Recently, I participated in a minor uproar on Twitter regarding VBAC.
The discussion arose from a story on CNN regarding Joy Szabo. The story detailed the fact that Ms. Szabo had been told that she could not have a VBAC at the hospital where she planned to deliver. As a result, she ultimately moved nearly six hours away from their home in Page, Arizona, to Phoenix to give birth at a hospital that does permit women to have VBACs.
And, thus, one woman’s quest for a vaginal birth after a cesarean became national news. How did it come to this? The fact that hospitals are refusing to even offer the option of a VBAC (with apparently no discussion of options or alternatives) is striking to me.
But, then again, I completed my OBGYN residency in the mid 90s when VBACs were at their peak. “The Golden Age of VBACs”. I also had the honor to work with the Midwifery Service at North Central Bronx Hospital after finishing my fellowship. In 1998 (when I finished my fellowship) the Obstetrics service at NCB boasted a C-section rate of 7-10% for first time mothers. Also, over 90% of women with a previous Cesarean had trials of labor and the vast majority had successful VBACs. Interestingly, I never experienced a uterine rupture during a VBAC attempt at NCB.
The conversation that developed around the case of Szabo spawned a number of tweets (and retweets) as well as lively blog posts by Nick Fogelson (@academicobgyn) and the blog Mom’s Tinfoil Hat . One of the thing that everyone agreed about was that in order to reduce the number of repeat cesarean deliveries, it would be important to decrease the number of first time cesareans. But how can that be done? and what is an unnecessary cesarean?
A quick story should provide some context. When I was a chief resident at Harlem Hospital, the team of physicians reviewed a fetal heart rate strip with clear evidence of fetal distress and decided to proceed with a cesarean section. As we prepared for the case, we sent the intern to the room to get consent from the patient for surgery. Several minutes later, the intern returned to tell us that the patient had refused the cesarean. The response from myself and other physicians was unanimous and immediate. “Nonsense. She *can’t* refuse a cesarean. Obviously the intern did not know how to “counsel” the patient regarding her “options”. I went to the room, spoke to the patient and within 2 minutes the consent was signed and the patient was on her way to the OR for the cesarean.
I use this story to remind people of the awesome power that a physician wields where an unborn child is concerned. Patient’s trust physicians to make tough calls by virtue of our expertise, training and because they believe that we want what is best for them. My fear is that physicians risk losing the trust and goodwill we have with patients if we steer them away from safe vaginal deliveries toward unnecessary cesarean deliveries for questionable reasons. The current trend towards not offering VBAC may have begun due to concerns regarding safety or even medico-legal exposure; however at present, it has metaststatized to inordinant levels that I have referred to as PVH (physician-VBAC-hysteria).
The reversals in the rate of VBAC have clearly increased the Cesarean rate in the US, but have not (in any definable way) improved maternal or fetal outcomes. Therefore, presented for your review is my most recent slideset on practical ways that patients can avoid some of the pitfalls which may result in an unnecessary cesarean delivery.
Enjoy.
Recently, I participated in a minor uproar on Twitter regarding VBAC. The discussion arose from a story on CNN regarding Joy Szabo. The story detailed the fact that Ms. Szabo had been told that she could not have a VBAC at the hospital where she planned to deliver.
As a result, she ultimately moved nearly six hours away from their home in Page, Arizona, to Phoenix to give birth at a hospital that does permit women to have VBACs.
And, thus, one woman’s quest for a vaginal birth after a cesarean became national news. How did it come to this? The fact that hospitals are refusing to even offer the option of a VBAC (with apparently no discussion of options or alternatives) is striking to me. But, then again, I completed my OBGYN residency in the mid 90s when VBACs were at their peak. “The Golden Age of VBACs”. I also had the honor to work with the Midwifery Service at North Central Bronx Hospital after finishing my fellowship. In 1998 (when I finished my fellowship) the Obstetrics service at NCB boasted a C-section rate of 7-10% for first time mothers. Also, over 90% of women with a previous Cesarean had trials of labor and the vast majority had successful VBACs. Interestingly, I never experienced a uterine rupture during a VBAC attempt at NCB.
The conversation that developed around the case of Szabo spawned a number of tweets (and retweets) as well as lively blog posts by Nick Fogelson (@academicobgyn) and the blog Mom’s Tinfoil Hat .
One of the thing that everyone agreed about was that in order to reduce the number of repeat cesarean deliveries, it would be important to decrease the number of first time cesareans.
