Ration This

Here’s the latest study in the long parade of studies about unnecessary procedures in US hospitals:

The relationship between rates of induction and cesarean delivery and rates of the three neonatal outcomes show intervention rates had no consistent effect on newborns.

Even after a second round of analysis that accounted for differences among pregnant women that could potentially impact the results, the finding was the same, hospitals with high intervention rates had newborn outcomes indistinguishable from hospitals with low rates.

It’s not “rationing” to cut down on expensive procedures that don’t make a difference in outcomes. And the free-market fairy won’t fix this solution, because a pregnant woman living in an area with high intervention hospitals can’t travel hundreds of miles to find a low-intervention hospital. So what’s left besides dreaded government intervention?






105 replies
  1. 1
    4tehlulz says:

    She gives birth in the nearest ditch, obvs.

  2. 2

    Among the medical reports I transcribe are deliveries of babies. Overall, I tend to agree with you. It seems like some doctors are quick to intervene, with C-sections and whatever.

    Then I come across a particular situation that could have resulted in death[s] a century ago and I’m not sure.

    Even with induction of labor, sometimes I wonder if it was done for convenience. And then other times I note that Mom was going into pre-eclempsia and I’m grateful to be typing the part that says “Mother and baby are doing well.”

    So in the end, I guess I’m ambivalent about interventions with deliveries. I don’t know.

  3. 3

    Actually, I’d like to see a discussion of this among pregnant women, perhaps including new moms.

  4. 4
    Uloborus says:

    A couple of things I want to interject early, in case the thread gets weird about medicine:

    There are indeed a long line of these studies. Doctors encourage these studies because there’s always more to learn about medicine. What seems like the logical course of action may not work, and these studies are the only way for doctors to find out. They are normally distributed to major medical associations who put them into ‘recommended practice’.

    Hospitals are the most erratic servers in health care – one reason an insurance system that drives people to ER visits is bad!

    Insurance companies heavily influence what health care is provided to a patient. And by ‘heavily influence’ I mean ‘demand and strongarm the doctor into doing things they don’t want because it’s the only way the patient can get treated at all’.

    All of these things will benefit from the government being able to set guidelines on appropriate care. More power to them.

  5. 5
    kerFuFFler says:

    Exactly! There are also other studies that show that some regions of the country tend to “over-treat” more than others—-that is they spend much more per patient for the same outcomes (controlling for age and health issue). Doctors and economists alike agree that this indicates wasteful allocation of health $$. Hospitals and doctors need incentives to provide the proper amount of care—–too many situations exist that encourage them to order too many tests, perform too many procedures or prescribe the most expensive meds.

  6. 6
    Villago Delenda Est says:

    @Linda Featheringill:

    Sorry, but when do the fleecees get to have input about being fleeced? After all, according to the forced birth lobby, they’re just incubators, anyways.

  7. 7
    kerFuFFler says:

    Malpractice suits have tended over time to increase the number of deliveries with both induction and C-sections.

    Changing the malpractice system (though CERTAINLY NOT the panacea many Republicans say it is—-and not changing it in the manner they propose) could help reduce the incentive for doctors to intervene at the drop of a hat. Currently, malpractice insurance for obstetrics is astonishingly high largely because tender hearted juries tend to award massive payouts since tragic outcomes in the delivery room are so, well, tragic. The desire to avoid malpractice suits at all costs encourages many OB’s to intervene in cases where it may not be necessary.

  8. 8
    nancydarling says:

    @Linda Featheringill: Linda, I wonder if the use of oxytocin AKA pitocin increases the need for C-section. I had my daughter normally. Twelve years later when I had my son I had to have a C-section. I was having a nice easy labor but things were going slowly. It was 7:00 on a Friday evening, 9 hours into labor. When they gave me pitocin, things got rugged real fast—waves of hard contractions with no recovery time for me or my son. His heart beat had no time to recover between contractions as there was no recovery time. They worried that the slow heart beat would lead to brain damage and whisked me to the OR. All went well and he and I were both fine, but I’ve always thought if given time, I could have delivered normally. Have you noticed and connection between the use of pitocin and c-sections in you transcription work?

  9. 9
    El Cid says:

    The Atlanta Journal Constitution has an interesting series on the growing markups by hospitals on treatments. Which of course particularly hit the uninsured harder.

    Markups for hospitals in metro Atlanta ranged from 157 to 702 percent in 2009, according to an analysis by The Atlanta Journal-Constitution of the most recent hospital financial disclosure data collected by the Georgia Department of Community Health.
    __
    These hospital bills fall heavily on uninsured patients. Many small business owners like Sheward do not have insurance because the individual plans available to them are much more expensive than group plans sponsored by larger employers.
    __
    But the hospital’s markups can force even patients with employer-sponsored insurance into debt when they have high deductibles or out-of-network bills.
    __
    And hospital markups — the difference between the cost of a procedure and a hospital’s full price — play a critical role in driving up medical bills across the country, say health policy experts.

    This clarifies that the problem is how ordinary people attempt to interfere with the Free Market in allowing medical professionals to be properly rewarded for their work.

    This is only more reason we should force the elderly to shop around for their medical treatment.

    Sure, it may be the case that they couldn’t get information about hospital markups if they wanted to, and that the increases are shared throughout the market.

    But the old certainly would have enough inspiration to make maximum use of their $15,000 Medicare voucher (which of course soon would be eliminated anyway) when seeking pricey care like heart disease treatments.

    Hospital pricing is less transparent than in most industries, allowing prices to rise faster than the costs of services, said Gerard Anderson, director of the Center for Hospital Finance and Management at the Johns Hopkins School of Medicine.
    __
    That’s largely because people don’t shop for medical care and hospitals don’t provide cost estimates, Anderson said.
    __
    “There is nobody saying to [the hospitals] on behalf of the uninsured and a few other groups that they can’t do it,” Anderson said.
    __
    “You just had a heart attack or your appendix burst, so you can’t negotiate a price and you wouldn’t know how much it cost even if you could,” he said.

    A Free Market assumes perfect and equal access to information on pricing and investment data, but the world isn’t perfect, and so The Math Demands letting the profitable lead the way.

  10. 10
    scav says:

    @Linda Featheringill: This isn’t about being for or against inductions and interventions. There are clearly instances where they are helpful. The issue is are they over-prescribed (wrong word, right idea). That’s certainly a story that’s been bubbling round in some form or another for a while: usually under the form of “Those self-indulgent women who are scheduling induction and cesarean so it doesn’t interfere with their careers and schedules”. I suppose the “Doctors/Hospitals overdoing it to get money out of insurance companies and optimize the throughput of their birthing rooms” version is floating about too. So this is seems to be just a study that, while not making any specific claims about why the procedures are occurring is try into figure out at a macro level do the higher levels of intervention lead to overall better medical results? and the answer seems to be no.

  11. 11
    BigHank53 says:

    Well, sailboats and ski condos don’t pay for themselves, you know….

    Snark aside, let’s look at our cultural expectations of doctors: we want them to fix things. We want them to do something. We pay them a lot of money for that, and not to wander in, look at you, and say, “I’ll be back to check on you in a couple hours.” We’re paying for attention and to be fixed, dammit, and we’re Americans, and we want to be fixed now.

    So…I can see why some docs like c-sections.

  12. 12
    Moonbatman says:

    Those cesareans are necessary. John Edwards said so

    THE NORTH CAROLINA SENATOR; In Trial Work, Edwards Left A Trademark

    “In 1985, a 31-year-old North Carolina lawyer named John Edwards stood before a jury and channeled the words of an unborn baby girl. Referring to an hour-by-hour record of a fetal heartbeat monitor, Mr. Edwards told the jury: “She said at 3, `I’m fine.’ She said at 4, `I’m having a little trouble, but I’m doing O.K.’ Five, she said, `I’m having problems.’ At 5:30, she said, `I need out.’ ” But the obstetrician, he argued in an artful blend of science and passion, failed to heed the call. By waiting 90 more minutes to perform a breech delivery, rather than immediately performing a Caesarean section, Mr. Edwards said, the doctor permanently damaged the girl’s brain…”

    .

