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What I’ve Learned After 30 Years of OB/GYN

Posted by MDViews on December 17, 2012

My first day of practice after I finished my OB/GYN residency at Iowa was July 19, 1982. That seems like a lifetime ago, probably because it is.

I thought I might share some thoughts on this thirty year journey I’ve been blessed to have. You may enjoy the read. (Or, you may not if you are included in my list of things that have gotten worse in the last 30 years!)

First, some things have not changed a bit.

1) The patient encounter. It is still a conversation, an exam, an investigation, a diagnosis and a plan. The most important part without a doubt is the conversation. With the conversation comes listening. Without listening, I never really get to the bottom of any patient’s problem. I’ve read that a doctor interrupts a patient after an average of 17 seconds during an encounter. Whew! Shame on us doctors!

2) Fear. All patients have some element of fear and uncertainty in the back of their minds when they see me. No one comes to the doctor 100% sure all the news will be good. That applies to every visit, whether a routine annual exam or a routine OB check up or a problem of a more serious nature. Is my baby OK? Do I have cancer? Will I bleed to death? Why do I always have pain? All doctor visits entail some anxiety for a patient.

3) Trust. Trust is the glue holding together the doctor-patient relationship. Without trust–trust in myself that I am up to the challenge of the patient encounter or trust the patient has in me that I am capable of helping her–the whole thing falls apart. I have to know–not just “think” or not just “hope,” but actually know–that I have the mental capacity, the ability, the knowledge, the skills and the desire to help my patient in a real way. If I don’t have trust in my skills as a doctor, I’m lying to her if I imply I can help. If my patient has doubts I could be a good doctor for her, if she doesn’t really trust me to help her, if she thinks me disinterested, incompetent, distracted, casual, insensitive or somehow not totally committed to her well-being, my chances of helping her decrease significantly. Patients, I think, can sense a doctor’s competence.

4) Care. Caring is the “product” or “service” I offer to my patients. I’ve learned I can’t hide it if I care and I can’t hide it if I don’t care. The signals may be subtle, but are unmistakable to patients. I’m far from perfect and have had occasions in which I’ve been fatigued, or rushed, or distracted by some outside event or just ill myself and have provided less than ideal care to my patients and have seen them move on to other doctors. Fortunately, I’ve not seen a lot of that through these years and have seen it more with patients leaving other doctors to come to me, but I’m guilty as well of not caring as much as I should have more times than I like to think. Patients have an ability to sense caring I’ve come to realize.

Some things have changed profoundly in the last thirty years for the better and all have to do with better technology which has improved patient care.

1) Ultrasound. When I started, real-time ultrasound was new and I was lucky if I could tell what part of the baby was coming first. Ultrasound now gives me such clear and accurate pictures, I only infrequently miss abnormalities as a pregnancy progress. Also, ultrasound for gynecology was worthless when I started. Now, it is indispensable at diagnosing gynecologic problems.

2) CT and MRI scans. CT scans were just invented when I started. MRI was only a dream. Now, I can order a scan and view the insides of any part of the body with unbelievable accuracy. Both are totally valuable and indispensable now.

3) Fetal monitoring. Monitoring the baby in labor was somewhat new when I first started OB, but is now commonplace and allows me to tell how the baby is doing in labor. There have been published studies that say listening with a stethoscope is just as good as a fetal monitor. Don’t believe it because it’s just not true. Fetal monitoring is worth it’s weight in gold, in my judgment.

4) Medicines. Several come to mind. One is Zofran for nausea and vomiting of pregnancy. What a godsend for women. I rarely have to hospitalize a woman for nausea and vomiting early in pregnancy any more. Acid reducers for heartburn late in pregnancy have also greatly increased a woman’s comfort during pregnancy. SSRI’s (Prozac, Celexa, etc.) have totally changed the face of depression in women. Those with disabling, depressive PMS and those with post partum depression get relief and can function. What a blessing! Antiviral meds for recurrent herpes have helped many women. None was available when I first started.

