just how nice they say you look while pregnant. However, most women assume that all OBs meet a certain standard of skill. High-risk women may have more tolerance for a doc with a lousy attitude and weak communication skills if they have the best medical skills to deal with their particular complication, but most low-risk women anticipating a fairly uneventful birth would prefer to be treated by a nicer, better communicating doc.
"For many women, birth doesn't have to be a highly medical, deeply skilled event, so what is wrong with making the birth as good of an experience as possible for those women?"
Nothing at all, except that one must never forget that the POTENTIAL for birth becoming a "highly medical, highly skilled event" is ALWAYS present, and at moments like that, it's not the gender or attitude of the doctor that matters.
I'm not an apologist for hospitals; I've always held that L&D units could be a lot more "user friendly" without sacrificing quality of care.
Nicely said, Antigonos.
As you say, it's not about "good docs" vs. "bad docs," and the communication issue goes far beyond OB. I think it's easier to focus on the humanistic aspects of care in the context of childbirth because, in most cases, we have the "luxury" of considering it carefully, given that women in developed countries generally have a choice between doctors, or between doc & midwife, and the choice one makes is rarely going to make a difference between life and death, and the end result will most often be good from a clinical standpoint. This "luxury" doesn't exist in many other areas of medicine.
OB is also almost unique in medicine because the patient usually isn't ill. When a person is desperately sick, he/she doesn't usually pay much attention to the HCP's attitude as long as the treatment is effective and the symptoms alleviated.
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