    Don’t allow the wingnuts to use this for tort reform butthutt.

    Peace Out. The Power is Yours. Free Crystal Mangum.

  13. 13
    Chrisd says:

    Doctors encourage these studies because there’s always more to learn about medicine.

    I’m glad you posted this, because it’s true. A lot of this idiosyncratic over-utilization is driven by local group-think which can be reassurring even if it is actually harmful and wasteful. I’m a doc, and most doctors in my experience do this out of fear or even laziness rather than greed.

  14. 14
    Omnes Omnibus says:

    @kerFuFFler: If you want to fix malpractice suits, you need universal coverage healthcare and a social safety net. The reason people sue is because medical mistakes often result in additional large medical bills and other costs. If you go to a doctor and he makes a mistake that results in $100,000 in medical bill, you are going to sue. If, however, the mistake results in some additional inconvenience only, you are less likely to sue and, if you do sue and win, your judgment amount will be smaller. This will lower malpractice insurance costs. The smaller judgments available will cause more lawyers to tell their clients that a suit is not worth it. Fewer suits being filed will also lower malpractice rates. The neat thing here is that, in those horrible cases where a drunk doctor amputates the wrong limb, the patient’s right to a remedy is not abrogated.

  15. 15
    Danny says:

    Great post, I wish more people would point out that it’s not rationing for the government to say “We’re not going to spend any money on this thing because we think it’s wasteful”. If Medicare stops paying for expensive, useless procedures there’s nothing stopping seniors from spending their own money on these procedures. It would only be rationing if the government actually made it illegal to get certain procedures.

    @Chrisd (13): I think this is another excellent point to make. The ACA included a bunch of money for medical studies so that we’d finally know exactly which procedures are useful. Part of the problem is I think most people assume that doctors are basing their decisions on established science rather than fear or group think. Unfortunately, that’s just not true and one of the only ways that’s going to change is if the government funds research. Of course, according to Mike Huckabee that will lead to death panels…

  16. 16
    PurpleGirl says:

    @El Cid: I liked your comment (#57) over at Krugman’s blog post “patients are not consumers.” Problem with the NYT is that it takes too long to post and makes it hard to tell someone you liked what they wrote. (It had just enough of your trademark snark.)

  17. 17
    mark says:

    We’ve had tort reform in california for 30 years. It hasn’t accomplished anything, aside from limiting compensation to less than actual damages.

  18. 18
    Yevgraf (fka Michael) says:

    @Omnes Omnibus:

    Kerfluffer was just fluffing the line for the most entitled, spoiled bund of stupid punk ass whiny ass titty babies the world has ever seen – the collective of American doctors.

    Yes, some are nice and competent, particularly if they limit their focus to actually delivering their product. Unfortunately, for every one of those, there are five more who’ve been told so long about how brilliant they are, they believe it and start doing other things. Their land and business speculations are for shit, their politics are wingnutty, and for a group that subsists so much on the public weal, they’re clueless about the necessity of a safety net. It is in this environment where total tards like Ron and Rand Paul thrive.

    In short, the medical share of the economy went from 1/7 when Hillary was trying to address it in the 90s, blasted through 1/6 and is now headed for 1/5, all so Dr Gotrocks II (son of Dr Gotrocks I) can buy new Hummers for each of his children every year from their 16th birthday on. That economic “success” is built on the backs of millions of people who are struggling or bankrupt.

    I find myself gleefully awaiting the popping of the medical price bubble (maybe we can securitize medical collectibles – that seems to be a product the Market is screaming for). Hopefully, I’ll get to live long enough after the wingnut originated collapse to watch one of these fine doctors pressed into service for a libertarian rape gang, treating sucking chest wounds for the warriors in a filthy, bombed out building for no pay, no vacation properties and no botox for his wife.

    At that moment I’ll say “boy, this is sure freer, isn’t it?”

  19. 19
    ccham44 says:

    Having just spent months educating myself on this particular issue (my son arrived just last week!), I concluded that this particular issue is more about education than anything else. The sense that I got is, a lot of medical professionals just don’t know what a normal birth without interventions looks like.

    Doctors are trained to look for problems and to fix them, and are well versed in how to handle any complication that may arise. Meanwhile, our midwife noted that most of the residents in the hospital are never exposed to an intervention-free birth.

    If a woman arrives early to the hospital you get a situation where a laboring woman is sitting around for hours and, even though nothing is wrong, the doctor and/or nurses can be struck with an overwhelming sense of needing to “do something” or “move things along”, for no other reason than that’s S.O.P. Compound this with a woman who is hunched over an moaning/yelling/etc. and the staff wants to do something (anything!) to help her cope, and encourages her to get an epidural, never realizing that she was coping well the whole time.

    As a disclaimer, there are obviously many, many occasions where cesarean birth has saved the lives of mother and baby. But it’s just as clear to me that there are many, many instances where women end up with major abdominal surgery that was never necessary. That’s not good for their own helth, and it’s definitely an unnecessary expense that we all end up paying for.

  20. 20
    Yevgraf (fka Michael) says:

    @mark:

    We’ve had tort reform in california for 30 years. It hasn’t accomplished anything, aside from limiting compensation to less than actual damages.

    I look at damage caps as the special tax on the injured, a wealth transfer from them directly into the pockets of the perpetrators, who are already in the top 2% of the economic heap.

    If anything, I’d reform by having a workers comp type setup for the lowest level mistakes, leaving the bad stuff for the tort system with “loser pays” for both sides after a secondary hearing on negotiations and excluded evidence.

  21. 21
    kay says:

    @kerFuFFler:

    Malpractice suits have tended over time to increase the number of deliveries with both induction and C-sections.

    This has never made sense to me.
    The study at the top of the page weighs the increased risk to the mother against any benefit to the baby on excessive intervention.
    Physicians are practicing “defensive medicine” by increasing risk to one patient (the mother) in order to decrease risk to the other (the baby)?
    So, people never sue when women are damaged or harmed in the course of delivery?
    This whole “maternity defensive medicine” theory completely ignores one crucial party in this threesome of mother, baby, physician.
    Everyone knows intervention increases risk to the mother. You’re told that 5000 times over the course of the pregnancy. But physicians don’t worry about malpractice there? JUST with the baby? How does that make sense?

  22. 22
    nancydarling says:

    @Yevgraf (fka Michael): This does not apply to any of the doctors I have had over the years.

    most entitled, spoiled bund of stupid punk ass whiny ass titty babies the world has ever seen – the collective of American doctors.

    Are doctors to become the ‘new teachers’? When did we stop calling them doctors and labeling them health care providers instead?

  23. 23
    CA Doc says:

    Ditto what Chrisd said. The c-section, early induction (which leads to more c-sections)problem completely hinges on the local culture. Hospitals 15 miles apart can have radically different c-section rates. Impatience, on the part of both patient and physician, is the main driver, but also fear of bad outcomes and lawsuits. The consequences of making the wrong decision are so dire, you’ll do anything to avoid it. Your cases get reviewed and you get second guessed when things go wrong, but nobody gets any pushback for doing a c-section if everything comes out fine.
    As I write this, it makes me wonder why I’m still delivering babies!? Because 99% of the time it’s the best part of my practice.

  24. 24
    Uloborus says:

    @nancydarling:
    The doctor sending patients to get expensive tests done on his own equipment is the strapping young buck buying t-bone steaks and cadillacs on welfare of some liberal circles. You’ll hear a lot of ‘doctors are the cause of high medical costs, grr!’ here, when the truth is that it’s fuck-all complicated. Unnecessary procedures and tests are a big part of the problem, and it ain’t the doctor that’s demanding them – it’s the insurance industry. Hospitals ARE a part of the problem, as they’re the only medical providers in a position to profit significantly off of unnecessary anything – plus, they’re not necessarily run by doctors and they’re ALSO being twisted eleven ways by insurance. And how many doctors own ANY testing equipment other than a small blood work lab?

    I put my previous comment in early because a lot of these threads devolve into ‘doctors are stupid and greedy’. A lot of people IN the medical industry aware of the shortage of any physicians except plastic surgeons (where the money actually is, and other doctors don’t really consider them doctors because of it) would be baffled by this.

