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The Infertility Conundrum

Posted by MDViews on March 25, 2014

Tears spilled on my desk as she described her four-year trial with infertility. Married for six years, she and husband actively tried to achieve pregnancy for four years prior to her visit with me. After one year of no success, she saw her OB/GYN doctor. After testing, her doctor determined her to have open tubes, normal labs and a fertile husband. Try another year, she was told. After no success, her doctor tried her on Clomid, a medicine that caused ovulation2, even though she ovulated every month. After six cycles of that without success, she visited a Reproductive Endocrinologist (RE), a doctor who finished an OB/GYN residency and an additional two years of training in Reproductive Endocrinology. The RE recommended Clomid and intrauterine insemination or IUI3. If no success after three cycles, she recommended Follistim shots4 and IUI for three cycles. If that failed, she recommended in vitro fertilization.

My patient and her husband tried the Clomid and IUI, but couldn’t afford the Follistim and IUI or the in vitro fertilization.

She returned to her OB/GYN doctor and received more Clomid, again, without success. She and her husband, both Catholic, lived with the guilt of trying IUI, a fertility procedure not approved by the Catholic Church. Her complaints of severe pain with her periods and pain in her pelvic area fell on deaf ears as her OB/GYN told her in vitro fertilization was the most effective way to achieve pregnancy, and recommended a return to the in vitro clinic.

Pregnancy rates after an in vitro cycle average 30%. I checked three fertility clinics in the Twin Cities and found one charged $16,500 for each in vitro cycle, another $22,000 and a third clinic $23,000 per cycle.

Pregnancy rates after one cycle of a fertile couple who has unprotected intercourse are 25 to 30%. Last I checked, the cost was $0. Pregnancy rates after one cycle for a couple with endometriosis5 is lower than that, often around 5% to 10%. As excellent medical studies have shown, however, surgical treatment of endometriosis and pelvic scarring improves pregnancy rates, often greatly. Not only that, surgical treatment constitutes a one-time event that often relieves pain and increases pregnancy success for many cycles.

If a woman has a 20% success rate per cycle after surgical treatment of endometriosis, her chances of pregnancy at the end of one year are much higher than the 30% chance after one in vitro cycle, or the slightly higher chance after two in vitro cycles. I rarely find a patient who has tried three or more in vitro cycles.

She heard about our clinic and underwent surgery at which time I discovered and surgically treated her severe endometriosis by careful handling of tissues, thorough treatment of endometriosis and placement of adhesion barriers to prevent recurrent scarring.

The surgery brought relief of her pain.

She conceived on her own the next month.

She is now on baby number two since the surgery.

In order to understand the tragedy this represents, you need some history. Back when I did my residency in OB/GYN, the Reproductive Endocrinologists were the best surgeons in the department, often the entire hospital. They performed difficult endometriosis surgery, tubal reconstruction and treated scarred tubes, which often required the operating microscope. Now, RE’s in my area do not come to the hospital, much less perform surgery. At the two hospitals where I work, not one Reproductive Endocrinologist performs surgery in spite of in vitro clinics in our service area.

In the last five to ten years, in vitro procedures for infertility have become the default treatment to the elimination of all other treatments. General OB/GYN doctors in my community have a laissez-faire attitude toward the surgical treatment of endometriosis and make little effort to treat the disease thoroughly surgically even if they find it at laparoscopy6. This, in spite of good data on the effectiveness of surgical treatment to improve fertility and relieve pain7.

1) Fallopian tubes – tubes that carry the egg to the uterus from the ovary. Fertilization actually happens in the tube.
2) Ovulation – When the egg pops out of the ovary and can be fertilized.
3) Intrauterine insemination (IUI) - A procedure in which a semen sample is specially prepared for safe insertion into the womb, or uterine cavity itself.
4) Follistim – A hormone given in daily injections to cause the ovaries to make eggs, sometimes several eggs.
5) Endometriosis - A female condition in which uterine lining cells implant in the pelvis and cause pain, scarring and infertility.
6) Laparoscopy - A minimally invasive surgery to look inside the abdomen in order to diagnose and treat a condition, often endometriosis or infertility.
7) UpToDate states in the section Reproductive surgery for female infertility, "laparoscopic surgical treatment was associated with a significant increase in the ongoing pregnancy/live birth rate..." October 2013.