5) New surgeries. The first would be operative laparoscopy. With that minimally invasive technique, I can treat endometriosis, adhesions, ovarian cysts, pelvic pain and infertility. Endometrial ablation, a procedure to destroy the uterine lining to stop bleeding done as an outpatient without hysterectomy, is another.

Some things in medicine were unsatisfactory 30 years ago and remain unsatisfactory today, and others have taken a turn for the worse in the last thirty years much to my dismay.

1) Lawyers. Believe it or not, the medical malpractice crisis is not new and a doctor’s fear of being sued is not new. When I chose OB/GYN as my specialty, the biggest hurdle I had to overcome in my mind was the high risk of lawsuits in OB/GYN. And that was 1976. Medical malpractice continues to be the bane of all OB/GYN doctors. Any baby born less than perfect can result in a lawsuit. No chart is perfect, so there is always something an opposing expert can or will say to blame the attending physician for any problems the baby may have, because any and every labor a mom experiences which results in the birth of a less than perfect baby is scrutinized and can result in a lawsuit. One of the unintended consequences of this sue-happy society is the rising cesarean section rate. When I started residency, the C/S rate at my hospital was about 5-7%. Now, the nationwide average is above 30%. Politicians and researchers say they don’t know how much of this increased rate they can attribute to lawsuits. Well, I do. About 99%.

2) Institutional and corporate physician employment. Private practice was the norm when I started out. Few doctors worked for large health care companies, government entities or universities. Even then, most of those physicians in academic medicine were in it for the right reasons–teach and do research. However, now, private practice, especially in Minnesota, is dying out. More and more doctors work for the large Fairview, Allina and HealthPartners of the world. They work for less money, but usually have only a 4 day work week and share call with a plethora of other physicians. In Minnesota, an on-call doctor never speaks to a patient after hours. All patients have to call a “nurse-call line” where they are told to go to the ER, stay home or go to OB. The ER or OB then contacts the doctor after the patient has been evaluated. Also, most doctors who work for the large companies do not take patient calls during the day as well. They go to the nurse-call line.

This change of institutional and corporate physician employment profoundly affects how physicians and patients interact. In such a system, physicians tend not to view themselves as one patient’s doctor. They lack loyalty to any particular patient. I’m generalizing here as there are exceptions. But, by and large, loyalty lacks significant influence over physician behavior. Therefore, the doctor/patient relationship is superficial. A superficial relationship hinders the trust and confidence a patient should have with their doctor. As I said above, patients can tell if you care and if you don’t care. If you are unavailable 3 days out of 7 and won’t take a phone call on the other four days of the week, what does that tell a patient about caring?

Also, the doctor is beholding to the corporation and must do whatever the corporation says. Corporate folks, however, are not generally medical. They sway with the wind of corporate style and change, the process du jour to improve productivity. Patients get called customers, physicians get called providers and hospitals take on strange-sounding names. Processes get copied from the auto industry (the Toyota way) or the airline industry, as if screwing bolts on a bumper or going through a pre-flight checklist somehow compares to the vagaries of a treatment plan for breast cancer.

The word to sum it up best in my mind would be de-personalized care. But if medicine is anything–anything at all–it is personal and it is private and it is a relationship. Trying to shoe horn medicine–this very complicated, private, personal, unique, caring relationship–into the one-size-fits-all corporate/institutional model results in a medicine best for the hospital, the bean counter, the coder, the administrator, the government rule-maker, the bureaucrat and the lawyers, but for the patient? Not so good. The patient is left to deal with a rushed, often surly doctor who is under the gun to produce (move patients in and out–see as many as possible in a short period of time) and follow the cookbook du jour (protocols are always changing and always getting more detailed and difficult to follow) in order to maximize income from those in control. At some big medical corporations, doctors pay is based on how well he or she follows the latest medical protocol cookbooks. The doctor becomes a puppet on a string, jerking here and there with the latest corporate or government fad or protocol leaving his or her best medical judgment at the exam room door.