  25. 25
    Yevgraf (fka Michael) says:

    @nancydarling:

    This does not apply to any of the doctors I have had over the years.

    I get to see them in their natural element – divorcing, blowing up their side businesses and investments, splitting up their medical practices over petty disagreements.

    Basically, think of slightly more erudite versions of Joe the Plumber with similar skills, a longer training period and far more grandiose senses of entitlement and privilege.

  26. 26
    Ija says:

    Shouldn’t we also consider the outcome for the mothers? I’m not saying that the conclusion would be different, maybe it is the case that increased hospital intervention also have no effect on the mother’s outcomes, or even negative outcomes.

    Just pointing out that when a woman goes to the hospital to give birth, she is also a patient, not just her baby. Her outcome should matter too, not just the outcome for the babies. I mean, god forbid anyone should suggest it matters just as much as the baby’s outcome, but it should count for something, right? So before we conclude conclusively that hospital are doing unnecesary procedures just based on the outcomes for the babies, maybe we should consider the outcome for the mothers, too. Even mere vessels can get sick and die after all.

  27. 27
    Felonious Wench says:

    This looks like another womb interference issue to me.

    I recently chose, with my doctor, to be induced at 35 weeks. My son was 7lbs, 14 oz. at birth. I am 5 ft. tall and tiny. It was a low-risk pregnancy, by definition. My son was and is fine.

    My choice. We can call it convenience, sure. Then tell me giving birth to a child as large as my son was getting is an “inconvenience.”

    This is another of those things between women and their doctors. Women have the choice on when to give birth, just like they have the choice on whether to give birth. And I’d like to see a study on the physical and mental health of the mother, with the same parameters, please…as well as their families.

  28. 28
    Jackie says:

    @kay: I would imagine that a lot of women who have complications after their delivery but who have a healthy baby feel they sacrificed to keep their baby safe and wouldn’t dream of suing the doctor that gave them that outcome. As OO said a lot of suits are driven by the financial stress of caring for a disabled child. And an disabled child is an incredibly sympathetic plaintiff and a terrifying idea that parents and the jury alike are a a lot happier believing would never happen if the doctor didn’t make a mistake. What suit would you rather defend, the pitiful disabled baby who will need a lifetime of very expensive care because “the doctor didn’t step in to save it” or the mom who had a complication after her
    doctor “saved”her baby with a c section?

    Who get’s sued and why, and who wins and why are way more random than logic would dictate.

  29. 29
    satby says:

    @ccham44: Good synopsis of the problem. And it’s been under debate for the 35 years since I left nursing school where I attended to train as a midwife.

    When it came to having my own sons, the long, slow labor I was in for the first inspired a small intervention (valium, to stop the labor hoping it would restart more “productively”), then increasing intervention until finally a c-section was performed. I still doubt the necessity for that, and the kid is 28 years old. So for the second birth I made sure to find a doctor who supported my desire to try to deliver normally, hired a monitoring midwife, and stayed home as long as possible so I wouldn’t be hanging around “unproductively” at the hospital. When we checked in with my Dr after about 3 hours of labor (midwife and I), it turned out my regular doc was on vacation, and her substitute went ballistic and told me to go immediately to the hospital for my c-sec, since I had one before. I switched doctors in the middle of labor to my midwife’s attending physician, stayed home with the midwife, and had a normal birth. But not every laboring mother has previous training as a midwife so I don’t advise anyone to do what I did.

  30. 30
    Jackie says:

    @Yevgraf (fka Michael): So you are like a cop who comes to believe that all people are lying scumbags because they spend their days surrounded by the people who are?

  31. 31
    Omnes Omnibus says:

    @Jackie: Or someone who does not see MDs through the rose colored glasses though which many in American society view them.

  32. 32
    cmorenc says:

    My wife is an OB-GYN who’s practiced for 26 years, and my late father was an OB-GYN who practiced for 40 years, and so I’ve been there plenty of times when they came home from a tough night on call from a difficult delivery where they are sweating bullets over staying the course with a vaginal delivery, or else not making the call for a C-section soon enough. In many cases, there’s at least the potential for negative impact on the baby and they won’t truly know for one to several days if it will all come out ok. Both are extremely competent, trained at top med schools and residency programs, but no one ever gets so good or expert that if they try to stick with the preferred vaginal birth route and avoid C-sections unless they are really “necessary”, they don’t intermittently wind up in situations of anguishingly second-guessing themselves about whether they should have gone the safe C-section route.

    IRREFUTABLE FACT: OB-GYNs who are inclined to elect C-Sections at the first sign of issues sleep better and are far less likely to get sued. Oh yes, there is the collateral benefit that C-Sections take less of the doc’s time and pay better, and so yes, there are *some* OB-GYNs who are inclined toward the C-Section route a bit too much for these reasons, rather than merely peace of mind and safety for the baby, mother, and of the doc from malpractice suits.

  33. 33
    scav says:

    @Felonious Wench: But, you must or at least should agree that it medically important to understand when inductions make a difference and the risks posed to both mother and child, irregardless of your ability to choose to to have one or not. I would furthermore hope that you would agree that it might be fair to bill differently (by which I probably mean different actors) for optional and medically required inductions.

  34. 34
    satby says:

    @satby: And the point of my story is that I had 2 years of training that enabled me to assess the risks realistically and make the decision I did, but the Republicans would require everyone to make those kinds of decisions as “health care consumers”. Some c-sections are vital for the mother and child, many are not. Right now the system is set up to slant toward having more than necessary, and that’s not good for anyone.

  35. 35
    Uloborus says:

    @Yevgraf (fka Michael):
    Oh, a lot of doctors are arrogant as Hell, I’ll give you that. I personally blame it on med school and residency. They’re soul-breakingly grueling, and it changes people.

    But I wouldn’t extend that fact any further. Those same doctors tend to be passionately devoted to taking care of their patients. Other than that… well, you’re describing humans in general on the sharp end of the stick.

  36. 36
    Jackie says:

    No question. I’m not making a case for sainthood. There are both incompetent doctors and greedy scumbags in the mix. And way more ego than in a random sample of the population. The profession is famous for bad business judgement. But to say you know what all doctors are like because you spend your days surrounded by people who are suing one another isn’t quite a random sample either.

  37. 37
    lou says:

    Of course, if women choose to skip the C-section and give birth at home, the midwife can be charged with manslaughter.

  38. 38
    nancydarling says:

    @Yevgraf (fka Michael): I worked for 36 years as a dental hygienist—somewhat related by being in the health care field. Some dentists are assholes, some are not. I’m sure it’s the same with MD’s. None of mine ever have been. For sheer numbers of assholes, I suspect the legal profession tops both doctors and dentist.

  39. 39
  40. 40
    Steve says:

    I have two kids, one hospital birth, one home birth. The homebirth was by far the better experience for everyone concerned. The choice is complicated and personal, but it’s important to understand that hospitals take wildly different approaches to childbirth, and some of them foolishly insist on treating every pregnancy like it’s a dire emergency in need of maximal intervention. Visiting hospitals well in advance and getting to understand their philosophy is pretty darn important if that’s the direction you’re going.

  41. 41
    Ija says:

    @scav:

    So this is seems to be just a study that, while not making any specific claims about why the procedures are occurring is try into figure out at a macro level do the higher levels of intervention lead to overall better medical results? and the answer seems to be no.

    Better medical results for who? This is a study that focuses on medical results for the babies only. What about the mothers? Why are people so quick to jump on the “unnecessary procedures” bandwagon based on a study that focuses on the effect on one part of the process only? Are mothers not part of the birthing process as well? Are we to be treated as mere vessels, our “outcomes” and “medical results” insignificant and irrelevant?

    Let’s look at what might happen if we go down this road. Let’s say there is a study that conclusively prove that epidural has no effect* on neonatal outcomes. If the principle in determining whether a procedure or drug is “unnecessary” is solely based on the outcomes of the baby, would epidural be considered “unnecessary drug/procedure”, thus a good candidate for rationing, either by the insurance companies or by the government?

    There are two patients in that delivery room. Mother and child. Please remember that.