Posted in Doctoring, Family, Medical Issues | 1 Comment »

The HPV Vaccine. Protecting Your Adult Child From Their Own Adult Decisions?

Posted by MDViews on January 9, 2013

A medical news article entitled, “Increasing HPV Vaccination Coverage Needed To Decrease HPV-Associated Cancer Incidence,” caught my eye and took me back to my days at Fairview when I was on the Quality committee. The HPV (human papilloma virus) vaccine (Gardasil) had just been release. The chairman of the committee, Mike Dummer, MD, told everyone that we needed to get as many adolescent girls vaccinated as possible. In order to do that, he said, we should present the vaccine to the mothers of these youngsters as a vaccine to prevent cancer of the cervix. We were not to use the word “STD” or sexually transmitted disease when speaking of the vaccine. He feared mothers of adolescent girls would refuse to have their daughters vaccinated if we called it an STD vaccine.

I challenged him and told him I thought that approach was wrong and could violate Fairview’s diversity and tolerance policies by not being culturally sensitive to devoutly religious folks, Christians in particular. I knew some Christian women who did not want their daughters vaccinated against an STD. He shot back that I was wrong, that it was important to tell them it was a cancer vaccine. After all, we didn’t tell patients with cervix cancer or an abnormal pap smear that it was caused by an STD. I challenged him again and told him I always told my patients with an abnormal pap or cancer of the cervix that the disease was from an STD, more likely in those with early onset sexual activity and multiple life time partners. He was truly surprised, that I would honestly share that information with my patients. The conversation ended with him sticking to his guns, that we should not tell moms of young girls that the vaccine was intended to prevent an STD which caused 70% of cervix cancers.

There were probably 15 docs at that meeting. None supported me. I resigned from the committee after that. I could see I didn’t belong there.

I’ve spoken with doctors and patients who fall on both sides of the issue, but most advance the notion that young girls (and now young boys) should receive the vaccine.

Protecting children from physical harm is a parental duty and cervix cancer causes real physical harm. So, aren’t we obligated to protect our young girls from this STD and get them the vaccine? No, I don’t think so. We can give them the vaccine, of course, as many do. But we are not obligated to do so as I argue below.

A child does not catch an STD by a sneeze or a cough so I can’t place this vaccine in the same category as the vaccine for whooping-cough or measles. If I had a preadolescent or adolescent daughter at home today, I would speak to her around the time of her menarche of the availability of the vaccine, its purpose, its effectiveness and encourage her to remain chaste until marriage. Should she decide to become sexually active prior to that, she would be making an adult decision and it would be her job to make another adult decision and go to her own doctor for the vaccine if she wished to receive it or talk to me about her desire to receive the vaccine. And once she were 18, she could make up her own mind without my input.

Cervix cancer is an adult disease. Currently, the CDC doesn’t even recommend a pap test for any woman until age 21. Receiving the vaccine before exposure to the HPV virus 9,11,16 or 18 will theoretically stop 70% of cervix cancers since 70% are caused by 16 and 18. (9 and 11 cause warts.)  Fortunately, even without the vaccine, cancer of the cervix is uncommon and is treatable in its pre-cancer state. 50% of cases of cervix cancer occur in women who have never (that’s right, never) had a pap test.

And, I would contend that sexual intercourse is an adult act.

I have difficulty generating excitement about protecting my adult children from an adult act for which they are responsible.

The other side of the argument cites the irresponsibility and rebelliousness of adolescent boys and girls who may have sex. Is that really an adult act? Shouldn’t you protect her then? What if your daughter gets raped at age 14? Wouldn’t you want her protected in that event? And what about those cultures in our society in which sex at age 15 or 16 is accepted as the norm, multiple partners are the norm and marriage is rare? I’m thinking of inner city minority populations where 80% of babies are born to unmarried women. Shouldn’t they receive the vaccine at age 10 or 11? Shouldn’t you push hard to get them vaccinated, even if it involved lying to them as in, “This is a cancer vaccine, not STD vaccine?”

My own approach on this issue is to inform patients of the vaccines availability but encourage no sex until marriage and one partner for life. That’s a medical recommendation. (What? A medical recommendation?) By remaining chaste until marriage and having one partner for life, an entire plethora of disease can be avoided, including HPV, HIV, Chlamydia, gonorrhea, genital herpes, pelvic inflammatory disease, infertility, hysterectomy and on and on. That’s what I mean by encouraging no sex until marriage, then one partner for life being a medical recommendation.