3) The electronic medical record (EMR). I’ve written on the problems with the EMR before here, so I won’t re-write the whole post. Care is even more de-personalized. If you’ve been to the office of a doctor who spent the whole visit looking at the computer screen and typing, you probably know what I mean. Privacy becomes a sad joke. Errors are perpetuated in the chart. Your visit notes become polluted with extraneous, irrelevant information and your doctor can commit coding fraud and you will never be the wiser, all because of the EMR. Thanks, EMR.

4) Nursing. The nursing profession (and I use that term with hesitation) was hijacked by the master degree and PhD degree nurses (nurses who no longer do actual patient care) who decided that nursing’s primary role from centuries ago was inadequate, demeaning and needed to be changed. What was/is nursing’s primary role? To carry out the orders of the doctor. (You probably didn’t know that, I’m guessing.) The doctor listens to the patient, examines, tests, reaches a diagnosis and develops a plan to treat the illness. This plan, at least in the hospital setting, is carried out by the nurse.

However, with the 1960’s and 70’s came the feminist movement. Since most doctors at that time were male and most nurses were female, you can see how this situation rankled those in feminist power. So, nursing developed their own “nursing diagnosis,” things like “potential for pain” for a patient who has had a surgery or “potential for a fall” for a very elderly, frail patient. How demeaning for nurses. Along with these nursing diagnosis came pages and pages of burdensome charting, charting which was read by no one except supervisor nurses. I know as a doctor, I could care less what a nursing diagnosis was, but I cared deeply to know how my patient was doing based on the nurses care and judgment. Her (or his) assessment of my patient’s status was critical to my decision-making.

A professional nurse who knew her job and cared about her patient could tell me in a short paragraph my patient’s status, whether or not she was getting better or worse, what new problems had developed, what old problems were resolving. Such information was critical to good patient care.

When I started in medicine, nurses routinely rounded with the doctor (me) and so would be able to fill me in on any problems the patient had, listen to the conversation between me and my patient, understand my exam and then understand where I wanted to go from there with new orders or a new plan. Communication occurred and misunderstandings were few.

In the 1980’s as nurses became more and more burdened with charting no one read, they had less and less time to round with me. The nursing higher-ups demanded this charting and placed a low value on rounding with the doctor. I guess they viewed rounding with the doctor a demeaning experience–you know, a woman subservient to a man, that sort of thing. They totally missed the picture of what was best for the patient.

Also, nursing unions removed from this noble profession the word “profession”. I hesitate to call nursing a profession any longer as so many nurses now have a union “them-against-us,” “we’re the good guys, they’re the bad guys,” “I’m only doing what my contract requires,” attitude. When you hear of unions threatening to go on strike, they always get the ear of the local papers who have always been in favor of the unions, it seems and against administration and doctors. So the interviews always come out favorable to the nurses and the nurses always say they are threatening to strike for the good of “our patients.” What a sad joke. They strike for money. When their shift is over, they care little about “their patient”. However, I still encounter nurses who are true professionals and who are in medicine for the right reasons. That number is less than 50% now in my judgment, but I’m still refreshed and pleased to find nurses doing real nursing and really caring.

So now, in 2012, I would say a nurse accompanies me on rounds less than 5% of the time, and that 5% is mostly by accident. She (or he) happened to be in the patient’s room when I made rounds. Instead, if I want to talk to my patient’s nurse, I’ll have to have him or her paged and wait. To get report from a nurse is like pulling teeth. Then, the nurse will sometime be upset at being inconvenienced by my call and request for information. How sad! I wonder how many patient realize that I have so much trouble getting important information about their condition from their nurse! I’m sure they think we work together as a team.

The last change in nursing I’ve seen, a change that could have some positives to it, but is really 80 to 90% negative, is the nursing dependence on protocols and the authority given nursing to directly countermand the decisions of the doctor.

We now have protocols–medical cookbooks–for almost everything. In general, they’re good. They keep me from forgetting something important. However, because all patients are unique, they don’t all fit the protocol. So sometimes, I have to write orders that don’t match the protocol. Oh dear. To nursing, these protocols are carved in granite. Add to that the explicit permission nurses are given to ignore a doctor’s order with which they disagree and you have recipe for trouble.