    *It’s not even worth discussing what would happen if a study claims that epidural can cause negative neonatal outcomes. I’m sure there will be laws passed by Congress tomorrow to ban the use of epidural in delivery rooms, regardless of the fact that most women would opt out of the drug by their own choice anyway.

  42. 42
    Nicole says:

    I had a baby less than a year ago and I had planned to deliver at my hospital’s birthing center, rather than the regular delivery floor. Then I got preeclampsia and had to be induced before full term. I give the hospital a lot of credit- rather than do a C-section they felt a vaginal delivery was the better option, because it was better for my health. Preeclampsia causes high blood pressure (mine was at seizure levels) and the only treatment is delivering the baby. A vaginal delivery is less stressful on the mother and so blood pressure levels will drop faster after the birth than if the body is also dealing with recovering from surgery. I felt I had exactly the right amount of intervention, but I was also in a genuine health emergency: preeclampsia can kill you. I adored the hospital, but, for all that they have a birthing center for low-risk pregnancies and really pride themselves on their maternity care, their C-section rates are not much different than most of the other hospitals in the area.

    I think the challenge with intervention is that it’s a domino effect- one thing is done, which triggers something else, and it goes downhill from there. And I sympathize with both parents, who face a lifetime of loss or high medical bills if birth doesn’t go well, and with doctors, who are under the constant threat of lawsuits. I think it comes down to a nation that doesn’t consider health care a responsibility.

    But sometimes the staff can just be jerks. A midwife I know had her own labor start too early (34 weeks) and while the hospital was great about the delivery, the two weeks the preemie had to spend in NICU was a different situation. One of the pediatricians on staff told her she HAD to start supplementing with formula; her own milk wasn’t providing enough nutrition. My midwife friend responded, “Well, having worked here before, I know you guys have a machine that can test the caloric content of breast milk.” The lab technicians were very excited to wheel out the (dust-covered) machine they never got to play with. And her milk was actually higher in caloric content than normal. But, like satby above, she is a midwife herself, and had the background to know how to advocate for herself. Me, I had no idea such a machine even existed.

  43. 43
    Ailuridae says:

    @kay:

    Physicians are practicing “defensive medicine” by increasing risk to one patient (the mother) in order to decrease risk to the other (the baby)?

    It is pretty obvious to me that the physicians’ are practicing offensive medicine here. Inducing labor and intervening have so many positive side effects for doctors that the only way you could ignore that they often make this decision in their own self-interest is you start at the supposition that “doctors never act in their own self interest”

  44. 44
    Uloborus says:

    @Ailuridae:
    Like… what positive side effects? Doctors don’t especially make more money off of it. You might think they do, but they don’t. It’s not more fun or easier for most doctors. They’re afraid of a law suit from either side of the equation, not to mention often incoherent state regulations.

    If they have anything to gain, Ailuridae, it’s so little they’re not conscious of it. Many are conscious of what they have to lose.

  45. 45

    @nancydarling:

    Sorry about the delay.

    Have you noticed and connection between the use of pitocin and c-sections in you transcription work?

    Actually, no I haven’t made that connection unless things are being hurried along because of concern about Mom’s health. Then sometimes the baby is in this weird position because it hasn’t turned yet and the docs feel it would be best to take the kid through a C-section.

    Some doctors, however, give medication to make the cervix dilate and then induce. The child is then born vaginally.

    Sort of like opening the barn door wider before you try to push the beast out. :-)

  46. 46
    Elie says:

    @Linda Featheringill:

    I agree with your comments Linda.

    I would add that I don’t know what sort of outcomes and in what time frame these ocurred.

    There is no doubt that there are excesses in some c-sections done for “convenience” of either the Mom or the doc. That said, as Linda cites, there are situations where you are grateful that the option exists.

    Its a very discretionnary decision that relies on the judgement of the doc and the pressures he/she may feel beyond the immediate clinical concerns.

    I do know this: it takes a while for some of the most negative outcomes to show. Cerebral palsy can take months to manifest itself as well as other birth injuries to the joints, brain and nervous system. Those outcomes can happen in both delivery modalities and I think must be included in developing appropriae guidelines for using c-section.

    Mistermix, do you have the details on the methodology used on this study and as importantly, the time frame that was used to follow the babies after delivery? I think its very important.

  47. 47
    scav says:

    @Ija: Did anyone ever imply this was the only study that would define whether intervention would be applicable? What is it with this misunderstanding of how evidence is built up out of components over time?

  48. 48
    Ailuridae says:

    @Uloborus:

    Inducing labor allows you to schedule it first and foremost. That’s a benefit, right? And are you really claiming that doctors don’t get compensated at a higher rate for C-sections? REALLY?

    We have a pretty good solution to the defensive medicine whine that doctors make. We have a health insurance system here in the US where doctors have sovereign immunity. Are C-sections and inducements performed at a higher rate within the VA as compared to outside the VA system. Seems to me that data is likely publicly available.

    There is a percentage of the population in the US who insists on believing that doctors and doctors alone operate against their economic self-interest on a day-today basis. Sorry, but that is fucking absurd.

  49. 49
    Uloborus says:

    @Ailuridae:
    Yes. Actually I am. You seem to be thinking that doctors are normally in a position to gouge patients for profit and thus the temptation to do so is a significant affector of their decisions. The doc who decides to perform any surgery is highly unlikely to be the doc who decides it’s necessary. Ditto labs. The convenience of a C-Section is almost entirely in that the decision is already made and they can stop sweating over it. That’s not exactly an enormous piece of self-interest. Not to mention that thanks to layers and layers of insurance and state regulatory controls, and patients rarely being able to afford preventative care, doctors aren’t often IN a position to make decisions like that.

    Your strapping young buck does not exist.

  50. 50
    KG says:

    @scav: the third story I’ve heard is along the lines of “doctor’s wanting to keep their tee times.” Basically, there’s been a spike in deliveries during “normal business hours” over the last decade or two. If I were an OB and the evidence suggested that there was no ill health effects and I didn’t have to worry (as much) about getting a call at 3 a.m. that a patient’s water had broke and I needed to get to the hospital, I could see myself suggesting inducing labor.

    My only experience with this has been when my sister had her kids and when my best friend’s wife had her kids. With my sister, they were worried about the size of the babies as her due date approached (baby #1 was looking to be about 10 pounds). With my best friend’s wife, baby #1 was a breach and a c-section was required. My sister went back to the hospital for #2 and will again for #3. My best friend’s wife decided to go the mid-wife/home birth route for her second and third.

  51. 51
    mark says:

    I have a good friend who just completed her residency in pediatrics, and I’ve met a lot of her colleagues over the years. Pediatricians are probably the most caring people in the doctor spectrum, but…

    When they weren’t talking about the boring details of work, they discussed two things: 1) how much money they were going to make. 2) how they have guaranteed jobs for life and all those people who sneered at them for putting off working until they were 30 can suck it.

  52. 52
    kay says:

    @Ailuridae:

    I don’t know. That’s the whole problem with pretending health care is a “market”. The patient is wholly dependent on an expert when deciding what to do. I could be very well informed on pregnancy, and still not be in a position to know whether being induced or a c-section was a “good” decision. Then there’s the absolute panic that ensues when things go wrong, which one physician I had described as “the mother falls off a cliff”.

  53. 53
    Yevgraf (fka Michael) says:

    @Ailuridae:

    Inducing labor and intervening have so many positive side effects for doctors that the only way you could ignore that they often make this decision in their own self-interest is you start at the supposition that “doctors never act in their own self interest”

    About 18 years ago I went to a dentist (I’d used his predecessor in the practice for years) for a routine teeth-cleaning. There was all sorts of new equipment around, and the place was more attractively staffed and there were brand new file cabinets and an attractive and color-coded new filing system. There was a lot of tut-tutting after his (attractive) hygienist did her work. The tut-tutting involved gravely serious words about what dramatically serious deep cleaning and scaling were needed. The initial estimated price was to be something around $950.00, and they wanted to go ahead and schedule. I didn’t have my calendar with me, and told them I’d have to call them back.

    As I was closing the door, I heard him say the following to his (attractive) receptionist:

    cha-ching

    Needless to say, I found another dentist.

