Thursday, May 8, 2014

On Obstetric Care and the Traditional Medical Model vs Midwifery and Alternative Medicine

 *Note: I don't even consider midwifery care under certified nurse-midwives with master's degrees and licenses actually very "alternative" as far as alternative medicine goes, but that's how the establishment of medicine as a whole (and insurance companies, particularly) see it, so that's how it must function.

     Fair warning: this post is going to be a longer one.  This week, I went in for our first OB/GYN appointment, at 18 weeks pregnant, because I want to do an ultrasound and get it covered by insurance.  I could get a referral to a radiology group from my midwives group, and pay out of pocket, but I thought I'd try to save us $150.  So here I am, a regular person with decent (not spectacular) insurance, seeing an OB while pregnant, paying a reasonable co-pay... what an experience.  I knew as soon as we walked out of the office that I had to write about this experience, because it was so drastically different from my experiences so far at my midwife. 
[Full disclosure: my doctor's office will remain anonymous because I didn't see the actual OB.  I will, however, tell you that I have been seeing and plan to have a home birth with South Coast Midwifery, which came highly recommended.]

     First of all, the reason I was connected to this OB/GYN’s office is that I called my insurance to get a list of doctors, and was told that I had already received authorization to see this doctor, whose name was long but started with a W.  I figured I’d be happy to save the time and effort getting authorization for another doctor, and just called that office to make an appointment with Dr. W.  When I spoke to the office staff, I made the appointment, and asked if we would do an ultrasound as part of the office visit, and I was told we would.  I was thrilled to have an appointment for Monday in which Andrew and I might be able to see the baby and even find out the gender, even though I had been ready to wait another two weeks to get an appointment to do so.

     When we arrived at the office, I didn’t see Dr. W’s name on the list of doctors there, but it said Women’s Clinic so I figured we were probably in the right place. I went to sign in, and asked if this was Dr. W’s office, just to make sure.  The office staff told me that Dr. W had retired over a year ago.  I found out after about ten minutes that my insurance had authorized me to see any clinician in that group and that I had an appointment there, but obviously not with Dr. W.  I told them I was fine to see a nurse-practitioner that day, since they gave me the option. I was confused why no one told me on the phone that I wouldn’t actually be seeing Dr. W for my appointment, but I let it go.  They called me back after we’d been there about 15-20 minutes, took my vitals, and started asking me basic history questions.  The medical assistant took us back to an office to ask questions about my medical history (strangely we never filled out the typical medical history form). We spent the majority of our time with her, and even though I had mentioned that I’d been seeing a midwife group for prenatal visits, she rattled off all the information about delivery, “Your doctor is Dr. A---, he delivers at these three hospitals, but you don’t get to choose, your insurance decides it.”  She also recited their office policy on bringing children to the office, and then asked if this was our first pregnancy.  Eventually she led us to an exam room, and said the nurse-practitioner would be in soon, so I should go ahead and get in a paper gown, which was actually a paper vest and large square paper for the lower half of my body.  Fun times. 

     When the nurse-practitioner came in, she muttered her name so quickly that I didn’t catch it, faced the computer for a moment, and then jumped right into the physical exam, followed by a pap smear.  That procedure was assisted by a random staff member who walked in and out without saying a word.  The nurse-practitioner checked the baby with fetal Doppler for about 10 seconds, and was done with me in less than 5 minutes, at the end of which time they told us we weren’t going to do an ultrasound today. 

     Here are my problems with this experience.  I was not only frustrated at times by this appointment, but I was appalled at the complete lack of concern for any human experience in it, or even a simple concern for “patient satisfaction”. 

-          We were there for over an hour and a half, and spent a total of less than five minutes with the actual clinician.  Everything was extremely assembly-line-efficient, at the expense of any human or caring touch.  I met the nurse-practitioner for the first time with my clothes already off (I was glad she was at least female). 

-          No one used my name other than to call me to the desk and then back to get started.

-          No one acknowledged Andrew’s presence except when the medical assistant asked me if I was married and then if he was my emergency contact.  The nurse-practitioner made a comment about/to Andrew because he had sat behind me to keep me warm while we waited for her to come in, and then proceeded to passive-aggressively and non-verbally push him out of her space. 