One can get a diploma RN degree with 30 months of school after high school and be employed as a hospital nurse. I spent 12 years after high school getting my college degree, then my MD degree and then OB/GYN residency training. Yet I’ve had happen again and again failure of nursing to follow my plan for patient care because they couldn’t understand why I wanted to do what I wanted to do, even when I spent much time explaining my rationale. If the staff nurse disagrees with my order, he or she goes to the charge nurse. The charge nurse goes to the head nurse on the floor or OB or surgery. Next, I’m called into an office to be told they won’t be following my plan since it doesn’t follow the protocol. My next step is to appeal to the head doctor of the department. If I can get the head of the department to agree with me, it’s possible my plan may be carried out, but even that is iffy. Sometimes, nursing insists on discussions at committees and changes in protocols processes which can take months. If I push hard to have my plan followed, I’m viewed as a troublemaker and a problem physician.

So the noble, honorable profession of nursing has, in my mind, gone downhill, led by feminists jealous of the role of a doctor, feminists who burdened nurses with menial tasks and cumbersome charting of questionable value, unions out to garner more money for nurses which changed nursing from a profession to a job and protocol/institutional/government influence on nursing which caused nurses to quit thinking and follow a medical cookbook at all costs.

5) Lastly, I have to mention–how do I say this–uncoupling of doctors from the tenants of the Oath of Hippocrates.

I’m not sure how much influence the Oath of Hippocrates had prior to my entry into medicine in 1974, but I think it was substantial. I base that opinion on the doctor’s attitudes I witnessed in my early medical training.

In 1973, when Roe v. Wade became the law of the land with one sweep of the Supreme Court’s pen, most (70 or 80%) of doctors eschewed abortion. Genetic testing did not exist. Ultrasound did not detect prenatal abnormalities. Doctors were trying to save babies, not kill them. Within two years, however, a sea change of opinion occurred and a majority of doctors became pro-choice. Why? Pressure from the liberal woman’s movement. If a doctor was not pro-choice, they were viewed as women-hating, misogynistic, backward, stupid troglodytes and were marginalized in the doctor’s lounges and medical meetings across the country. It’s a testimony to the weakness of the pro-life commitment doctors held prior to Roe. Apparently, the medical profession’s pre-Roe pro-life commitment was (metaphor alert) a mile wide and an inch deep. Not much there. The doctors folded like a cheap suit.

But the Oath is not just pro-life, but pro-God, pro-morality, pro-privacy, pro-honesty, pro-only-work-for-the-good-of-the-patient. I’ve written about the Oath in much more detail here so you can get my detailed analysis of the Oath and why I think it should still be followed.

This uncoupling contributes to the current decline of medicine today. If doctor’s followed the Oath, medical records would not touch the internet without a patient’s consent. Billing would be honest. Life would be honored. Greed would be less. There would be no death panels. The phrase, “cost-effective care,” would disappear from the lexicon. All patients would be treated with equal dignity, respect and the best medical judgment a physician could muster. All patients would feel safe in a doctor’s care. Protocols would be just gentle guidelines as reminders for good patient care, not inflexible rules with harsh consequences trumping a doctor’s best judgment. Doctors would have a concept of their “profession” instead of viewing doctoring as a 9 to 5 job four days a week, a don’t-bother-me-unless-I’m-on-call and where’s-my-paycheck attitude.

So those are my thoughts on medicine from then to now. I know for myself, I’ve finally grown up medically, I think. I relate to George W. Bush who so famously said, “When I was young and dumb, I was young and dumb.” That’s me. I did many things I now deeply regret as a Christian, a husband, a father and a doctor. I’m totally convinced of my depravity.

I take my medical calling with all the seriousness I can muster. I embrace medicine with both hands–the good and the bad–recognizing that it’s my duty and my privilege. I more fully recognize the unique role God has given me and the responsibility that goes with it. I more humbly thank God for this “job”, this calling, having suffered through a period of unemployment. I pray I can be effective as a Christian physician until my health fails or God calls me home.

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