  54. 54
    Ailuridae says:

    @Uloborus:

    You do know that you can just look up publicly available Medicaid reimbursements, right?

    http://www.hfs.illinois.gov/assets/032309mch.pdf

    127% in IL. I really don’t have the time to go through state by state but let’s be honest – you know your claim is fabulously full of shit and were just trying to pull a fast one here right?

    Even a cursory familiarity with this or with anyone in insurance or doctors will tell you that almost without exception doctors make more money off C-sections than vaginal deliveries. Now you can argue that the difference in compensation isn’t enough to influence behavior but you can’t argue it isn’t there. My training is in economics – when I see people doing something unnecessary that enriches themselves despite no evidence that it is delivering better results I break out Ockham’s Razor and realize that yes, indeed, many of them are acting in their economic self-interest. Just like when I see a deliberate supply constraint in a field like medicine I realize that the people establishing that supply constraint are doing it to enrich themselves.

  55. 55
    Elie says:

    @Ailuridae:

    Typically, deliveries are priced in a package that covers prenatal care and delivery – independent of the mode. Complications of pregnancy are reimbursed differently, both before and after delivery, but the package pricing for a normal pregnancy does not pay the doc differently for c-section versus vaginal deliveries. Insurance companies actually do care about that and that is one way that “incentive” to generate more income by the doc is nipped in the bud.

    I don’t think that the VA has extensive experience with pregnancy care — probably not a high volume service for that system.

    I think in general it is an oversimplification to cast the medical profession as generally just interested in doing c-sections. There are many things that can go wrong with both delivery means. There are also a lot of things that can go wrong in just managing a pregnancy medically, independent of the means of delivery. That is what makes the docs sweat and result in decreasing numbers of Obstetricians wanting to do pregnancy. Some of you act as though the only points of consideration in managing pregancy is the means of delivery. There is plenty of sweat and worry way before that. By the time delivery is imminent, a lot of that previous experience determines the choice — and mistakes can be made.

    I think that women nowadays have many choices from midwives to standard pregnancy care given by a hospital affiliated physician. Some women may even choose to deliver at home with minimal attendants. The question of which is “best” requires a lot of careful data collection – a LOT of data – and analysis looking carefully at outcomes for babies and Moms NOT just in the immediate 6 months after delivery, but perhaps even longer.

  56. 56
    Ailuridae says:

    @kay:

    Health care s a market – it is just a market whose primary driver is a supply constraint that artificially limits the numbers of doctors so that the doctors the US has have an enormous lack of competition. In the long run there are many ways to solve this problem but they all boil down to two end games: either the cartel has to give up the supply constraint or, like in MD they have to accept cost/price controls. The alternative is bankrupting the country.

  57. 57
    Pete says:

    You all realize that, for the most part, insurance companies reimburse a C section and a ‘regular’ birth at the same rate, right?

    People figured out a while ago that it was bad to incentivise one over the other. Like, in the 80’s.

  58. 58
    Brachiator says:

    So what’s left besides dreaded government intervention?

    So, let’s see. Evil insurance company intervening in health care decisions to increase profits, bad, bad, bad.

    Government intervening in health care decisions to control costs, right and necessary.

    I am in favor of universal health care, but I don’t see how government magically becomes knowledgeable to make decisions about medical care.

  59. 59
    Svensker says:

    @El Cid:

    A couple of years ago my husband had scheduled outpatient surgery in a local hospital. When we talked to the hospital’s money people, they offered us a flat rate of $10K for the hospital’s bill if we paid up front and dealt with our insurance ourselves. We thought that was an outrageous amount for a few hours in the hospital (did not include surgeon, anesthesiology, lab, etc.), so we opted to have our insurance company negotiate the price after the fact. The hospital billed our insurance $20K which was negotiated down to $18K.

    Think about it. The health care crisis in the US is not just because the evil insurance companies are skimming off the top.

  60. 60
    Yevgraf (fka Michael) says:

    @Ailuridae:

    either the cartel has to give up the supply constraint or, like in MD they have to accept cost/price controls. The alternative is bankrupting the country

    Like I said above – we went from the 1/7 problem when Hillary was trying to deal with it and blasted right through 1/6 as we head rapidly toward 1/5.

    Just this morning, I was telling my oldest kid to take herself and her swelling arm to the student medical services office first (something may have happened when she donated blood last week), as we have a $15,000.00 deductible on our $500.00 a month health policy.

    Keeping in mind that the family plan offered by my trade association is $1,400.00 a month, same as my mortgage, which is way too expensive for me. A guy I used to work with has a $2,800.00 a month policy which he has to keep because he’s got some pre-existing condition problems.

    “Greatest health care system in the world”, my ass.

  61. 61
    Elie says:

    @Svensker:

    Yes, as with much of reality, things are more complex. We want them SIMPLE though, and black and white.

    Darn it! ;-)

  62. 62
    Ailuridae says:

    @Brachiator:

    Well, we have a test lab for more direct government intervention in MD right and we know it has largely worked right? If the state of MD could do it wouldn’t it seem to at least be possible that it could also be done on a nationwide level with MD as a starting point (O’Malley for POTUS in 2016!)

    @Svensker:

    I had a friend have a severely deviated septum fixed and he had almost the exact ratios told to him. Price X from hospital if he paid up front, then the hospital billed insurance for 2X after the surgery.

  63. 63
    kay says:

    @Ailuridae:

    You have more belief in the “cartel” idea than I do, as we’ve discussed before.
    How it looks right now, at the state level, is that states are simply going to expand licensing of allied professions, rather than making more physicians. They’re already doing it in California and Ohio and other places. It was inevitable. They can’t pay this much, and if the supply doesn’t increase re: physicians, they’re simply going to look elsewhere.

  64. 64
    Ailuridae says:

    @Yevgraf (fka Michael):

    Yeah, a large part of the American middle classes struggles in the last two decades can be explained by a massive transfer of wealth from the populace at large to health care providers (hospitals, doctors, doctor’s groups etc). But nobody is willing to be honest about it.

  65. 65
    WereBear says:

    If this is a market; it’s a completely unique and idiosyncratic one. In fact, this is why I never call it a market; while there are economic factors in play, it is not anything like that.

    “Market” theory assumes things not in evidence with health care; free choice, rational actors, and competition are all huge stretches to apply to this situation in a way that computers, Internet access, and ice cream “markets” are not.

    For instance, in my area dominated by small towns, I have a choice of ONE hospital. An hour away there’s another, and within a three hour radius I have some really big choices. But that means sweet-damn-all if I slide off an icy road (heaven forbid).

    In fact, the need for medical care is an entirely involuntary one; I’d rather NEVER need it, but that chance is none.

    Even something like having a baby or an appendectomy has so many factors, from the amount of fat on my abdomen to my age and health to how big the baby or appendix is. There is no set rate… there can’t be.

    All of this makes “market” talk meaningless.

  66. 66
    JCT says:

    @Ailuridae: There are many levels to attack this problem. Actually, in the past 5-8 years more med schools have opened in the US than in the previous 25. It takes a lot of time,effort and money at the educational level (all the way from med school through residency) to train a competent MD, it is not just opening new med schools or expanding class sizes (~120 -160 / class currently).

    No one in this thread has acknowledged the enormous debt that medical students face — and has largely fueled this rush away from primary care in the US. Finishing med school with $250,000 in debt (and often more if you have undergrad debt or if you marry a fellow physician) and then embarking on 3-8 years of additional house officer training at middling wages can seriously change your “outlook”. Many of the fellows I train are in their mid to late 30’s before they have paid off their med school debt (sometimes via moonlighting). This situation is basically limited to the US and my European colleagues bring it up all of the time at meetings.

    Again, I am not excusing the behavior of some of my colleagues who push the latest and greatest test when they have a stake in the gear (don’t get me started on cardiac calcium scoring), but while generating more MDs is an important goal, there are real problems with the current situation that need to be addressed.

    And I should add that I loved my OB/Gyn rotations in med school — but the biggest lesson I learned in L & D (in a big NYC public hospital) is that humility is paramount because there are some things that we as physicians cannot “make happen”.