But how can that be done? and what is an unnecessary cesarean?
A quick story should provide some context.
When I was a chief resident at Harlem Hospital, the team of physicians reviewed a fetal heart rate strip with clear evidence of fetal distress and decided to proceed with a cesarean section. As we prepared for the case, we sent the intern to the room to get consent from the patient for surgery. Several minutes later, the intern returned to tell us that the patient had refused the cesarean. The response from myself and other physicians was unanimous and immediate. “Nonsense. She *can’t* refuse a cesarean. Obviously the intern did not know how to “counsel” the patient regarding her “options”. I went to the room, spoke to the patient and within 2 minutes the consent was signed and the patient was on her way to the OR for the cesarean.
I use this story to remind people of the awesome power that a physician wields where an unborn child is concerned. Patient’s trust physicians to make tough calls by virtue of our expertise, training and because they believe that we want what is best for them.
My fear is that physicians risk losing the trust and goodwill we have with patients if we steer them away from safe vaginal deliveries toward unnecessary cesarean deliveries for questionable reasons.
The current trend towards not offering VBAC may have begun due to concerns regarding safety or even medico-legal exposure; however at present, it has metaststatized to inordinant levels that I have referred to as PVH (physician-VBAC-hysteria). The reversals in the rate of VBAC have clearly increased the Cesarean rate in the US, but have not (in any definable way) improved maternal or fetal outcomes.
Therefore, presented for your review is my most recent slideset on practical ways that patients can avoid some of the pitfalls which may result in an unnecessary cesarean delivery.
Enjoy.
David Harlow has an excellent post over at HealthBlawg, which summarizes recent discussions regarding patient control over health data over at his blog:
He also does an excellent job at posing two questions which require further consideration.
Below are some of my initial thoughts to his queries. I would encourage my readers to take a look at HealthBlawg and join the conversation at David’s Blog, er Blawg.
The two questions are:
#1: Are patients now ready to insist on having their health care providers upload their health information to PHR systems such as Google Health or Microsoft HealthVault? Answer: Yes. Absolutely, and the person who finds the most seamless way to do this will reap immeasurable financial and reputational rewards. See details below… #2: Are PHR platforms and health care providers prepared (and equipped) to act on these requests? Answer: No. And that’s too bad. (See my answer to #1). A quick reference point. In my practice as a high risk pregnancy specialist, I am often asked to evaluate patients who have had a previous stillbirth. This is a difficult situation and (of course) the first question that a patient has for the next pregnancy is; “Will I have another stillbirth?” In many cases, the answer lies in the cause of the initial stillbirth. Invariably, at the time of the initial adverse outcome, there are a large battery of tests done to determine the cause of death for the first child. Unfortunately, many patient’s do not have or know the results of these tests when they come to see a specialist like myself with their next pregnancy. A large part of my job is putting on my Sherlock Holmes cap to search through records from other hospitals. In some cases, I can call and have records in (literally) 5 minutes. In other cases, I have to fax multiple signed requisitions and then wait days or even months to get the information I have requested. In one case, I received records from a hospital in Brazil faster than I received records from across town. This would not be the case if patient’s had access and control to their own health data. My hope is that this bottleneck will one day become archaic. I’m hopeful that this will happen quickly due to the nature of disruption and progress in a digital age. Consider this. There was once a time when to make a withdrawal from a bank you had to physically present yourself to *your* bank to do so. We now take for granted the ability to have immediate access to our funds from any ATM or grocery store. Any bank that did not give it’s customers access to funds immediately would (in the current setting) rapidly become obsolete. Dave DeBonkart (@ePatientDave) has popularized the phrase “Give me my damn data,” and I clearly think he is on to something. In this day and age, no one would tolerate non-realtime, non-interactive silos for their financial resources. When banks realized this, they bent over backwards to make sure that consumers had constant access to their funds. Eventually, health care systems will realize that patients will not tolerate silos for their health information. When that happens, (soon) I see rapid development of the type of real-time access to transportable health data. The current barriers will fall only when someone realizes that the old system is inefficient and ultimately less profitable.From The Decision Tree Blog Based on new research, Dave Dobbs introduces the idea of two types of people, “dandelions” and “orchids”. Dandelions can thrive anywhere, despite their environment or upbringing. Orchids, however, are more temperamental, and require a stable environment to survive. At first glance, the orchids may seem like a liability, and in fact, they often carry genes that make them susceptible to mood disorders and psychological disease. The astounding part of Dobbs’ report is that he shows that given the right care, or environment, the orchids don’t just do OK, but far surpass the dandelions in perfomance. In other words, given the right training, orchids may in fact be destined for greatness.