-          I felt lied to, because I had specifically asked and been told that ultrasound was a part of the appointment, only to find out at the end that they weren’t going to do one. 

-          There was NO education whatsoever.  The only questions they asked about the pregnancy mentioned morning sickness and bleeding, but there was no discussion of what’s normal and what isn’t with regards to symptoms like ligament pain, or when to expect to feel movement.  There was no discussion at all about nutrition during pregnancy, except to ask if I was taking a prenatal vitamin (which isn’t all you need, in case that’s not obvious).

-          There was absolutely no recognition of the emotional side to pregnancy, except a half-hearted “congratulations” from the medical assistant.  There was no acknowledgement of an emotional response to hearing the baby’s heartbeat, for what could have been the first time for all they knew.

-          Some office staff had literally no idea what I meant when I told them I am seeing a midwife group for my prenatal care and didn’t need to see the doctor again.

     See, my midwife group doesn’t have to do much to be leaps and bounds above my experience at the OB/GYN.  They don’t need to be nicely decorated, or have very comfortable rooms, or make sure that you meet all the midwives at your various prenatal appointments so that you know whoever it is that ends up delivering your baby.  They just need to be human, and treat you like a person.  All the rest of those things are just icing on the cake, because by simply acknowledging that pregnancy is an emotional and personally meaningful experience, by using your name and customizing care to you as a person, they have already succeeded where we in the traditional medical model are apparently failing. Andrew and I said to each other several times while in the appointment, and more so afterwards, “This is why we’re going to a midwife!”, but I can’t help but think about all the people who don’t have that option.

     Firstly, there are all the millions of women who don’t even know that they have choices about where and how they deliver their babies, or who don’t know they should be utterly unsatisfied with mediocre care and no prenatal education, with no personal caring.  Additionally, there are plenty of families for whom choosing something other than what is covered by insurance is simply not an option financially.  Of course, I know that not all OB/GYN offices provide the kind of experience I had; perhaps it was because the Women’s Clinic group I saw primarily serves cheaper insurances and low-income women.  Does that make it any more acceptable?  Of course not!  In fact, it’s more maddening to me, because of all the women who need good prenatal care, with education about what to expect, and what kind of nutrition they need, it’s low-income women!  The fact that certain populations (i.e. upper middle class and upper class) can afford to educate themselves with birthing classes and receive better prenatal care by going to their first choice of OB/GYN or choosing to see a midwife does not solve the problems of the traditional medical model of obstetric care.  Sadly, all it does is widen the gap of health care from one end of the spectrum of income to the other.

     How do we fix this?  How do we move away from the assembly-line model of care for pregnancy and birth, in OB/GYN offices and hospitals? How do we improve our absolutely terrible rates of maternal death and complication, preterm birth, and our sky-high rates of C-sections? How do we reduce the costs of healthcare as a whole and of pregnancy-related hospitalizations specifically?  Obviously, there are no easy, one-quick-fix answers to any of these issues.  That certainly doesn’t mean that there are no answers.  I think we start by encouraging women from every walk of life to educate themselves, through free classes offered by hospitals, information available at public libraries, and reputable websites.  Insurance companies would do well to cover midwifery care under licensed midwives for low-risk pregnancies, which are in fact most pregnancies.  The majority of births should be pushed out of the typical hospital setting and back into the home, or the birthing center, and birthing centers attached to hospitals.  Women and their partners in the birth process should be thoroughly educated about the real risks and complications of epidurals, C-sections, and every other intervention that is used in delivery, and never manipulated by any clinician.  Doctors should be trained with at least 75% normal deliveries, and see at least a handful of births with no medical interventions at all, including those in non-traditional positions.  All health care staff who work with laboring women need to evaluate their expectations for the length of time labor and deliver should last, and make sure that they’re realistic, and not merely ‘by the book’.  These changes would make for a good start in the right direction.