  67. 67
    Ailuridae says:

    @kay:

    The end game for doctors is the same either way though. They’re going to have to accept price controls or competition – the question is whether it is going to be peaceful or violent.

    And I am not sure there is much to argue with about the cartel. We have too few doctors, that decision through regulatory capture is largely at the whim of doctors and then the rest of the putrid system is almost inevitable without the government deciding what doctors can charge.

  68. 68
    aimai says:

    @Omnes Omnibus:

    Also, in the case of bigger issues (the child born with brain damage because of something that went wrong with the birth) you pretty much have to sue in order to get the child’s educational and service needs met long term. If SS or Medicare or Medicaid would pay for those things routinely you wouldn’t have to sue. This would mean that people would only sue to prevent true cases of negligence from going unpunished. But if the medical profession and the hospitals would police themselves more effectively most people wouldn’t even sue under those conditions–even people who have suffered grievous harm are actually, generally speaking, reluctant to go to court to vindicate their position. If people knew that bad doctors or bad nursing practices would be punished or corrected without a law suit even those suits would largely evaporate. But because hospitals and medical practitioners won’t admit mistakes because they are afraid of admitting liability the entire process is adversarial from the get go.

    aimai

    aimai

  69. 69
    Ailuridae says:

    @JCT:

    Like most reasonable people I would happily trade off entire debt forgiveness for medical school in exchange for price controls and more doctors. Those go hand in hand.

    The US health care economy is 3T. That’s trillion with a T. the US graduates around 17000 doctors a year. The system to meet demand needs about 23000 (1/4 of all doctors starting in the US in any given year are actually not US med schools graduates). at 250K a year in forgiveness that is 575M a year. Not to be an ass hole but 575M/3T is a tiny number. So tiny as to be irrelevant Forgiving those loans (and let us remember that like a lot of my physician friends who are fourth or fifth generation doctors not everyone is taking loans) for price controls would probably recoup the costs by 3 AM on January first of any given year. That’s how outrageous health care pricing is in this country

  70. 70
    Omnes Omnibus says:

    @aimai: Exactly. I don’t have the study at hand right now, but it appears that the best way for an MD to avoid a malpractice suit (except in truly high expense cases like brain damage or loss of limb) is for the MD to admit error and apologize. As far as the rest goes, universal coverage and a safety providing support for those who need it will take care of much of the problem. I know, just a small hill to climb, right?

  71. 71
    Brachiator says:

    @Ailuridae: Well, we have a test lab for more direct government intervention in MD right and we know it has largely worked right? We don’t know this at all. Health care experiments in various places, including Massachusetts, are interesting, and useful to observe. But I am not seeing easy solutions.

    Health care s a market – it is just a market whose primary driver is a supply constraint that artificially limits the numbers of doctors so that the doctors the US has have an enormous lack of competition.

    This is a huge oversimplification. I’m not seeing easy ways to quickly increase the numbers of doctors, or nurses, and to make sure that all communities have fair access to medical care.

  72. 72
    opie jeanne says:

    @Linda Featheringill: How about an older mom? I had my last child 28 years ago, and the high rate of intervention in pregnancies was being discussed then with alarm. At some hospitals the Caesarean rate was approaching 50%, and the general consensus was that the cause was the fear of malpractice suits.

    That last pregnancy of mine was induced because the baby was 3 1/2 weeks late and showing signs of distress.

  73. 73
    JCT says:

    @Ailuridae:

    The US health care economy is 3T. That’s trillion with a T.

    Thanks for the clarification, I didn’t know numbers went higher than a billion.

    And I’m happy for your 4th and 5th gen physician friends who didn’t take out loans, but that is not remotely the norm. Not even close. As someone who is currently paying for my kid’s college education 100% so she can at least have some sort of shot at choosing a career without having to get out from under debt first, there is no way in hell I could (or would) pay for professional school. Getting out of med school without debt is a profound rarity.

    Actually, I completely agree with you re: debt forgiveness. As a matter of fact that is how the govt encourages med students who have an interest in science to become academics. And the ONLY reason it works is because it pays for med school in exchange for years spent in postgraduate research. It’s what I did. And I make about 1/3 what my 100% clinical colleagues do. And I could care less because i like what I do.

    But you know, I haven’t heard anyone in a leadership position propose a broadening of this approach. Why? Because it costs money — and we all know that spending money on education is verboten these days.

  74. 74
    Ailuridae says:

    @Brachiator:

    I didn’t right anything about Massachusetts though, right? I wrote in relation to Maryland. That system is nearly thirty five fucking years old. It isn’t a recent experiment by any stretch

    http://online.wsj.com/article/.....07403.html

    As for getting more doctors if the claim is that it is simply too hard for the US government to find a way to educate 6000 more doctors a year I must weep for the republic.

  75. 75
    Elie says:

    @aimai:

    While I understand your point, Aimai, it isnt always clear cut that a particular bad birth outcome resulting in brain damage, for example, is due to a delivery error. That has been an assumption that has, in my opinion, actually hampered a more enlightenned approach to managing those outcomes. When one assumes that it was something happening at birth, the medical profession is “at fault”. Some brain damage and dysfunction is unrelated to the birth means or events, but people are encouraged to sue, because, as you say, they have to get the money to raise the child with an impairment.

    Of course, no one wants to take on the cost of that — not only the education, but tending the impaired adult that the child becomes. Ultimately, the state does manage that after the parents become impoverished. Medicaid handles some of it and Medicare provides health coverage for the disabled. The social services get much trickier with people piecing together a patchwork of services, both federal and state, to take care of their impaired child or adult.

    As a society, we have barely committed to educating and preparing normal children. We are light years from the enlightenment to turn the corner on the impaired child or adult. But that is OUR fault — not the government. The people could decide that we want that.

  76. 76
    kay says:

    @Ailuridae:

    And I am not sure there is much to argue with about the cartel.

    That’s true, for the narrow subject that mistermix raised, but you know it’s not that simple for “health care”.

    It’s physicians, it’s medical equipment manufacturing, it’s over-capacity at hospitals, but it’s also decent wages for lower-level staff. It’s complicated. As I know you know :)

    I don’t think doctor cartels are our best argument. I don’t want to get into “pick the monster of the week” like conservatives do.

    That’s too easy, and it’s so oversimplified it’s not accurate and so, not honest. It’s too incomplete to be honest.

  77. 77
    JaneGoth says:

    Well here in the UK where we do have a nationalised health service C-section rates have been creeping upwards for many years. (No links I’m afraid I’m on my phone). Ideas put forward for this include, increasing maternal age, increasing maternal weight, decreasing doctor experience of normal delivery of breech birth and the biggie the increasing cost of payouts for damages.
    Some also blame the “fashion” of being to “posh to push”
    But that’s mostly the daily mail.

    With my son, I had to be induced 36 hours after my waters broke. 24 hours after being induced I had an emergency c-section due to failure to proceed. Would I go thru the same pain & misery again? If it meant having a healthy child hell yeah. Not a rhetorical question as I’m 20 weeks pregnant.

  78. 78
    Elie says:

    @opie jeanne:

    These days there are tests that are done on “post term” pregnancies to assess the baby’s capability to endure labor — specifically, the contraction of the uterus that temporarily restrics blood flow (and oxygen) to the baby with each contraction. In sustained labor, with a child that has perhaps been enduring a less than ideal rate of perfusion through the placenta, you would want to make sure that you would not be adding to the baby’s stress. Some of this testing was not available 28 years ago, but it is now pretty routinely. It is hard for me to think that a parent would want to forego that testing just to have the goal of a vaginal delivery.

    Most of the time, the baby is fine, and do well on the
    “stress test”, encouraging the physician to proceed to allow a regular labor and delivery. It is hard however, to think that one would go for a vaginal delivery seeing your baby’s heart rate drop dramatically during a contraction. It is also hard to think that the doc would see that and ignore that in order to cary out a vaginal delivery no matter what.

    Of course, one could opt not to test the baby’s wellbeing and just let nature take its course. Would one then, give the doc and yourself, the benefit of the doubt should the baby have less than an optimum outcome? THAT is the reality check we all have to face with honesty. That said, the overwhelming percent of the time, things are going to be just great. Its the small but horrible percent. Once you have seen the floppy, gray severely asphyxiated newborn, there is a tendency to lose the bravado. As a neonatal ICU nurse, believe me, those babies stick with you.