See the complete Blog post by Brian Mossop here: http://thedecisiontree.com/blog/?p=1093 The original article by Dave Dobbs is here: http://www.theatlantic.com/doc/200912/dobbs-orchid-gene Sent from Onyeije’s BlackBerry Storm
Earlier today, a patient that I saw for an ultrasound asked me a peculiar question.
“When am I going to have my baby?” A review of her medical records revealed that she was 30 years old and pregnant for the first time. Her estimated due date was in the second week of January. She has had no medical problems and has had an uncomplicated prenatal course.
On one level, my answer to her question should have been pretty clear. ”I don’t know when you are going to have your baby. Your baby will arrive whenever it is ready to come…”
If pressed, I could have responded with a little more definition, as in “Well, I doubt that you are going to have the baby within the next hour. And I am very confident that you will not be pregnant on Valentines day…”
But of course that type of glib irony is not appreciated by most pregnant women. Trust me. I know.
After further questioning the patient I discovered her OB-GYN had told her that she was going to have her baby “about 2 weeks early”.
Amazing. I wonder if that OB-GYN could help me out with some lottery numbers…
One of the things that I have noticed during my years of practice has been the way in which increasing numbers of patients and doctors are unwilling to allow the natural birth process play itself out prior to the birth of a baby. It is very common for patients and their doctors to plan an elective induction at a pre-arranged date not for medical reasons but because it fits their schedules.
As a father of three boys, I can relate to the angst and anxiety that comes at the end of a pregnancy and the desire to “get the baby out” at a time is convenient. There is also the nagging concern that something might happen to the baby “in there”; but that the baby will be safe when it is “outside”. I understand the reasoning behind delivering early.
This would be fine if the process of labor induction was the same as the process of spontaneous labor. But it is not. When a mother undergoes induction of labor, there is always the chance that the induction process will fail and that a cesarean delivery will be necessary. Indeed, a large part of the increased cesarean rate in the US is due to failed inductions of labor. This is important because, although a cesarean is very common and very safe; it is not (and never will be) as safe as a vaginal delivery (statistically speaking).
Furthermore, once a patient has had one cesarean delivery the prospects for a vaginal birth after cesarean (VBAC) are becoming vanishingly smaller since many physician (unfortunately in my opinion) do not offer a trial of labor for VBAC. The risks of a previous cesarean are not limited to repeat cesarean deliveries either. Patients who have had one cesarean are at risk for abnormal placement of the placenta (placenta previa), bleeding problems and surgical complications with future children.
The birth process is amazingly efficient. I often tell patients that for 90% of pregnancies a high risk pregnancy specialist like myself is not necessary. (Oops. Should I be admitting that?). But it’s true. We provide high risk perinatal services to a large group of the uncomplicated pregnancies to catch that 10% because we have made the decision that it would be unacceptable to discount those babies. However, it does not change the fact that for the most part, women with uncomplicated pregnancies tend to do better with less rather than more intervention.
So, my point for consideration today is this. Certainly, there will be cases where there is a medical reason for an expedited early delivery. But such cases are in the distinct minority. Perhaps one of the best “low tech” ways we could improve health care outcomes for women in this country would be to allow babies to do what they have done for centuries. Come when they are ready!
This is a case where we as doctors and our patients should sit back and allow things to occur. In the end, I suspect the outcome will be better for everyone involved.
From what I can see, every medical blogger worth his salt has weighed in on the controversy involving the USPSTF and their new mammography guidelines. I have had a number of respectful disagreements with bloggers that I admire. Although we agree to disagree about the specific guidelines, I would like to use this blog post to detail another important aspect of the current controversy.
By now, we are all aware of the controversy which erupted when the USPSTF came out with new recommendations regarding mammography screening. The recommendations and the subsequent firestorm of criticism have been covered extensively in the media.
The panel (in my opinion) did a fantastic job in compiling and analyzing the very best research and evidence regarding mammography. This research has developed slowly and consistently in the academic literature. Anyone who is familiar with the statistics and recent scholarship in this area would not be surprised that there are ample questions regarding the utility of routine mammograms for women in their 40s without other risk factors.