Think of this. No doctor hesitates to scold a patient for smoking cigarettes and tell them to quit smoking because of the increased risk of lung cancer, heart disease and emphysema. No doctor hesitates to scold the overweight patient and tell them to start exercising and losing weight because of the increased risk of high blood pressure, diabetes and heart disease. No doctor hesitates to tell a patient to wear their seat belt, lower their cholesterol, treat their high blood pressure, get their eyes checked, and on and on and on.

Why the taboo against recommending abstinence until marriage and one partner for life to avoid the diseases which result from promiscuous sexual activity? Mainstream medicine conveys the message that adolescents will have sex like rabbits anyway, so limit disease and pregnancy. Get the vaccine, wear a condom, use birth control, have an abortion if the birth control doesn’t work, don’t ruin you life with a (gasp!) baby.

Only, that message hasn’t worked, doesn’t work and won’t ever work. Just look around. God knew what He was doing when He defined marriage as the union of one man and one woman and that sex outside of the marriage bond was sin. He defined this morality which, no surprise to me, is medically spot on.

Posted in Doctoring, Medical Issues | 5 Comments »

The Contraceptive Mandate

Posted by MDViews on January 8, 2013

Birth control. Who can be opposed to birth control?

Isn’t birth control just having the babies you want and no more? Isn’t that just common sense? Who can afford more than two kids anyway? Who wants more than two kids any way? Do you have any idea how expensive day care is? And who wants to clean some rug-rats bodily fluids off the leather seats in the back of your Beemer? Do you have any idea how the other passengers look at you if you take your kid on an airplane to go to the Bahama’s for a vacation? Besides, maybe you’re a teenager and a pregnancy would ruin you life. Shouldn’t you be on birth control? Come to think of it, maybe you should be required to take birth control. I mean, isn’t over-population a big problem? Shouldn’t we all have fewer kids, like China? And how are you going to climb the corporate/educational/governmental ladder if you have to worry about day care/dance lessons/soccer/after-school care? Kids! What a noose around your neck! Plus, what if you end up with some disabled kid who cost even more? Do you know what day care is for a kid with autism? (Well, I think they have homes you could put someone like that in, don’t they? I mean, you shouldn’t have to care for a kid like that, should you?)

Let the Duggers have 19 kids. Let those weird Catholics who actually believe Pope John Paul’s Humana Vitae use natural family planning and have 8 kids. (Is it legal to have that many kids? Maybe we should do something about that, too. )

And anything that’s as important as birth control should be covered by insurance, shouldn’t it? I mean, $4 a month at WalMart seems like a lot to me.

And so it goes. The arguments for birth control in general and the contraceptive mandate in particular.

But let’s separate some facts from the fog and see what this contraceptive mandate is really about.

First, define birth control, because you cannot separate birth control from abortion.  Most of you probably don’t know that the government, drug companies, IUD’s companies, birth control pill companies, progesterone-only birth control companies and the “morning-after” pill companies define abortion as pregnancy loss after implantation. That means an egg is fertilized, becomes an embryo, travels down the fallopian tube over 4 or 5 days, but then, instead of implanting in the wall of the uterus, passes through unnoticed because the “contraceptive” made the uterine wall hostile to implantation. One package insert said it prevents the “egg” from implanting in the uterine lining! To those entities above, that is birth control, not abortion. All of the package inserts for the birth control pill, IUD’s, progesterone-only birth control pills and shots and the “morning-after” pill companies list a hostile uterine environment as one of the mechanisms of action. (For birth control pills, the primary method of action is stopping ovulation, but it doesn’t stop ovulation all the time.)

For those of us who are pro-life, that mechanism of action means 1) possible, occasional abortion for the birth control pill, 2) likely abortion for IUD’s and progesterone-only pills and shots and 3) almost certain abortion for the “morning-after” pill.

I’m an OB/GYN doctor and have wrestled with these issues in my conscience for many years. I quit placing IUD’s shortly after I started in private practice, but did place them during my residency. I quit prescribing progesterone-only pills and shots many years ago and I quit prescribing the birth control pill two years ago. I feel good about all of those decisions.

So defining “birth control” helps us, I think, realize why the “contraceptive” mandate is a deep moral affront to pro-life people on its face. “Contraceptives” should be called “contra-gestational” agents, meaning they prevent a pregnancy from “gestating” or growing in the uterus, but don’t prevent “conception.” At least not all the time. In that regard, they are all potential abortifacients, some more than others.