  79. 79
    Elie says:

    — and let me add, on the maternal side… sometimes you have to get the baby out of a hostile environment. If the Mom is strggling to live from either an accidental or pregnancy related complication which impairs her circulation or other physical environment, this is obviously going to impact the baby and also her own ability to achieve recovery. Sometimes youu just have to get the baby out.

  80. 80
    Church Lady says:

    Two children, two C-sections. I went into labor with the first child over five weeks early. She was breech and the Dr. recommended a C-section, which I agreed to. She wound up in the neo-natal unit for one day due to breathing problems, then was able to be transferred to the regular nursery.

    Second child was actually a little late. At a week after my due date, my doctor scheduled me in for induction. My plan was to do a VBAC delivery in order to avoid having another C-section. My son had different ideas. The day before my scheduled induction I went into labor and just like his sister, he was butt down. At that point, my OB told me that I no longer had a choice as to delivery method and put me in line for an OR. Suddenly, the baby’s heart rate started dropping, bells started ringing, people rushed into the labor room and they immediately rushed me into the OR and had the baby out in what seemed like seconds (I’d already had my epidural, so that time was saved and I able to be awake for the delivery). They delivered him so fast that my husband and I didn’t really even have time to get scared about what was happening with the baby.

    In each case, both mother and baby were fine. If I had not had a C-section each time, who knows what the outcomes might have been? Studies and government bean counters are not on the front lines and don’t have to make these decisions in real time, but the doctors and nurses do. I’ll rely on the expertise and experience of my Doctor to make these decisions, because they know a heck of a lot more than I do about giving birth.

  81. 81
    Elie says:

    @Church Lady:

    I will challenge one point, however. We need the bean counters and interested (and informed) third parties to make sure that data and correct synthesis of that data results in actual improvement of care.

    I don’t automatically give in to any one or two actors in the delivery and design of care. We need good practitioners who are in turn accontable and challenged by real information and strategic oversight…. Nobody has ALL the answers

  82. 82
    R-Jud says:

    @JaneGoth: Congrats on your second pregnancy and hope it’s going well.

    I’m also in the UK, and while I was pregnant I had a fairly long talk with a very experienced midwife (during the early part of my labor, actually) about the rise in C-section rates. She felt convinced that maternal age was the biggie, in spite of the UK’s relatively high teen pregnancy rate. The other midwives who attended me agreed.

    I was 29 when I had my first (emergency C-section, btw, due to knots in the cord), and the MW said even ten years ago that would have raised eyebrows– as in, I should have had children earlier– but now it seemed to her that most first-time mothers were pushing 30. My sister-in-law, for instance, had her first child at 40; she’s expecting again, too.

    But like I said, this is all anecdotal.

    Any Juicers who want to dig into more about maternity care under the NHS can look at these figures from the Centre for Maternal and Child Enquiries: they produce triennial reports on childbirth, maternal deaths during or following childbirth, and obesity and childbirth.

    I’m not aware of a similar organization that tracks these things in the US. I imagine our fragmented “market” makes that difficult.

  83. 83
    liberal says:

    @Brachiator:

    I am in favor of universal health care, but I don’t see how government magically becomes knowledgeable to make decisions about medical care.

    The point isn’t about knowledge. There are certainly examples where insurance companies have done the right thing—refusing to cover nasty forms of treatment for breast cancer that turned out to be extremely expensive and no better than conventional treatment, for example.

    Rather, the government can try to optimize long-term health care outcomes given a fixed budget constraint. Private actors in a “free market” cannot do that, period, because it’s impossible to construct a market with the right incentives: if you invest more now to make your clients healthier a long way down the road, you can’t capture the eventual payoff, because at that time they can always switch to another provider. Not to mention that modern capitalism is obsessed with quarterly financial results.

    Governments, however, don’t have to rely only on incentives.

  84. 84
    liberal says:

    @Church Lady:

    Studies and government bean counters are not on the front lines and don’t have to make these decisions in real time, but the doctors and nurses do.

    But unless we want health care to consume 200% of GDP, someone has to lay out what is and is not effective care. Can’t be the physicians themselves, because they’ll just write themselves blank checks. (Not because they’re physicians, but because they’re human.)

  85. 85
    JCT says:

    @liberal: You do realize that deciding what is effective and what is “not” is not exactly straightforward, right? Medicine is not always a cookbook, the stories shared upstream make that pretty clear.

    What does it mean to be effective? Most of us who deal in the more procedure-oriented fields are constantly trying to determine how to balance risk and benefit in both diagnostic and treatment-oriented modalities. Meanwhile balancing how to incorporate newer modalities that may be a bit more expensive but decrease procedure-based risk, etc.

    I’m strongly in favor of clinical guidelines and use them extensively, but I’ve been in practice long enough to know that making these sorts of determinations are problematic when measured against normal human variability.

    And sure, just for fun I always write myself blank checks when I decide on diagnostic approaches because I just love dealing with layers of redundant and potentially conflicting clinical data — it’s all about the benjamins after all.

  86. 86

    If I may jump in for just a moment:

    My mother had a non-scientific, old-fashioned opinion that increasing C-sections might be partially due to decreased walking in prepubescent girls. Walking helped the gils lay down strong muscles throughout the whole pelvic girdle. Everybody used to walk just about everywhere at one time but not so much any more. I wonder if urbanization might have something to do with that. Or suburbanization, if that is a word.

  87. 87
    Teabow says:

    >>a pregnant woman living in an area with high intervention >>hospitals can’t travel hundreds of miles to find a
    >>low-intervention hospital.

    Like that would even be on the table.

  88. 88
    satby says:

    Mistermix’s original point was

    It’s not “rationing” to cut down on expensive procedures that don’t make a difference in outcomes.

    Everybody’s got an opinion, everyone’s fallible. There are always exceptions. My own personal experience was just mine, an anecdote, not data. We need data like the study he mentioned to chart a course for better managed care.
    And we have to realize that not every birth will have a perfect outcome. Regardless of how much or how little intervention there is.

  89. 89
    HyperIon says:

    @mark wrote:

    We’ve had tort reform in california for 30 years. It hasn’t accomplished anything, aside from limiting compensation to less than actual damages.

    yes. you CA folks have evidence that tort reform does not work.

    yay, evidence-based arguments!

  90. 90
    HyperIon says:

    @nancydarling wrote:

    Are doctors to become the ‘new teachers’?

    Not unless we start paying docs a lot less.

  91. 91
    HyperIon says:

    @Ailuridae wrote about the number of docs:

    The system to meet demand needs about 23000..

    per year, I assume from what you wrote.

    I saw a HCR muckety-muck (doc i have seen talk elsewhere) on my Seattle public access channel last week say that he didn’t think we needed more docs. The numbers are OK but the distribution is wrong. Fewer specialists. Many fewer specialists. But..guess who makes the most money? specialists!

  92. 92
    Gretchen says:

    Mark@51: A young woman of my acquaintance is struggling with the decision of whether to accept her place in a prestigious medical school Tuition is $78,000 per year for four years. Apartments in the area are well over $1000 per month. Although she has dreamed of being a doctor since I met her when she was in the 7th grade, and has worked very hard toward that goal, the thought of being HALF A MILLION DOLLARS IN DEBT as she starts her life at age 26 has her second-guessing her decision. Anybody who wonders why doctors consider how much they are making needs to consider what it’s like to start your young life HALF A MILLION DOLLARS IN DEBT! There’s got to be a better way to provide medical education. And no, scholarships are not available. It’s all loans to pay that half a mil.

  93. 93
    HyperIon says:

    so not only am i talking to myself on a dead thread but i also wrote a bad word and am in moderation. *sigh*

  94. 94
    Wolfdaughter says:

    @Yevgraf (fka Michael):

    It sounds like you are a lawyer, or maybe an accountant. Do you think you might be seeing the worst of the crop? I’m a retired medical librarian and used to work with a lot of doctors, plus I have health issues and get to see various doctors as a patient. In my experience, most of them are dedicated professionals who really do want to do the best for their patients.