     Although I have personally chosen to have my prenatal care and delivery with a midwife, I strongly identify with the traditional medical care system, and I know we can do better.  We have a duty to our patients to do better with our care, because we should care and remember they are people first.  We have an obligation as a country to do better with the cost of health care, because our debts and spending are out of control.  We have a responsibility as an example to the world to do better, because we are a first-world country with third-world rates and stats. 

Want to educate yourself? Here's a great place to start:

Wednesday, May 7, 2014

On Healthcare & Technology

     This post may be on the intersection of healthcare and technology, but in a way it's just a portion of the way technology is used - social media. Otherwise, I could make this part one of many, and I'm not sure I want to do that just yet. This came up recently at work; a family member was trying to film some nurses doing their jobs while the family was in disagreement with or simply unsatisfied with the health care team about their loved one's care.

     Today I want to share some of my thoughts on why it can become an issue that technology is everywhere, and that so many people are trigger-happy with that "Share" button for social media.  These days, most healthcare facilities have several policies on the use of technology and social media, if not a person whose job that is, or even entire departments devoted to it.  Sometimes they cover the public relations for the facility, and most of the policies relate to how staff members are expected to appropriately use technology/social media, but some are focused on how members of the public can use technology and social media while in that facility.  For example, I have heard of a hospital where the staff is instructed to not allow family members to film the birth of their child, because it's against the policy.  I think that's an extreme end of the spectrum, but let me explain some of what our thinking is (members of the health care team, that is).

     First, and the biggest concern for hospitals, is that the use of technology and social media in patient care areas is a major threat to patient privacy, which is protected by federal laws, and enforced with hefty fines against the facility. It doesn't matter if the hospital has no idea that the relatives of the patient next door to you take a picture that has your name and room number in the background, or you for that matter, and post it online, it's considered the hospital's breach of HIPAA laws and the facility pays the price.  The fact that technology is everywhere means that we have hardly any control over this happening, so if we do see it, we don't allow it.  

     Now what if you want to take a video of me while I'm doing my job, whatever the motivation?  I personally wouldn't let you film me doing my job, for several reasons, whether or not my facility has a policy against doing so.  Primarily my concern in that situation is quality of care.  I don't need to deal with the distraction when I'm in the middle of a code blue, or any situation that may arise in ICU (or elsewhere).  This use of technology is very distracting, and cannot simply be ignored, because of a few problems.  One, if you are not 100% satisfied with my care, or your doctor's care, etc,  you can put me and my facility in the court of public opinion by posting a video online, rather than through normal channels of making a formal complaint, that goes to people that hear both sides, and know all the facts and variables.  This is especially true because anyone can edit a video to show only what they want to show!  I could easily lose my job and risk losing my license because of someone's vendetta -- like I said, public relations, which sometimes necessitates that the facility take action so they look like they're doing something about a situation, even if the person getting fired is really a scapegoat.  The second problem is a more personal one: I have no control over my personal privacy if you take a video of me and post it online.  I personally am fairly cautious about what I post online, and am extremely guarded about what I own up to by attaching my own name (searchable by future employers, to say the least). If you take a video of me, and list my name (even if it's a generally positive video!) I still have no control over it.

     Thankfully, this issue doesn't come up terribly often for me, but in some areas of medicine/nursing it comes up frequently. One of those areas is, of course, labor and delivery, where people want to film their births. I think this should generally be an exception to the facility's rules about video/photos, because it's a very special moment in a family, and not merely a medical issue.  I can, however, completely understand why a facility would want to cover themselves by outlawing even that.  If something goes wrong during the birth, you have proof that you can manipulate through editing to say whatever you want when you go to sue the doctor and/or facility.  The reality is, you as the patient chose to give birth at that hospital, and by doing so must abide by their policies.  You have options (usually).

     Like I said, I think there should be exceptions to these policies. I am fine with photos and video as long as they are in the patient's room (and it's a private room) so that no other patient's privacy is infringed upon, and as long as they are patient-focused.  I would allow and even encourage recording video messages or taking photos/videos of a person who was dying, for example.  The main difficulty is that hospitals have an easier time enforcing an across-the-board, this-is-never-allowed sort of policy than any policy that involves exceptions for certain circumstances. Just look at visiting hours policies to see proof of that!