The USPSTF concluded (similar to many other researchers) that the benefits of screening younger women have been overestimated and that the risks have been underestimated.
Writing in the Boston Globe, op-ed, Ellen Goodman said it best…
“They went on to recommend that women start having mammograms at 50 and then have them every other year instead of annually. But then they dropped these guidelines onto an unprepared public like leaflets from a helicopter of experts who didn’t understand the conditions on the ground.”
Indeed, those of us who think the recommendations from the USPSTF are evidence based, and reasonable have been fighting a battle which has been made harder by at least three factors:
- The main stream media looking for a “controversy” in the story that would capture ratings
- The knee-jerk response that this represents some type of health care rationing scheme by the Obama recommendation and that the administration wants “women to die”
- Legitimate fears of health care consumers which were exacerbated by the two aforementioned factors and the poor public relations utilized by the USPSTF in conveying this information.
In what may be described as the understatement of the decade, Dr. Diane Petetti stated that “We probably, in retrospect, could have been more clear.’’
Carnegie Mellon’s Baruch Fischhoff, an expert in risk communication describes the faults of the USPSTF as one of an external view in conflict with an internal view. He states that what the task force did was to “give an external view of what’s true at the population level.’’ In other words, they told the statistical story from up high, when what the general population was looking for was an internal view; “ does this mean for my life?”
A familiar case of gown being out of touch with town. With striking ramafications.
Gary Schwitzer of the Schwitzer health news blog has done a phenomenal job in documenting the deficiencies in mass media medical reporting. His observations are similar to what many of us who practice clinical or academic medcine would agree with.
I would strongly recommend that my readers refer to his blog for more information on this topic.
The poor communication by the USPSTF cannot be ignored by those of us who are concerned with propagating evidence based guidelines to improve patient care. If we are to move toward practices based on evidence and not anecdotes need to be prepared for the fact that the immediate response by some who have a vested interest in the status quo will be ridicule, questioning of motives and false allegations. Taken from this perspective, the controversy and vilification of the USPSTF represent a head-on assault at evidence based medicine.
The traditional medical scholarly publishing model is clearly in the process of being disrupted by more direct online communication. We are moving quickly into an age where the adoption of digital record-keeping along with accelerating quantities of outcomes based data from registries and EHRs will enable new models for medical research and analytics. If those of us who value evidence based medicine are content to have our side of the story conveyed on the editorial page of the NEJM we face the real possibility of being scooped and outflanked by bloggers and the twitterverse.
As recently commented on by Janice McCallum “Interpreting the results from the increasing number of empirical studies will take skill in statistics, public health and communication.” Perhaps it is unreasonable to think that public health scientists shoud also become public relations specialists, but the recent brouhaha over the USPSTF recommendations make it clear that this is a skill that will be in much demand.
We desperately need a new model for medical information communication that can translate and publish the most recent medical data into a form that can be easily digested by the general public.
We desperately need a new model for medical information communication that can translate and publish the most recent medical data into a form that can be easily digested by the general public.
This episode has highlighted the fact that the facts don’t speak for themselves. They need to be delivered by people who have not only facts, but context and who can frame the message as a story to a prepared public. Only then will the evidence become relevant and suitable for general dissemination.
Sent from Onyeije’s BlackBerry Storm
—–Original Message—–From: conyeije
Date: Sun, 29 Nov 2009 14:48:05 To: Chukwuma Onyeije
Subject: Father Son Weekend Project: Laser Show Lunchboxen… Found this project in volume 20 of Make Magazine. Metal lunchboxes are used to produce a laser light show. Each box is
constructed with old speakers and amps and connected to a laser. The
entire apparatus is then connected to an ipod for what will hopefully be a
fascinating display. All we need now is some assistance in assembling the
voltage regulator. Instructions are found here: http://makezine.com/20/lunchboxen Any assistance would be greatly appreciated.
Many people have asked me “What is Twitter?” and “What is it you talk about on Twitter?”. I still have difficulty in answering the first question, but at least I now have a pictorial answer for the second question, thanks to Chad Scira of tumblr.icodeforlove.com . File this under “Nerd Art”. LOL.
The original cloud can be found here. You can create your own TwitterCloud here.
words (ordered by most used)
Many people have asked me “What is Twitter?” and “What is it you talk about on Twitter?”. I still have difficulty in answering the first question, but at least I now have a pictorial answer for the second question, thanks to Chad Scira of tumblr.icodeforlove.com .
File this under Nerd Art. LOL.