Second, our devout Catholic friends, both patients and doctors, are required by the teachings of the Catholic church to only use periodic abstinence (natural family planning) to prevent pregnancy. I’m much more aware and informed of that teaching now that I work in a clinic with all Catholic physicians who hold to the teachings of the Catholic church. That means they advocate for natural family planning, (specifically NaPro Technology) and never prescribe any artificial birth control agents. It’s easy to see why the mandate would be unacceptable to them. Also, that means requiring a Catholic organization or a Catholic employer to pay for condoms, spermicides, tubal ligations and vasectomies in addition to those other forms of  “birth control” is a moral outrage and mocks our first amendment right of freedom to practice our religion as we choose.

One can argue that our taxes already pay for abortion in the United States, and that is true in some states (Minnesota, for one, where I live) through the Title 19 program.

But our tax dollars already fund program after program I find morally objectionable. I have no choice about paying taxes. When Jesus said to give to Caesar what is Caesar’s and to God what I God’s, the Roman empire was not exactly a morally upstanding place.

However, requiring payment for “contraceptives” by purchased private health insurance when health insurance is a voluntary fringe benefit offered to employees from an organization or employer bears no similarities to a tax. It’s the government interfering in a private fiduciary relationship between an employer and an employee.

It is clearly the heavy hand of government violating the first amendment right of freedom of religion for those organizations and employers who find “contraceptive benefits” morally objectionable.

As my little vignette above describes, the real reason secular people (and many evangelical Christian and Catholic couples) use birth control is, well, because they don’t understand the gift of life. Children are a de facto burden, not a blessing; a curse to be avoided, not a life to be cherished; a pet to be shown off when convenient then shuffled off to daycare, not an integral part of the family to be fully accepted, loved, valued and included; a carbon footprint to be viewed with a jaundiced eye, not a treasure created in the very image of God.

Pro-life Christians and Catholics are in cross-hairs of the liberal establishment because we embrace a morality from outside of who we are, a morality codified first in the tablets from Mt. Sinai and expanded by Jesus and the apostles in the New Testament. Liberals fly by the seat of their pants inventing their morality as they go along, mostly by what ever would increase their personal happiness at that moment in time, whether morally right or wrong (situational “ethics”, or a better description, situational lack-of-ethics). We now live in a liberal echo chamber in which the establishment has never met a death (embryo, fetus, handicapped baby, or elderly ill person) it didn’t like–except for those convicted of capital crimes in which death is a deserved punishment–those deaths they fight against always.

It makes sense, dear Christian friend. God is not surprised, fooled or unaware. Their behavior is nothing new. Read what the Psalmist says in Psalm 106:36-39 and see if it doesn’t describe the current state of our culture to you.

They served their idols,
which became a snare to them.
They sacrificed their sons
and their daughters to the demons;
they poured out innocent blood,
the blood of their sons and daughters,
whom they sacrificed to the idols of Canaan,
and the land was polluted with blood.
Thus they became unclean by their acts,
and played the whore in their deeds.
(Psalm 106:36-39 ESV)

And, we know that we will suffer for Christ’s sake if we take a moral stand. It’s a guarantee from God. Paul’s phrase from I Thessalonians 3:4 makes it clear he knew he was to suffer affliction and then did suffer affliction.

    For when we were with you, we kept telling you beforehand that we were to suffer affliction, just as it has come to pass, and just as you know.
(1 Thessalonians 3:4 ESV)

So the contraceptive mandate is not a surprise to God and should not be a surprise to us. In our culture, what’s right is what’s wrong and what’s wrong is what’s right. Since liberals control the reigns of power in government, entertainment, education and large corporate businesses, we are at the mercy of the laws they pass, the courses they teach, the movies and TV programs they make and the rules they make for employment as they employ many of us. But we don’t have to watch their movies and TV programs which always portray us a incompetent, stupid, bigoted troglodytes. We don’t have to buy the products of those companies actively supporting the goals of more birth control and abortion. We can home-school and choose to attend conservative colleges and universities. And when the laws become too onerous to follow, we can use civil disobedience (and go to jail? Yes, and go to jail). In the mean time, we must fight, protest, vote our hearts and throw every roadblock we can in front of them whenever we can.

Posted in Abortion, Family, Medical Issues, Politics, Pregnancy | 4 Comments »

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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