    I have one criticism of doctors: they spend very little time with you and will interrupt you. I don’t let them do that because I’m not intimidated by them, and after almost 40 years in my biz, I can sling the medical lingo with the best of ’em. But a lot of their not spending enough time with patients is due to the insurance industry and the demand to “move ’em in, move ’em out”.

    Joke. There was a long line at the pearly gates. A doctor had just died, and he bustled up to the front of the line, full of self-importance, demanding that St. Peter not make him wait but take him first. St. Peter said to him, “I’m sorry, sir, but in Heaven all souls are equal. You will need to take your proper place in line.”

    The doctor sulked and fussed, but eventually went to the end of the line. Pretty soon a man in a white coat, stethoscope hanging out of on pocket, strode up to the pearly gates, and St. Peter just waved him on through. Outraged, the doctor stormed up to the front of the line and demanded to know why he couldn’t also be waved through, since St. Peter had just let that other doctor through. St. Peter replied, “Oh, that’s God. He just thinks he’s a doctor.”

  95. 95
    JCT says:

    @Gretchen: Gretchen, if she truly wants to be a physician more than anything else she should carefully think about some outside-the-box ways to pay. One option would be to do one of the medical-ROTC programs or look into spending a few years post-residency in an underserved area. Both of these approaches limit your flexibility and are pretty strongly slanted towards primary care, but they can put a big hole in the tuition debt. Worth thinking about.

  96. 96
    Arclite says:

    My wife was in labor for 12 hours and not progressing at all, so they gave her some pitocin to help her along. After 24 hours in labor she was dialated enough to start pushing. She pushed for 3 hours, at which point the baby’s heart rate started to fade, so they went for an emergency C. My 95 lb wife gave birth to a 8.5lb baby girl. For our 2nd child, they said, given your history, you will most likely end up in the same situation with additional complications due to the first C. So, we just scheduled it. Again, she gave birth to an 8.5 lb. baby boy.

    If there hadn’t been access to that procedure, I don’t know what would have happened, that baby just didn’t want to come out. But also, I feel like we did things the “right” way, trying to have naturally first before resorting to the procedure for our initial child.

  97. 97
    Elie says:

    @Linda Featheringill:

    Again Linda, you (or your Mom), may have a very very good point about the pelvic musculature.

    Oddly/interestingly enough, my gyne pointed out a related phenomenon for retired women coming from urban environments but retired in more “rural” settings. She anectodately spoke of seeing increasing episodes of pelvic muscle problems in post menopausal women who now were, literally, “hauling wagons”, pushing wheelbarrows, etc to tend their gardens etc in retirement. For the ladies who had always been in rural environments where they had to undertake certain strengthenning activiies, they had over the years built up the muscles of the pelvis and pelvic floor. But if your main activity is driving and maybe a litte running and other workout to just to keep trim, but not necessarily vigorously work those muscles, you could experience some problems.

    Again, this is anecdotal, and perhaps more data would not support, but its worth thinking about and testing. Perhaps our young women need different conditioning?

  98. 98
    Cassidy says:

    The other side of this argument is the natural birth nazis who feel that anything more advanced than a pan of warm water and a crone is too much. Personally, I think the profession of “doula” should be criminalized.

  99. 99
    JaneGoth says:

    @R-Jud: Thanks, I’m one of the elderly mums. I had my son at 39 and if we get to term with this one I will have just turned 42. Actually I have a high risk pregnancy I’ve had scans, tests and a procedure in 3 different hospitals so far and in May I have to go to Sheffield for a fetal MRI to check the baby’s brain (it should be OK but there is acanthus risk) My lead consultant wants to see me every other week and for the community midwife to see me in the alternating weeks. Although that all sounds very scary we now have about the same chance of having a healthy full term baby as in any low risk pregnancy, this level of observation is to keep it that way. I hate to think what this level of treatment would cost in the US.

  100. 100
    Ailuridae says:

    @HyperIon:

    Per year, yes. Fully 1/4 of the doctors that start in the US any year are educated at medical schools outside the country whether they are actually foreign national or US born kids who have to go to med school in Costa Rica or Israel because they can’t get into US schools. So for every four “openings” every Spring in the US for a doctor there are three US medical school graduates. And it has been that way for decades. I know many South Asian families whose children are my age (36) and were born in the US after their parents came here from Pakistan or India and were educated in medical school there. It is, after all, by design to keep salaries up – that’s why cartels use supply constraints.

  101. 101
    FlyingToaster says:

    As a woman who required a C-Section (and we knew in advance that I would, see below), and who developed pre-eclampsia at week 37.3 with the fetus lying transverse, I get really ticked at these studies.

    The hospital I delivered at has higher than local-average rates of C-Sections (I don’t have data on inductions), because the average age of women who give birth there is 39. Which was exactly why I wanted to give birth there, seeing that I was 46 with gestational diabetes and a family history of pre-eclampsia.

    What the studies (in general) seem to be missing isn’t just local culture; isn’t just one doctor versus another; but is also whether the pregnancies were deemed high-risk from the beginning.

    /rant

  102. 102
    opie jeanne says:

    @Elie: The tests for placenta health were available at the time, but they hadn’t started doing them on me yet. I met another woman who had had her second test and she was really frustrated and nervous because her baby was more overdue than mine. She told me she didn’t understand why they didn’t just induce “or something”.

    I think they would have started doing those tests on me on that day if the decision to induce hadn’t been made.
    I’m trying to remember all of the details. I was at the Kaiser hospital to have a checkup, and my doc sent me for a non-stress test and at first they thought the baby was asleep, can’t remember why they thought that, so they gave me a cup of apple juice to “wake her up”. Maybe I’m remembering that part incorrectly, but she became more active and started hiccupping.
    The doctor who monitored the test became worried because every time i had a Braxton-Hicks contraction the baby’s heartbeat wavered. They were trying not to scare me, assured me that they would deliver the baby right away if things got worse, but they also said it could be something as simple as the baby being in a strange position (the dr had done an emergency C-section only to find the baby grasping the umbilical cord and squeezing it during a contraction). So they had me walk to another room for a stress test, inserted an IV for the pitocin drip, and monitored me for a while. The baby’s heartbeat stopped reacting to the contractions, everything seemed normal except for the due date being so long past. The doctor in charge of the maternity ward consulted with my OB, who came down and held a very animated argument in the hallway outside my door. The doc in charge of the ward must have overruled my OB, because he came in and asked me if I would like to just “turn up the juice” and have the baby that day. I was 32, this was my third child and I felt like I’d been pregnant for 18 months by then so I told them to wait until my husband could get to the hospital, but yes.

    I know, looking back on it especially from the perspective of what we know now, how attitudes have changed, this was probably a really stupid thing to do.

    My OB’s nose was out of joint for a while, and he told me that I had miscalculated the date the pregnancy started. Yeah, with his help. She wasn’t a huge baby, though, so she may have been right on schedule if we both had mistaken the due date.

  103. 103
    opie jeanne says:

    @Linda Featheringill: I remember walking a lot with each pregnancy, especially the 2nd and 3rd. It was recommended to pregnant women to ease delivery. We lived in a great neighborhood for long walks at the time, nice even sidewalks, low traffic.

  104. 104
    Wolfdaughter says:

    @WereBear:

    Good post. The other factor is that if you need health care right now (heart attack, bleeding out, broken bones or other severe injuries, severe asthma attack), there is no time to comparison shop or negotiate. You take whatever care you can get and worry about payment later. You hinted at this but didn’t make it explicit, at least as far as I could tell.

  105. 105
    Mark says:

    @Gretchen: you are what’s known as a liar.

    The highest tuition in the country last year was Temple at $57457:

    http://services.aamc.org/tsfre.....ontrol=PRI

    Southern Illinois University – which is not prestigious – charges $79000 for the first year and $28500 for years 2-4:

    http://services.aamc.org/tsfre.....ontrol=PUB

    We guarantee doctors lifetime employment and a six-figure+ income. You want me to feel sorry for them because they take 30% more debt than a lawyer?

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